Medical Documentation Rules

1. Medical Documentation Rules

2. Medical Documentation RulesGeneral principles The documentation of each patient encounter should include: Chief complaint • Relevant history of present illness(HPI) • Physical examination • Findings • Prior diagnostic test results • Assessment, clinical impression ordiagnosis. • Plan for care • Date and legible identity of the observer.

3. Medical Documentation RulesGeneral principles… • The rationale for ordering diagnostic andotherancillary services should be easily inferred • Past and present diagnoses should be accessible to the treating and/or consulting physician • Appropriate health risk factors should be identified • The patient’s progress,response to and changesin treatment, and revision of diagnosis should bedocumented.

4. Medical Documentation Rulesgeneral principles… • Codes reported on the health insurance claim form or billing statement should be documented in the medical record. • Patient’s confidentionality • Plan for care should be recorded and include patient teaching and monitoring. • Dosage and treatment schedule

5. Medical Documentation Rulesgeneral principles… • Draw a line on mistakes, never erase the data • Record counsulting:request,render,report.

6. Medical Documentation Rulesdocumentation of history • The levels of E/M services are based on four types of history: • Problem Focused • Expanded problem focused • Detailed • comprehensive

7. Medical Documentation Rulesdocumentation of history… • Each types of history includes the following elements: • Chief complaint(CC) • History of present illness(HPI): • Past, family and/or social history(PFSH) • Review of systems(ROS)

8. Medical Documentation Rules • Chief complaint

9. Medical Documentation Rules chief complaint • The CC is a concise statement describing the symptom,problem,condition,diagnosis,physician recommended return,or other factor that is the reason for the encounter.

10. Medical Documentation RulesHistory of present illness(HPI) • HPI is a chronological description of the development of the patient’s present illness from the first and/or symptom or from the previous encounter to the present. It includes the following elements:

11. Location Quality Severity Duration Timing context Modifying factors Associated signs and symptoms. Medical Documentation RulesHPI

12. Medical Documentation Rulesdocumentation of history • The levels of E/M services are based on four types of history: • Problem Focused • Expanded problem focused • Detailed • comprehensive

13. Medical Documentation RulesPast, Family and/or SocialHistory(PFSH) • Past: the patients experiences with illnesses,operations,injuries and treatments. • Family: review of medical events in the family ,(hereditary or place the patient at risk) • Social; an age appropriate review of the past and current activities

16. Documentation of Examination • Inspection • Palpation • Percussion • Auscultation

17. Documentation of Examination

18. Documentation of Examination

19. Documentation of Examination

20. Documentation of examination • The levels of E/M services • Problem Focused • Expanded Problem Focused • Detailed • Comprehensive

21. Documentation of examination • P F:A limited examination of the body areaororgan system. • Exp PF:A limited examination of theaffectedbody area or organ system and othersymptomatic or related organ system(s). • Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s). • Com:a general multi-system examination or complete examination of a single organ system.

22. Documentation of disease coarse • Two methods: • 1-admit note/follow-up note/treatment note/daily note • Progress note • Final note

23. Documentation of Disease coarse • 2-SOAP • Subjective • Objective • Assessment • Plan of treatment

24. Documentation of the complexity of medical decision making • The levels of E/M services recognize four types of medical decision making: • Straight-forward • Low complexity • Moderate complexity • High complexity

25. Documentation of the complexity of medical decision making

26. Documentation of Medical terminology • 1-Diagnostic services • 2-Surgical services

27. Documentation of Medical Terminology • Do not use abbreviation in: • Final examination • Management activities • External causes of emergencies • Death causes

28. Documentation of Medical terminology… • It is recommended do not use abbreviations in: • Discharge…(File summary sheet) • Surgical procedures…(Operation report sheet)

29. Documentation of Medical terminology • It is better to use the complete term at first it appears then use the abbreviations for further refers. • Clarify precisely the anatomic site and don’t use – or + for normal or abnormal findings.

30. Documentation of Medical terminology • Surgical terms: • Simple laceration • Intermediate laceration • Complex lacerations

31. Documentation of Medical • Mention also: • Tools,facilities,and duration of their usage • Kind of incisions; undermining, take down,lysis of adhesions( different tariff and codes). • Patient position;lithotomy,dorsal,vaginal…

32. Documentation of Medical terminology… • RUQ,LUQ,RLQ,LLQ • Right hypochondriac • Left hypochondriac, epigastric,right lumbar, left lumbar,umblical,right iliac,left iliac,hypogastric

33. Documentation Rules • Document while or just after performance. • Do not ask the others to complete your document.