Chapter 17: Medical Documentation

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