Chapter 11: Medical Documentation - Amazon S3 · – Health care audit: ... – Social history – Results of physical examination ... LWW PPT Slide Template Master Author: Dale Gray

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 11: Medical Documentation


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


Purposes of Documentation (cont’d)

• Assessment

– Vital signs

• Respiration rate

• Blood pressure

• Pulse

• Temperature

– Circumstances surrounding visit

– Symptoms experienced

– Medical history



• Quality Assurance

– Quality of care patient receives

– Competence of professionals providing care

– Health care audit: random review of patient records by committee



• 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



• 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



• Education

– Training of new people in the field using patient records

– Used in clinical portion of many health education programs



• Research: Useful Data Gained From Patient Records

– Significant similarities in disease presentation

– Contributing factors

– Effectiveness of therapies


Computerized Documentation

• Reasons for Conversion to Computer Documentation

– Advances in:

• Computer technology

• Medical recordkeeping software

• File-transfer security


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



• 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



• 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


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


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



• 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



• 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



• Medical History and Examination Sheet

– Patient history

– Family history

– Social history

– Results of physical examination

– Current medical condition



• Patient History Information

– Allergies

– Immunizations

– Childhood diseases

– Current & past medications

– Previous illnesses

– Surgeries

– Hospitalizations



• Family History Information

– Familial diseases

– Cause of death in family members



• Social History Information

– Marital status

– Occupation

– Education

– Hobbies

– Diet

– Alcohol & tobacco use

– Sexual history

– Guide for patient education



• Reports

– Blood tests

– Electrocardiographs (EKGs)

– X-rays

– Computed tomography (CT) scans

– Magnetic resonance images (MRIs)

– Copies of consultation reports



• 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


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


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)



• Conciseness

– Only relevant information

– Partial sentences & phrases

– Refer to patient as “patient,” not by name

– Universal abbreviations & acronyms



• Legibility

– Neat, legible hand writing to avoid mistakes & miscalculations



• Organization

– Problem-oriented medical record (POMR)

– Source-oriented medical record (SOMR)

– Most recent info appears first

– Date & time stamp, initials on all entries


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


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



• 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



• 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



• Sample notes in the SOAP format



• 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


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

Chapter 11: Medical Documentation - Amazon S3 · – Health care audit: ... – Social history – Results of physical examination ... LWW PPT Slide Template Master Author: Dale Gray

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