chapter 17: medical documentation
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 17: Medical Documentation
Chapter 17: Medical Documentation
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Purposes of DocumentationPurposes 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
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Purposes of Documentation (cont’d)Purposes of Documentation (cont’d)
• Assessment– Vital signs
• Respiration rate
• Blood pressure
• Pulse
• Temperature
– Circumstances surrounding visit
– Symptoms experienced
– Medical history
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Purposes of Documentation (cont’d)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
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Purposes of Documentation (cont’d)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 © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Purposes of Documentation (cont’d)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
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Purposes of Documentation (cont’d)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
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Purposes of Documentation (cont’d)Purposes of Documentation (cont’d)
• Research: Useful Data Gained From Patient Records
– Significant similarities in disease presentation
– Contributing factors
– Effectiveness of therapies
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Computerized DocumentationComputerized Documentation
• Reasons for Conversion to Computer Documentation
– Advances in:
• Computer technology
• Medical recordkeeping software
• File-transfer security
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Computerized Documentation (cont’d)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
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Computerized Documentation (cont’d)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
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Computerized Documentation (cont’d)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
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Types of Information in Patient RecordsTypes 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
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Types of Information in Patient Records (cont’d)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
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Types of Information in Patient Records (cont’d)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
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Types of Information in Patient Records (cont’d)Types of Information in Patient Records (cont’d)
• Progress Notes
– Record of each contact provider has with patient
– Includes communication via:
• In person
• Phone
– Covers patient’s treatment, progress, & any issues
– Electronic format most effective
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Types of Information in Patient Records (cont’d)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
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Types of Information in Patient Records (cont’d)Types of Information in Patient Records (cont’d)
• Patient History Information
– Allergies
– Immunizations
– Childhood diseases
– Current & past medications
– Previous illnesses
– Surgeries
– Hospitalizations
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Types of Information in Patient Records (cont’d)Types of Information in Patient Records (cont’d)
• Family History Information
– Familial diseases
– Cause of death in family members
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Types of Information in Patient Records (cont’d)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
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Types of Information in Patient Records (cont’d)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
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Types of Information in Patient Records (cont’d)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
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Characteristics of Good Medical DocumentationCharacteristics 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
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Characteristics of Good Medical Documentation (cont’d)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)
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Characteristics of Good Medical Documentation (cont’d)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
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Characteristics of Good Medical Documentation (cont’d)Characteristics of Good Medical Documentation (cont’d)
• Legibility
– Neat, legible hand writing to avoid mistakes & miscalculations
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Characteristics of Good Medical Documentation (cont’d)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
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Types of Progress NotesTypes 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
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Types of Progress Notes (cont’d)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
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Types of Progress Notes (cont’d)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
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Types of Progress Notes (cont’d)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
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Types of Progress Notes (cont’d)Types of Progress Notes (cont’d)
• Sample notes in the SOAP format
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Types of Progress Notes (cont’d)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
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Military TimeMilitary 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
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