Chapter 11: 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 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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