Medical Documentation CHAPTER 17

Purposes of Documentation  Communication  Most patients receive care from more than one source  Allows all health care providers to have access to the same, up-to-date information  See scenario on page 280

Purposes of Documentation  Assessment  Vital signs  Circumstances surrounding the visit  Symptoms experienced  Medical History  This allows medical professionals to compare patient data from one visit to another

Purposes of Documentation  Quality Assurance  Provide evidence of the quality care the patient receives  Shows competence of the professionals who provided that care  For example: during a health care audit, a committee may review patient charts at random to ensure that certain care standards are met  If deficiencies are found, in-service training can be provided

Purposes of Documentation  Reimbursement  Medical records verify the care the patient received  This determines how much the insurance company will pay and how much the doctor will be paid  Medical coding

Purposes of Documentation  Legal Record  Medical records are LEGAL DOCUMENTS!  “Anything you write can be used against you in the court of law”  Can be used as evidence in court proceedings  Can also be used when a patient makes an accident or injury claim.

Purpose of Documentation  Education  Can be used as a tool to help train new people in the field  May be used during the clinical portion of many health education programs

Purpose of Documentation  Research  Researchers often learn how best to recognize or treat health problems by examining similar cases.  Data gathered from groups of patient records is helpful in determining:  Significant similarities in disease presentation  Contributing factors  Effectiveness of therapies

Computerized Documentation  EMR – allows multiple people to view the same chart, regardless of location  Advantages include:  Info is easy to store/retrieve  Nearly unlimited file space  Easy to back up for added security  Info is easily added or attached  Charting is easier to read  Data and be entered more quickly when typed than written  

What’s in a Patient Record?  Admission Sheet  Demographic Info  Insurance Info  Graphic Sheet  History of patient’s vital signs in date order

What’s in a Patient Record?  Physician’s Orders  Any orders for patient care including: medication, treatments, tests, follow up care  Progress Notes  Record of each contact the provider has with the patient  Snapshot of patient’s treatment, progress and any other issues

What’s in a Patient Record?  Medical History and Exam Sheet  Patient History  Family History  Social History  Results of physical exam  Current medical condition

What’s in a Patient Record  Reports  Lab or any other test results

What’s in a Patient’s Record  Correspondence and Miscellaneous Documentation  Copies of all correspondence regarding patient’s care  Letters from physician to patient  Letters to/from specialists  Consent forms  Advance directives

Characteristics of Med. Documentation  Accuracy  All entires include only facts  Correct spelling, medical terms, abbreviations and acronyms are used  Errors are marked with a single line, noted “error” and initialed

Characteristics of Med. Documentation  Completeness  Must include all relevant data to see a “picture” of the patient  Include patient concerns, questions

Characteristics of Med. Documentation  Conciseness  Although entries should be complete, they should also be brief  Use approved abbreviations  When in doubt, spell it out

Characteristics of Med. Documentation  Legibility  If what you write is difficult to read, mistakes will be made!

Characteristics of Med. Documentation  Organization  Problem Oriented Medical Record (POMR) – organizes info by patient problem  The patient’s medical problem is listed on the 1 st page of the record and assigned a number.  All documentation about that problem is assigned the same number

Characteristics of Med. Documentation  Organization  Source-Oriented Medical Record- groups info by type instead of by problem  All radiology reports together, all lab reports together, etc  Most recent information always appears first  All pages should have a date and be signed by a medical professional  Data should only be entered after an event has occured

Types of Progress Notes  Narrative Notes  Oldest and least structured medical documentation style  Paragraph indicating the contact with patient, what was done, and the outcomes  SOAP Notes  Subjective Data  Objective Data  Assessment  Plan

Types of Progress Notes  Charting by Exception  Becoming more common with electronic charting  Documents only significant or abnormal findings  Many benefits  More time with patient  Charting is done sooner (closer to patient contact)  Important data is found easily

Military Time  24 hour time  0000 – 2359  12:00 AM – 11:59 PM  Decreases confusion between AM and PM