1 / 34

Chapter 17: Medical Documentation

Chapter 17: Medical Documentation. Purposes of Documentation. Communication Up-to-date patient information for all providers Patient record is key means of communication for health team Example: Nurse updates patient ’ s record with new info from patient

keener
Download Presentation

Chapter 17: Medical Documentation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Chapter 17: Medical Documentation

  2. Purposes of Documentation • Communication • Up-to-date patient information for all providers • Patient record is key means of communication for health team • Example: • Nurse updates patient’s record with new info from patient • Doctor sees nurse’s note & orders cholesterol test • Lab tech views patient drug history to interpret lab results • Doctor sees lab tech’s note & writes prescription for new drug • Pharmacist views medical history before filling prescription

  3. Purposes of Documentation (cont’d) • Assessment • Vital signs • Respiration rate • Blood pressure • Pulse • Temperature • Circumstances surrounding visit • Symptoms experienced • Medical history

  4. Purposes of Documentation (cont’d) • Quality Assurance • Quality of care patient receives • Competence of professionals providing care • Health care audit: random review of patient records by committee

  5. Purposes of Documentation (cont’d) • Reimbursement • Verification of care provided so provider can be reimbursed • Determination of: • Reason for patient’s visit • Type of care given • Diagnosis made • Tests ordered • Treatment provided • How much to pay for services

  6. Purposes of Documentation (cont’d) • Legal Record • Patient records = legal documents • Admissible as evidence in court proceedings • Useful in defending against charges of: • Improper care • Malpractice • Needed when patient makes accident or injury claims

  7. Purposes of Documentation (cont’d) • Education • Training of new people in the field using patient records • Used in clinical portion of many health education programs

  8. Purposes of Documentation (cont’d) • Research: Useful Data Gained From Patient Records • Significant similarities in disease presentation • Contributing factors • Effectiveness of therapies

  9. Computerized Documentation • Reasons for Conversion to Computer Documentation • Advances in: • Computer technology • Medical recordkeeping software • File-transfer security

  10. Computerized Documentation (cont’d) • Advantages of Computerized Documentation • Ease of access to data • Multiple users simultaneously • Different locations • Various devices • Easy storage & retrieval; faster recording of data • Nearly unlimited file space • Easy back-up for security • Easy to add or attach info • Improved legibility

  11. Computerized Documentation (cont’d) • Guidelines for Safe Computer Recordkeeping • Don’t share passwords/computer signature • Don’t leave logged-on terminal unattended • Follow protocol for correcting errors • Allow only authorized personnel to create, change, or delete files • Back up records regularly

  12. Computerized Documentation (cont’d) • Guidelines for Safe Computer Recordkeeping (cont’d) • Don’t leave patient info displayed on monitor in view of others • Keep running log of electronic copies made of files • Never use unencrypted email to send protected health info • Follow confidentiality procedures for sensitive material

  13. Types of Information in Patient Records • Admission Sheet • Basic patient data collected before visit • Sometimes mailed to patient to be completed before visit • Demographic & insurance info • Must be updated by patient regularly • Scan or photocopy of patient’s insurance card required

  14. Types of Information in Patient Records (cont’d) • Graphic Sheet • History of patient’s vital signs & dates taken • Vital signs recorded • Respiration rate • Blood pressure • Pulse • Temperature • Weight • Helps provider quickly spot changes over time • Paper vs. computer-generated version

  15. Types of Information in Patient Records (cont’d) • Physician’s Orders • Orders for: • Medications • Treatments • Tests • Follow-up care • Very precise & detailed • Covers: • Medication dosages • Treatment specifics • Type of testing • Dates for follow-up • Auto. transmission to: • Pharmacists • Specialists • Lab technicians

  16. Types of Information in Patient Records (cont’d) • Progress Notes • Record of each contact provider has with patient • Includes communication via: • In person • Phone • Mail • Email • Covers patient’s treatment, progress, & any issues • Electronic format most effective

  17. Types of Information in Patient Records (cont’d) • Medical History and Examination Sheet • Patient history • Family history • Social history • Results of physical examination • Current medical condition

  18. Types of Information in Patient Records (cont’d) • Patient History Information • Allergies • Immunizations • Childhood diseases • Current & past medications • Previous illnesses • Surgeries • Hospitalizations

  19. Types of Information in Patient Records (cont’d) • Family History Information • Familial diseases • Cause of death in family members

  20. Types of Information in Patient Records (cont’d) • Social History Information • Marital status • Occupation • Education • Hobbies • Diet • Alcohol & tobacco use • Sexual history • Guide for patient education

  21. Types of Information in Patient Records (cont’d) • Reports • Blood tests • Electrocardiographs (EKGs) • X-rays • Computed tomography (CT) scans • Magnetic resonance images (MRIs) • Copies of consultation reports

  22. Types of Information in Patient Records (cont’d) • Correspondence and Miscellaneous Documentation • Correspondence between providers & patient • Correspondence about patient received from other providers • Signed consent forms (HIPAA privacy notice) • Instructions regarding end-of-life decisions: • Organ donation form • Living will • Durable power of attorney for health care

  23. Characteristics of Good Medical Documentation • Accuracy • Only facts • Correct: • Spelling • Medical terms • Abbreviations & acronyms • Errors marked through, labeled with “error,” initialed, & dated • Recorded in the correct patient’s record

  24. Characteristics of Good Medical Documentation (cont’d) • Completeness • All relevant data • All phone messages, emails, & other correspondence • All conversations between patient & providers • All notes related to patient’s care • All supporting documentation for reports or tests (x-rays)

  25. Characteristics of Good Medical Documentation (cont’d) • Conciseness • Only relevant information • Partial sentences & phrases • Refer to patient as “patient,” not by name • Universal abbreviations & acronyms

  26. Characteristics of Good Medical Documentation (cont’d) • Legibility • Neat, legible hand writing to avoid mistakes & miscalculations

  27. Characteristics of Good Medical Documentation (cont’d) • Organization • Problem-oriented medical record (POMR) • Source-oriented medical record (SOMR) • Most recent info appears first • Date & time stamp, initials on all entries

  28. Types of Progress Notes • Overview • Three types: • Narrative notes • SOAP notes • Charting by exception • Column vs. no column format • Electronic vs. handwritten • Date, time, signature, & credentials required

  29. Types of Progress Notes (cont’d) • Narrative Notes • Oldest & least structured type • Paragraph format • Covers: • Contact with patient • What was done for patient • Outcomes • Time-consuming to write & difficult to read

  30. Types of Progress Notes (cont’d) • SOAP Notes • Subjective data • Statements from patient describing condition • Symptoms experienced • Objective data • Data that provider can measure, see, feel, or smell • Test results • Vital signs

  31. Types of Progress Notes (cont’d) • SOAP Notes (cont’d) • Assessment • Patient’s diagnosis • Possible disorders to be ruled out • Plan • Description of what should be done • Diagnostic tests • Treatments • Follow-up

  32. Types of Progress Notes (cont’d) • Sample notes in the SOAP format

  33. Types of Progress Notes (cont’d) • Charting by Exception • Covers only significant or abnormal findings • Decreased charting time • Greater emphasis on significant data • Easy retrieval of significant data • Timely bedside charting • Standardized assessment • Greater interdisciplinary communication • Better tracking of important patient responses • Lower costs

  34. Military Time • A 24-hour cycle • Counts hours of day from: • 0000 (12:00 am) to • 2359 (11:59 pm) • Prevents confusion between am & pm times • Use digital watch with military time to make mental shift

More Related