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

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

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)

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

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

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

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

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

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

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

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.

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

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.

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

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.

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

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

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

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

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.

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.

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.

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.

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

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

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

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

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

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.

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

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

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

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

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

Specialty Diagnostic Services Cardiology reports Neurology reports Surgical services

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

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

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

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.

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.

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

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

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.

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

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

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.

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

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.

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

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

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

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

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.

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.

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

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

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

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

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

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.

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

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

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.

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.

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

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

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

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

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

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

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

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

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

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.

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

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

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