Documentation in Medicine

1
MEDICAL DOCUMENTATION

• Dr.T.V.Rao MD

2
What is Documentation

• Anything written or printed
• Relied on as a record of proof for authorized
  persons
• Vital part of professional practice

3
Purposes of Documentation

• Quality of care
• provides evidence that care was necessary
• describes responses to care
• describes any changes made in plan of care
• Coordination of care
• plan interventions
• decision making about ongoing interventions
• evaluation of patient's progress
• used by all team members

4
Purposes of Documentation in Medicine

• Clinical records are reviewed to ensure the
  facility meets the required standards assessed
  for ongoing compliance

5
Importance of Medical Documentation

• Proper and adequate medical documentation is
  essential for quality of medical care and health
  care services throughout the industry, from
  receiving proper and correct treatment

6
Who Writes Medical Documents

• Medical documentation or documentation of a
  medical condition means a statement from a
  licensed physician or other appropriate
  practitioner providing information the agency
  considers necessary

7
Function of Medical Documentation is Important
When Referring Patients

• Why is important medical documentation vital?
  Without it, your health care would be
  compromised. One doctor wouldn't know what
  another doctor was doing. Without adequate
  documentation of visits, lab tests, treatments or
  surgeries, quality of care would certainly be
  erratic and potentially deadly. Medical
  documentation generally provides all the
  information about a specific patient that any
  doctor looking at a medical record would need to
  know to treat that patient

8
Documentation increases Patient Care

• Medical record documentation is required to
  record pertinent facts, findings, and
  observations about an individual's health history
  including past and present illnesses,
  examinations, tests, treatments, and outcomes.
  The medical record chronologically documents the
  care of the patient and is an important element
  contributing to high quality care.

9
General Principles

• A. The medical record should be complete and
  legible.
• B. The documentation of each patient encounter
  should include
• reason for the encounter and relevant history,
  physical examination findings and prior
  diagnostic test results
• assessment, clinical impression or diagnosis
• plan for care and
• Date and legible identity of the observer.

10
Ethics and Documentation

• Adequate medical documentation assures patient
  confidentiality and ensures that standards of
  care are being met. Doctors and other medical
  personnel have an obligation to treat illnesses
  to the best of their ability in regard to
  information documented in a patient's medical
  record.

11
Patients Health Care Information a Vital Document

• The patient's history is a vital piece of
  information that enables physicians to determine
  the best diagnosis and treatment plan for that
  individual, based on information found in the
  medical record.

12
Must contain Subjective/History

• Past Medical History (PMH)
• Medications Allergies
• Allergies Medications
• Illnesses Pertinent past history
• Doctor Last oral intake
• Surgery Events leading to illness or injury

13
Common standards for documentation

• assessment
• plan of care medical orders
• progress notes
• discharge summary

14
Skills Used in Documentation

• Cognitive
• Technical Interpersonal Ethical/Legal

15
A Documents of all Critically ill patients be
given due care in filing

• Clinical findings from the most recent medical
  evaluation, including any of the following which
  have been obtained Findings of physical
  examination results of laboratory tests X-rays
  EKG's ECG MRI CT Scans and other special
  evaluations or diagnostic procedures and, in the
  case of psychiatric evaluation of psychological
  assessment, the findings of a mental status
  examination and the results of psychological
  tests, if appropriate must be filed with due care

16
Good Documentation Increases Legal Protection

• Peer review
• Requirements for reimbursement
• Legal protection
• Research continuing education

17
Patient Records Helps in Planning Your Future
Actions

• Communication
• Care Planning
• Quality Review
• Research
• Decision Analysis
• Education
• Legal Documentation
• Reimbursement

18
Residents should Document

• Computer-based Records
• Standardization
• Legible
• Follow policies and procedures to ensure
  confidentiality

19
Fill all Laboratory Requests with Sense of
Responsibility

• Name xxxx Age Sex
• IP/ OP No xyz Time Date
• Ward xx123 Urgent / Routine
• Nature of specimen
• Investigation needed
• 
  Doctor/Staff
• Contact
  No 1234567

20
Patients Records are confidential do not discuss
without purpose
21
Correct your Mistakes with Sense and Legality

• Never use whitener
• Never scratch out
• Draw a line through the mistake
• Initial above the mistake

22
Document the Patient Record with Institutional
Protocols

• Initial evaluation
• Age and gender (Pt. is 20 y.o. white
• male)
• Prior level of function (including
• occupation/ functional status
• Social history (Lifestyle, home
• situation, home accessibility)
• Emotions/attitudes
• Direct quotes (to illustrate
• confusion, denial, attitudes, etc.)
• Chief complaints or complains of
• MOI
• Onset (insidious or traumatic)
• DOI

23
Documentation Standards Vary from Situation and
Specialties

• Pain scale (1-10)
• Location and type of pain (burning,
• stinging, sharp, dull, radiating, etc.)
• Aggravates and alleviates pain
• Details since onset (history of
• injury)
• PMHx
• PRx (Past treatment)
• Date of surgery (DOS)
• Special tests (x-rays, MRI, CT scan)
• Rule out
• Meds and allergies
• Patient and/or family goals

24
Every Case sheet should contain a Minimal Data

• Personal info age, sex, occupation, training,
  family...
• Risk factors tobacco, alcohol, life styles...
• Allergies and drug reactions
• Problem list
• Disease history diseases, operations. . .
• The disease process main problem, history, exam,
  lab.
• Management plan advice, education, medication. .
  .
• Progress notes in the P S O A P format

25
Rules in keeping medical records as it requires
Confidentiality

• Personal biographical data include the address,
  employer, home and work telephone numbers and
  marital status.
• All entries in the medical record contain the
  authors identification. Author identification
  may be a handwritten signature, unique electronic
  identifier or initials.
• All entries are dated.
• The record is legible to someone other than the
  writer.
• Significant illnesses and medical conditions are
  indicated on the problem list.
• Medication allergies and adverse reactions are
  prominently noted in the record. If the patient
  has no known allergies or history of adverse
  reactions, this is appropriately noted in the
  record.

26
Record all the Progress of the Patient As
Things can go Wrong

• Future notes
• Response to treatment and rehab.
• Reassessing subjective information from previous
  notes
• Change in function
• Change in pain (location, type)
• Patient compliance issues

27
Legal Aspects of Charting

• Do not erase, use white-out, or scribble out
  errors
• Do not write retaliatory or critical comments do
  not place blame on your colleagues
• Correct all errors promptly
• Spell correctly
• Record all facts in objective terms

28
Court Believes your Documents only

• Document completely in court - if it's not
  documented, it wasn't done

29
Legal Aspects of Charting

• Be accurate about time chart as soon as
  possible after an event
• Document omissions (med not given or treatment
  not completed) reason actions taken
• Do not leave blank spaces
• Record legibly in black ballpoint pen

30
Legal Aspects of Charting

• Use only approved abbreviations
• Record clarification requests /or corrections
• Chart only for yourself
• Avoid vague statement
• Begin with time and end with appropriate
  signature

31
In order to prevent legal problems

• Record everything you do (including phone
  consultations)
• Apply guidelines LEARN FROM YOUR SENIORS OR
  CONSULTANTS
• Don't use erasable pencils
• Dont use humiliating expressions

32
Why to keep records?

• Helps in medical decisions
• (is the size of a lymph node or nodule
  increasing with time?)
• Helps to share responsibility with the patient
• Legal obligation.
• Protects the patient as well as doctor in front
  of the court

33
Still you want to Correct the Errors

• When a correction becomes necessary, merely draw
  a single line through the entry so that the
  original entry is still readable. Make a notation
  explaining the correction, or directing the
  reader to the appropriate addendum. Date and sign
  the correction. If using an addendum, place it in
  sequence or chronological order

34
Hand over the Matters when changing the Shifts

• Change-of-shift report
• Accurate information
• Factual information
• Organized
• What how you say it can make a big difference
  in quality of care
• Avoid negativism subjectivity
• Use written or printed guide to prompt
  thoroughness organization

35
Medical Billing and Coding Needs Documentation

• Without adequate medical documentation, your
  health care providers might not be reimbursed for
  providing you with care, leaving you stuck with
  the bill. There's an old saying in the health
  care industry "If it's not documented, it didn't
  happen.

36
Why to keep records?

• Helps in medical decisions
• Helps to share responsibility with the patient
• All reputed Hospitals Keep Your Documents for
  several decades.
• Legal obligation.
• Protects the patient as well as doctor in front
  of the court

37
When documenting Spell the Words Correctly

• medication names

38
Last But Not the Least Do not miss
spell the wordsIt is Your Identity

• clavicle
• clavical

X
39
Excellence in Medical Documentation Reduces
Malpractice Allegations

• Excellence in medical documentation reflects and
  creates excellence in medical care. At its best,
  the medical record forms a clear and complete
  plan that legibly communicates pertinent
  information, credits competent care and forms a
  tight defense against allegations of malpractice
  by aligning patient and provider expectations.

40
Be Familiar with Computer Documentation as
Technology is taking over every Profession even
ours
41
Your Scientific Documentation saves you from Many
Litigations
42

• Created by Dr.T.V.Rao MD for e Learning for
  Medical Professionals in the Developing world
• Email
• doctortvrao_at_gmail.com