Chapter 11 Medical Documentation Copyright 2012 Wolters Kluwer

Purposes of Documentation • Communication – Up-to-date patient information for all providers – Patient

Purposes of Documentation (cont’d) • Assessment – Vital signs • Respiration rate • Blood

Purposes of Documentation (cont’d) • Quality Assurance – Quality of care patient receives –

Purposes of Documentation (cont’d) • Reimbursement – Verification of care provided so provider can

Purposes of Documentation (cont’d) • Legal Record – Patient records = legal documents –

Purposes of Documentation (cont’d) • Education – Training of new people in the field

Purposes of Documentation (cont’d) • Research: Useful Data Gained From Patient Records – Significant

Computerized Documentation • Reasons for Conversion to Computer Documentation – Advances in: • Computer

Computerized Documentation (cont’d) • Advantages of Computerized Documentation – Ease of access to data

Computerized Documentation (cont’d) • Guidelines for Safe Computer Recordkeeping – Don’t share passwords/computer signature

Computerized Documentation (cont’d) • Guidelines for Safe Computer Recordkeeping (cont’d) – Don’t leave patient

Types of Information in Patient Records • Admission Sheet – Basic patient data collected

Types of Information in Patient Records (cont’d) • Graphic Sheet – History of patient’s

Types of Information in Patient Records (cont’d) • Physician’s Orders – Covers: • Medication

Types of Information in Patient Records (cont’d) • Progress Notes – Record of each

Types of Information in Patient Records (cont’d) • Medical History and Examination Sheet –

Types of Information in Patient Records (cont’d) • Patient History Information – Allergies –

Types of Information in Patient Records (cont’d) • Family History Information – Familial diseases

Types of Information in Patient Records (cont’d) • Social History Information – Marital status

Types of Information in Patient Records (cont’d) • Reports – Blood tests – Electrocardiographs

Types of Information in Patient Records (cont’d) • Correspondence and Miscellaneous Documentation – Correspondence

Characteristics of Good Medical Documentation • Accuracy – Only facts – Correct: • Spelling

Characteristics of Good Medical Documentation (cont’d) • Completeness – All relevant data – All

Characteristics of Good Medical Documentation (cont’d) • Conciseness – Only relevant information – Partial

Characteristics of Good Medical Documentation (cont’d) • Legibility – Neat, legible hand writing to

Characteristics of Good Medical Documentation (cont’d) • Organization – Problem-oriented medical record (POMR) –

Types of Progress Notes • Overview – Three types: • Narrative notes • SOAP

Types of Progress Notes (cont’d) • Narrative Notes – Oldest & least structured type

Types of Progress Notes (cont’d) • SOAP Notes – Subjective data • Statements from

Types of Progress Notes (cont’d) • SOAP Notes (cont’d) – Assessment • Patient’s diagnosis

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

Types of Progress Notes (cont’d) • Charting by Exception – Covers only significant or

Military Time • A 24 -hour cycle • Counts hours of day from: –

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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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Purposes of Documentation (cont’d) • Assessment – Vital signs • Respiration rate • Blood pressure • Pulse • Temperature – Circumstances surrounding visit – Symptoms experienced – Medical history Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Purposes of Documentation (cont’d) • Research: Useful Data Gained From Patient Records – Significant similarities in disease presentation – Contributing factors – Effectiveness of therapies Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Computerized Documentation • Reasons for Conversion to Computer Documentation – Advances in: • Computer technology • Medical recordkeeping software • File-transfer security Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Information in Patient Records (cont’d) • Physician’s Orders – Covers: • Medication dosages Orders for: • Medications • Treatment specifics • Treatments • Type of testing • Tests • Dates for follow-up • Follow-up care – – Very precise & detailed – Auto. transmission to: • Pharmacists • Specialists • Lab technicians Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Information in Patient Records (cont’d) • Patient History Information – Allergies – Immunizations – Childhood diseases – Current & past medications – Previous illnesses – Surgeries – Hospitalizations Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Types of Information in Patient Records (cont’d) • Family History Information – Familial diseases – Cause of death in family members Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Characteristics of Good Medical Documentation (cont’d) • Legibility – Neat, legible hand writing to avoid mistakes & miscalculations Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins