Medical Records

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Medical Records
Turan SET, Assist. Prof. Atatürk University
Medical Faculty, Erzurum
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Objectives

• At the end of this presentation, the participants
  should be able to
• Define source oriented medical record
• Define problem oriented medical record
• List items to be included in the medical record
• Discuss reasons for keeping medical records
• Explain the PSOAP acronym for keeping records

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It is always easier to find your way if you have
a road map!
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Which data are we recording in practice?
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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

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• Has economic benefits
• Useful to produce health statistics
• Provides epidemiological data
• Assists practice management
• Useful in QI activities
• Is a communication tool

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Types

• According to the method
• Source oriented
• Problem oriented

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• Source oriented medical record Data taken from
  the source are recorded as they are (Source
  patient, relative, laboratory etc.)
• Easy and fast to record
• Flexible
• Omitting information is highly possible
• Difficult to access the information

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• Problem oriented medical record
• Structure is defined in advance.
• The patient with problem is in the focus
• It is systematic
• Data is easily accessible
• Not flexible. Recording information is difficult
  and time consuming

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Which data to record?

• 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

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PSOAP

• Problem
• Everything the patient reports and doctors
  findings which are regarded as problems
• Subjective
• History of the problem what the patient feels or
  thinks about the problem
• Objective
• Doctors findings related with the problem
• Assessment
• Evaluation of the problem the diff. diagnosis
• Plan
• Prescription, consultation, advice, control
  visit...

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Source Oriented Medical Record
Visits 21 February 1996 dyspnea, coughing and
fever. Dark defecation. PE BP 150/90, pulse
95/min, Fever 39.3 oC.Ronchi , no abdominal
tenderness.Medications 64 mg Aspirin/day.
Possible acute bronchitis and cardiac
decompensation.Possible bleeding due to
Aspirin.Rx Amoxicilline 500 mg 2x1, Aspirin 32
mg/day. 4 March 1996 no cough, slight dyspnea,
defecation normal.PE light rhonchi, BP 160/95,
pulse 82/min.Rx Aspirin 32 mg/day. Lab 21
February 1996 ESR 25 mm, Hb 7.8, Fecal occult
blood . 4 March 1996 Hb 8.2, Fecal occult blood
-. X-ray 21 February 1996 Chest x-ray no
atelectasis, light cardiac decompensation findings
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Problem Oriented Medical Record
Problem 1 Coughing 21 February 1996 S dyspnea,
coughing, fever. O pulse 95/min, Fever 39.3
oC. Rhonchi. ESR 25 mm. Chest x-ray no
atelectasis, light cardiac decompensation
findings. A Acute bronchitis. P Amoxicilline
500 mg 2x1. 4 March 1996 S no coughing, slight
dyspnea. O pulse 82/min. Slight rhonchi. A
minimal bronchitis findings.
Problem 2 Dyspnea 21 February 1996 S
Dyspnea. O Rhonchi, BP 150/90 mmHg. Chest
x-ray no atelectasis, slight cardiac
decompensation findings. A Slight decompensation
findings. 4 March 1996 S slight dyspnea. O BP
160/95, pulse 82/min. A No decompensation.
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 Problem 3 Dark colored defecation 21 February
1996 S Dark feces. Using Aspirin 64 mg/day. O
No abdominal tenderness, rectal exam revealed no
blood, Hb 7.8 mg/dl. Fecal occult blood A
Possible intestinal bleeding due to Aspirin. P
Decrease Aspirin dose to 32 mg/day. 4 March
1996 S Defecation normal. O Fecal occult blood
- A No intestinal bleeding symptoms. P Continue
Aspirin dosage 32 mg/day
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Rules in keeping medical records (NCQA)

1. Each page in the record contains the patients
   name or ID number.
2. Personal biographical data include the address,
   employer, home and work telephone numbers and
   marital status.
3. All entries in the medical record contain the
   authors identification. Author identification
   may be a handwritten signature, unique electronic
   identifier or initials.
4. All entries are dated.
5. The record is legible to someone other than the
   writer.
6. Significant illnesses and medical conditions are
   indicated on the problem list.
7. 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.

http//www.ncqa.org/LinkClick.aspx?fileticketdmQO
rIgyvMQ3Dtabid125mid766forcedownloadtrue
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National Committee for Quality Assurance (NCQA)

1. Past medical history (for patients seen three
   or more times) is easily identified and includes
   serious accidents, operations and illnesses. For
   children and adolescents (18 years and younger),
   past medical history relates to prenatal care,
   birth, operations and childhood illnesses.
2. For patients 12 years and older, there is
   appropriate notation concerning the use of
   cigarettes, alcohol and substances (for patients
   seen three or more times, query substance abuse
   history).
3. The history and physical examination identifies
   appropriate subjective and objective information
   pertinent to the patients presenting complaints.
4. Laboratory and other studies are ordered, as
   appropriate.
5. Working diagnoses are consistent with findings.
6. Treatment plans are consistent with diagnoses.
7. Encounter forms or notes have a notation,
   regarding follow-up care, calls or visits, when
   indicated. The specific time of return is noted
   in weeks, months or as needed.

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NCQA

1. Unresolved problems from previous office visits
   are addressed in subsequent visits.
2. There is review for under - or over utilization
   of consultants.
3. If a consultation is requested, there a note from
   the consultant in the record.
4. Consultation, laboratory and imaging reports
   filed in the chart are initialed by the
   practitioner who ordered them, to signify review.
   (Review and signature by professionals other than
   the ordering practitioner do not meet this
   requirement.) If the reports are presented
   electronically or by some other method, there is
   also representation of review by the ordering
   practitioner. Consultation and abnormal
   laboratory and imaging study results have an
   explicit notation in the record of follow-up
   plans.
5. There is no evidence that the patient is placed
   at inappropriate risk by a diagnostic or
   therapeutic procedure.
6. An immunization record (for children) is up to
   date or an appropriate history has been made in
   the medical record (for adults).
7. There is evidence that preventive screening and
   services are offered in accordance with the
   organizations practice guidelines.

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Legal Problems

• Not recorded Not done !

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In order to prevent legal problems

• Record everything you do (including phone
  consultations)
• Apply guidelines (e.g. NCQA)
• Don't use erasable pencils
• Dont use humiliating expressions

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• Do not use vague expressions such as the patient
  feels well
• If you need to make changes just strike through
  and record also the date of change
• If you stated that the patient is not cooperative
  give the reason
• If patient rejects a procedure or test, mention
  it and give the reason why you requested it

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Follow-up Charts

• It is practical to use follow-up charts for
  chronic diseases
• DM,
• Hypertension
• Obesity

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Charts - Obesity
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Medical Records are Our Road Maps
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Summary

• What are the benefits of keeping records?

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• Source oriented medical record is easy. Data
  entry is flexible.
• Correct
• Wrong

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• Problem oriented medical record is systematic.
  Access to information is easy.
• Correct
• Wrong

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• Source oriented medical record contains a
  personal problem list.
• Correct
• Wrong

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• Can you explain the meanings of PSOAP in the
  medical record?

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• What are the core elements requested by NCQA in
  the medical record?