1. Chapter 11: Medical Documentation

2. 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

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

4. 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

5. 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

6. 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

7. 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

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

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

10. 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

11. 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

12. 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 to send protected health info
Follow confidentiality procedures for sensitive material

13. 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

14. 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

15. 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

16. 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
Covers patient’s treatment, progress, & any issues
Electronic format most effective

17. 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

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

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

20. 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

21. 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

22. 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

23. 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

24. Characteristics of Good Medical Documentation (cont’d)
Completeness
All relevant data
All phone messages, s, & other correspondence
All conversations between patient & providers
All notes related to patient’s care
All supporting documentation for reports or tests (x-rays)

25. 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

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

27. 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

28. 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

29. 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

30. 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

31. 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

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

33. 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

34. 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