Dynamics of Care in Society Written Communication & Medical Documentation 1

Written communication “practical writing”… for a specific purpose, ex: Reports Business letters Interoffice memos Manuals Forms Applications Chart documentation

“Practical Writing” Types Narrative writing…tells what happened, paragraph form, Descriptive writing…details of person, object, event Informative writing…giving directions, explaining how to, answering questions, making something easier to understand, use bullets or steps, Persuasive writing..giving an opinion or stating a point of view and supporting it with reasons in order to persuade the reader to accept or possibly take action on it

Recording and Reporting Record patient information completely & precisely Record information only in secure & appropriate locations Record any action you take concerning a patient (“if it is not documented…it didn’t happen”) Just the facts… Minimize medical jargon (if for a patient)

Get started… get comfortable, be concise, have logical transitions of thought Outline ideas… organize before you write * brainstorm * group similar ideas together * find unifying themes * have a beginning, middle, end Revising…check for… * clarity * sentence & paragraph structure Proofreading… refinement…check for… * grammar, punctuation, spelling * final touches Drafting hints…

Tips for… “Well & Clearly Written” - create an outline to clarify and order your concepts - write a really bad first draft with no rewriting - rewrite, read out loud, rewrite, read again and rewrite - have colleagues comment on your draft - trust feedback from reviewers and rewrite again - let it sit, return for a fresh read out loud, and finalize

Ideas for Learning to Write Better Read examples you like and also review your colleague’s draft papers and edit them. Take course in essay writing - good analysis, clear arguments and exposition, and convincing conclusions. Write for broad audiences too - if you can capture them, you can capture professionals Read your writing out loud and then edit!

For Research Assistance… UCLA Library under services menu tab choose references & research help UCLA Library

MEDICAL DOCUMENTATION

Purposes of documentation in HC 1. Communication among the health care team 2. Assessment (vital signs, hx, symptoms…) 3. Quality Assurance (competence & quality of care) 4. Reimbursement (verification for insurances…) 5. Legal Record (admission of evidence) 6. Education (use for training) 7. Research: Useful Data Gained From Patient Records

Examples: Nurse updates patient’s record with new info from patient Doctor sees nurse’s note & orders cholesterol test Pharmacist views medical history before filling prescription Discharge planner evaluates physical therapist’s notes on progress in ambulation (note the communication process w/in the medical record)

Electronic Medical Records are here…

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 Advantages of Computerized Documentation

Safe Computer Recordkeeping 1.Don’t share passwords/computer signature 2.Don’t leave logged-on terminal unattended 3.Follow protocol for correcting errors 4.Allow only authorized personnel to create, change, or delete files 5.Back up records regularly 6.Don’t leave patient info displayed on monitor in view of others 7.Keep running log of electronic copies made of files 8.Never use unencrypted to send protected health info 9.Follow confidentiality procedures for sensitive material

What you’ll find in the medical record… Admission sheet – general demographic info, insurance info… Graphic sheet – aka Flow sheet - for vital signs… MD orders – for medications, instructions, procedures… Progress notes – on patient’s progress, new or changing info from multiple health care team members Medical history and exam – "Listen to your patient, he is telling you the diagnosis," Sir William Osler, M.D. – Johns Hopkins Allergies, Immunizations, Childhood diseases Current & past medications Previous illnesses, Surgeries, Hospitalizations

Family medical history Reports – test results, lab results, consultations… Psycho-Social History Marital status Occupation Education Hobbies Diet Alcohol, drug & tobacco use/misuse Sexual history Miscellaneous – correspondence, AD, organ donor…

Good Medical Documentation Tips 1.It is accurate (ex. Correct spelling, Errors marked through, labeled with “error,” initialed, & dated…) 2.It is complete (ex. All supporting information – lab results …) 3.It is concise (ex. Only relevant information), just the facts 4.It is legible 5.It is organized (ex. Most recent information first, date stamped…) 6. It is signed, initialed, dated and/or timed *– as required

See article about accurate documentation

Progress Notes Types 1. 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 Assessment Patient’s diagnosis Possible disorders to be ruled out Plan Description of what should be done Diagnostic tests Treatments Follow-up

2. 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 More cost effective

3. Narrative  Paragraph format  Includes: Contact with patient What was done for patient Outcomes  Can be time-consuming to write & difficult to read  It is the oldest & least structured type

Handout… PROPER TELEPHONE COMMUNICATION ANSWERING…. 1.ANSWER PROMPTLY 2.IDENTIFY SELF 3.FIND OUT WHO IS CALLING 4.SPEAK COURTEOUSLY, CLEARLY & PLEASANTLY 5.USE DISCRETION IN RELEASING INFORMATION, REMEMBER CONFIDENTIALITY 6.END CALL GRACEFULLY

Handout… SCREENING…. 1.DON’T OFFEND CALLER 2.ASK WHO IS CALLING, NATURE OF BUSINESS OR EMERGENCY 3.ANSWER QUESTIONS TACTFULLY 4.ASK IF MESSAGE CAN BE LEFT 5.PLACE ON HOLD AND GET GUIDANCE, HELP IF NEEDED

TAKING A MESSAGE…. 1.OBTAIN TIME, DATE, NAME OF CALLER, PURPOSE OF CALL 2.TAKE NOTES, REPEAT INFO BACK TO CALLER FOR ACCURACY 3.USE MESSAGE FORMS & FOLLOW THOUGH WITH PASSING MESSAGE TO CORRECT RECIPIENT. Handout…

HANDLING COMPLAINTS…. 1.STAY CALM 2.GATHER INFO 3.BE SYMPATHETIC 4.OFFER TO FIND OUT WHAT CAN BE DONE 5.END CALL ON PLEASANT NOTE Handout…

Assign: What is the message for each? Handout…