1. Documentation for Acute Care
Chapter 3
Content of the Acute Care Health Record

2. Documentation in acute care records includes:
Administrative information – name, address, age, consents, etc.
Clinical information – medical history, diagnostic/therapeutic orders, observations, etc.

3. Hospital records should conform to three healthcare data sets:
Uniform Hospital Discharge Data Set (UHDDS)
Data Elements for Emergency Department Systems (DEEDS)
Uniform Ambulatory Care Data Set (UACDS)

4. Admitting and Demographic Information
Demographic Data – used to confirm the identity of the patient
Financial Data – used to complete the claims forms for third-party payers
Clinical Data – used as the basis of care plans and determinations of medical necessity

5. Consents, Authorizations, and Acknowledgments
Consents related to clinical care
Implied consent
Expressed consent
Consent to treatment
Consents related to confidential health information
Notice of privacy practices
Acknowledgments
Advance directives
Patient’s rights information

6. Clinical Information
The most important function of the acute care record
Physicians, surgeons, and nurses are the main authors of clinical documentation.

7. Medical History
A summary of the patient’s illness from his/her point of view
Includes:
Chief complaint
Present illness
Past medical history
Social and personal history
Family medical history
Review of systems

8. Physical Examination
Provides objective information on the patient’s condition.
Initial physical examination should be performed within 24 hours of admission.
For planned admissions, the physical examination may also be performed within 7 days before admission

9. Physical Examination – cont’d:
An assessment of the main body systems by:
Observing the patient’s physical condition and behavior
Palpating the patient’s body
Tapping the patient’s chest and abdomen
Listening to the patient’s breath and heart sounds
Taking the patient’s vital signs

10. Physical Examination – cont’d
Readmitted patients to the same hospital for treatment of the same condition within 30 days after the previous admission may use an interval note in place of a complete history and physical.
Includes:
Information about the patient’s current complaint
Any relevant changes in condition
Physical findings since the last admission

11. Physician Orders
Instructions that the physician gives to other healthcare professionals who perform diagnostic and therapeutic procedures, provide nursing care, formulate and administer medications, and provide nutritional services to the patient.
Must be signed and dated by the ordering physician.

12. Types of Physician Orders
Written by the physician
Verbal
Telephone
Standing
Special
DNR
Use of seclusion or restraints
Discharge

13. Progress Notes
A chronological record of the clinical observations of the patient’s condition and response to treatment during the hospital stay.
Justifies continued care treatment and support the medical necessity of the services being provided to the patient.

14. Progress notes include:
Patient’s health status on admission and discharge
Findings of physical examinations
Observations of vital signs, including pain assessments
Chronological record of the patient’s course, including response to treatment
Results of laboratory and imaging procedures along with interpretations and plans for follow-up
Requests for consultations and reasons for the requests
Records of patient and family education

15. Consultation reports
One physician seeks the advice of another physician before making decisions about diagnoses and treatment.
The principal physician documents the request for a consultation in the patient’s records.
The consulting physician then documents results of his/her examination.

16. Consultation records include:
Name of the physician who requested the consultation and the reason for the consultation
Date and time the consultant examined the patient
Pertinent findings of the examination
Consultant’s opinion, diagnosis, or impression
Recommendations for diagnostic tests and/or treatment
Signature, credentials, and specialty of the consultant

17. Nursing Services Nursing assessments Care plans
Clinical practice guidelines and protocols
Case management reports
Progress notes
Medication records
Flow charts
Transfer records

18. Nursing Assessment documents the patients’:
Reason for being in the hospital
Current and past illnesses
Cognitive status
Functional status
Psychosocial status
Family history
Nutritional status
Drug allergies and sensitivities
Current medications

19. Care Plans include: Initial assessment
Statement of treatment goals based on the patient’s needs and diagnosis
Description of the activities planned to meet the treatment goals
Patient education goals
Discharge planning goals
Timing of periodic assessments to determine progress toward meeting the treatment goals
Indicators of the need for reassessing the plan to address the patient’s response to treatment and/or development of complications

20. Clinical Practice Guidelines and Protocols
Clinical practice guidelines – step-by-step, knowledge-based procedures designed to standardize clinical decision making.
Clinical protocols – specific instructions for performing clinical procedures established by authoritative bodies, such as medical staff committees
Clinical pathways – tools designed to coordinate multidisciplinary care planning for specific diagnoses and treatments.

21. Case Management Reports
The process of ongoing and concurrent review performed to ensure the necessity and effectiveness of clinical services being provided to the patient.

22. 5 Step Case Management Process
Perform preadmission care planning.
Perform care planning at the time of admission.
Review the progress of care.
Conduct discharge planning.
Conclude postdischarge planning.

23. Nursing Progress Notes
Provide a complete record of the patient’s care and response to treatment.
Vital signs are recorded every 2 hours, at a minimum
Every 8 hours a complete assessment of the patient’s condition is documented.

24. Medication Records Date and time each drug was administered
Name of the medication
Form of administration
Medication’s dosage and strength
Signed and dated by the person who administered the drug

25. Flow charts Graphic illustrations of data and observations.
Used in addition to narrative progress notes
Input/output patterns
Blood glucose records
Pain assessments

26. Transfer records
Records the patient’s movement from one hospital department to another.

27. Nutritional records
Based on an initial assessment by a registered dietitian.
Assessment includes:
Patient’s diet history
Weight and height
Appetite and food preferences
Information on food sensitivities and allergies

28. Nutritional Care Plans include:
Confirmation that a diet order for the patient was issued within 24 hours of admission
Summary of the patient’s diet history and/or the nutritional assessment performed upon admission
Documentation of nutritional therapy and/or dietetic consultation
Timely and periodic assessments of the patient’s nutrient intake and tolerance of the prescribed diet
Nutritional discharge plan and patient instructions
Documentation that a copy of the plan was forwarded to the facility to which the patient was transferred after discharge from the hospital, if applicable
Dietitian’s signature, credentials, and date

29. Diagnostic and Therapeutic Reports
Routine laboratory analyses of blood and other bodily fluids
X-ray examinations
Other imaging procedures
Surgical explorations, excisions, or resections
Circumstances and findings of these procedures require precise documentation in the form of reports to be placed in the health record.

30. Special consents are required for:
Procedures that involve the use anesthetics
Treatments that involve the use of experimental drugs
Surgical procedures that involve the manipulation of organs and tissues
Procedures that involve a significant risk for complications

31. Special consents Become a permanent part of the record
Include the following:
Patient identification, including name and record number
Name of the procedure to be performed
Description of the procedure to be performed
Date the procedure is to be performed
Patient’s or representative’s signature
Date the consent was signed

32. Ancillary Services Laboratory reports Imaging reports X-rays
Computed tomography
Magnetic resonance imaging
Positron-emission tomography

33. Laboratory reports include:
Patient identification, including name and record number
Name of the test performed
Date the test was performed and time in/time out of the laboratory
Signature of the laboratory technologist or scientist who performed the test
Name of the laboratory where the test was performed
Results of the test

34. Imaging reports include:
Patient identification, including name and record number
Image identification data including image number and hospital number
Physician’s order for the examination, signed and dated
Name of the examination performed
Date the examination was performed
Type and amount of radiopharmaceutical administered, if applicable
Radiologist’s interpretation of the images, with date and signature

35. Specialty Diagnostic Services
Cardiology reports
Neurology reports
Surgical services

36. Cardiology reports Exercise and pharmacological stress tests
Tilt-table tests
Holter monitoring
Electrocardiography
Echocardiography
Cardioraionucleide imaging
Myocardial imaging
Cardiac catheterization

37. Neurology reports Mental status examinations Electroencephalography
Echoencephalography
Cerebral angiography
Myelography
Lumbar puncture

38. Surgical Services Consents for surgery
Preoperative history and physical reports
Anesthesia evaluations and records
Transfusion records
Postoperative progress notes
Recovery room records
Operative reports
Pathology reports
Implant information
Transplantation and organ donation records

39. Consents for surgery
Except in emergency situations, written documentation of the patient’s consent to surgery must be obtained before the operation can begin.
The consent indicates that the surgeon has explained the benefits and risks of the procedure.

40. Preoperative history and physical reports
Except in emergency situations, every surgical patient’s chart must include a report of the a complete history and physical conducted no more than 7 days before the surgery is to be performed.
Advance directives and organ donation forms must also be in the chart.

41. Anesthesia Evaluation and Records
Preoperative anesthesia evaluation
Intraoperative anesthesia record
Postoperative anesthesia record

42. Preoperative anesthesia record
Collects information on the patient’s medical history and current physical and emotional condition
Basis for an anesthesia plan
Type of anesthesia to be used
Addresses the patient’s risk factors, allergies, drug usage
Considers the patient’s general medical condition

43. Intraoperative anesthesia record
Patient identification, including name and record number
Name of the anesthesiologist or nurse-anesthetist
Type and amount of anesthesia administered
Induction mechanisms
Medication log, including gases and fluid administration
Usage of blood products
Placement of lines and monitoring devices
Patient’s reaction to anesthesia
Results of continuous patient monitoring, including vital signs and oxygen saturation levels.

44. Postoperative anesthesia record
Documents any unusual events or complications that occurred during surgery
Documents the patient’s condition at the conclusion of surgery and after recovery from anesthesia

45. Transfusion Record includes:
Type and amount of blood products the patient received and any reaction to them.
The blood group and Rh status of the patient and the donor
The results of cross-matching tests
A description of the transfusion process

46. Postoperative progress notes
The primary surgeon must write a brief progress note immediately after surgery and before the patient leave the operative suite.
This is to communicate postoperative care instructions to recovery room nurses.
Should include the presence or absence of anesthesia-related complications or other postoperative abnormalities, plus the patient’s vital signs and general condition at the end of the operation.

47. Recovery Room Records
Used by nursing staff to document the patient’s reaction to anesthesia and condition after surgery.
Includes:
Level of consciousness
Overall medical condition
Vital signs
Medications given
Intravenous fluids administered

48. Operative Reports
A formal document prepared by the principal surgeon to describe the surgical procedure(s) performed for the patient.
Should be written or dictated immediately after surgery and filed in the health record within 24 hours.

49. Operative report includes:
Patient identification, including name and record number
Patient’s preoperative and postoperative diagnoses and indications for surgery
Descriptions of the procedures performed
Descriptions of all normal and abnormal findings
Descriptions of any specimens removed

50. Operative report includes:
Description of the patient’s medical condition before, during, and after the operation
Estimated blood loss
Descriptions of any unique or unusual events that occurred during the course of surgery
Names of the surgeons and their assistants
Date and duration of the surgery
Signature of principal physician, credentials, and date the report was written

51. Pathology reports
Pathology examinations must be performed on every specimen or foreign object removed or expelled during a surgical procedure.
Includes macroscopic and microscopic evaluation

52. Basic information in pathology reports
Patient identification, including name and record number
Date of examination
Description of the tissue examined
Finding of the microscopic and macroscopic examination of the specimen
Diagnosis
Name, credentials, and signature of the pathologist

53. Implant Information International Implant Registry, created in 1988
Collects information about patients who have received implants worldwide
Information about the type of medical device, its manufacturer, and any product numbers on the device should be included in the operative report.

54. Discharge Summaries Functions:
Ensuring the continuity of future care by providing information to the patient’s primary care physician and any consulting physicians
Providing information to support the activities of the medical staff review committee
Providing concise information that can be used to answer information requests from authorized individuals or entities.

55. Contents of the Discharge Summary
Concise account of the patient’s illness
Course of treatment
Response to treatment
Condition at discharge
Discharge instructions

56. Required data elements at the time of discharge
Name of the physician principally responsible for the patient’s care
Date and time of discharge
Principal and secondary diagnoses
ICD-9-CM code for the external cause of the patient’s injury, if applicable
Diagnostic and therapeutic procedures and the dates on which the procedures were performed
Name of the surgeon or surgeons who performed surgical procedures, if applicable
Disposition of the patient

57. Principal diagnosis
The condition established, after study to have been the main reason for the patient’s admission to the hospital.
Must be documented in the patient’s health record no more than thirty days after discharge.
Must be described completely without the use of symbols or abbreviations

58. Autopsy Reports
Description of the examination of a patient’s body after he/she has died.

59. Specialty Care Documentation
Obstetrical services
Neonatal services
Observation services
Psychiatric services
Rehabilitation services
Reanl dialysis services
Respiratory services
Chemotherapy services
Radiotherapy services

60. Obstetrical Services
Contain documentation elements similar to general health records.
Prenatal care documentation constitutes preadmission history and physical
Cesarean deliveries are operative procedures and need informed consent, operative report and anesthesia documentation.

61. Obstetrical Services
Discharge summaries are not required for normal deliveries, a discharge progress note is sufficient
Labor and delivery record takes the place of an operative report for normal deliveries

62. Labor and delivery record contents:
Patient’s married and maiden name
Patient’s record number
Delivery date
Gender of the infant
Names and credentials of the physician and any assistants
Description of any complications that developed
Type of anesthesia
Name of the person who administered anesthesia
Names of other persons who witnessed the delivery

63. Neonatal Services
Newborn health records are maintained separately from their mothers’ records
In normal deliveries, duplicates much of the information in the mother’s record
Premature infants and others who require ICU after birth require full documentation.

64. Observation Services Considered outpatients
Must include a physician’s order for admission to an observation bed or unit as well as the time and date of the patient’s admission and discharge.

65. Psychiatric services documentation includes:
Demographic data
Source of referral
Reason for referral
Patient’s legal status
All appropriate consents
Admitting psychiatric diagnosis
Psychiatric history
Record of complete patient assessment
Medical history
Physical examination
List of medications
Provisional diagnosis
Written, individualized treatment plan

66. Psychiatric services – cont’d
Documentation of course of treatment and all evaluations and examinations
Multidisciplinary progress notes & conferences
Special treatment procedure documentation
Updates to treatment plans
Documentation of unusual occurrences
Correspondence related to the patient
Discharge/termination summary
Plan for follow-up
Aftercare/posttreatment plan

67. Rehabilitation services documentation requires:
Patient identification data
Pertinent history
Diagnosis of disability
Rehabilitation problems, goals, and prognosis
Reports of assessments
Reports from referring sources
Reports from outside consultations, lab, x-ray, etc
Designation of a manager for the patient’s program

68. Rehabilitation services documentation cont’d
Evidence of the patient’s/family’s participation in decision making
Evaluation reports from every service
Reports of staff conferences
Patient’s total program plan
Signed and dated service and progress notes
Correspondence pertinent to the patient
Release forms
Discharge report
Follow-up report

69. Renal Dialysis Services Documentation Requirements
Patient identification, including name and record number
Diagnosis
Name of the procedure
Duration of the procedure
Date the procedure was performed
Findings/results of the procedure
Name, credentials and signature of the nurse or physician who oversaw the procedure

70. Respiratory Services
Services must be ordered by the patient’s physician
Assessments and treatment plans contain:
Information about the patient’s diagnosis
The services to be provided
The goals of the treatment

71. Chemotherapy services documentation includes:
Patient identification, including name and record number
Diagnosis
Name of the agent and method of administration
Date the procedure was performed
Findings or results of the treatment procedure
Date of report and signature of the oncologist who oversaw the treatment

72. Radiotherapy services documentation includes:
Patient identification, including name and record number
Diagnosis
Name and site of the procedure
Findings or results of the treatment procedure
Date of report and signature of the radiologist who oversaw the treatment

73. Outpatient Services Provided in Acute Care Facilities
Emergency and Trauma Care
Ambulatory Surgery
Diagnostic and therapeutic services

74. Content of the emergency health record:
Patient identification
Time of arrival
Means of arrival
Name of person/organization that transport the patient to the ED
Consent to treatment
Pertinent history
Significant physical findings
Lab, x-ray, EEG, EKG findings
Treatment rendered and results
Conclusions at end of treatment
Disposition of patient
Condition at discharge/transfer
Diagnosis upon discharge
Instructions
Signatures and credentials of caregivers.

75. Ambulatory Surgery
Documentation requirements are the same as inpatient surgical cases.

76. Diagnostic and therapeutic services documentation requirements:
Summary page that lists the patient’s diagnosis, past procedures, medications, and allergies
Results of outpatient procedures

77. Standardized Clinical Data Sets
Identify the data elements that should be collected for every patient
Provide uniform definitions for common terms.
UHDDS
UACDS
DEEDS
EMEDS