Goodbye ICP-I II

1. Goodbye ICP-I & II 1979 � 2004 ICP-II Moving On 2004 - ? CFMP-II

2. Hello CFMP-I / IIClinical Foundations of Medical Practice CFMP-I Phys Dx with Focus on Basic Skills Bates Exam Bedside Std Px Exam Basic Medical Humanities Medical Ethics Death & Dying Human Sexuality Medical Interviewing IRAT-I / GRAT-I Intro Path / Pharm / Micro Immunology CFMP-II Phys Dx with Disease Focus Advanced Disease Focus Exam/s in Phys Dx Advanced Medical Humanities IRAT-II / GRAT-II Earlier Disease Presentation for Path / Pharm / Micro to help in Phys Dx

3. The Medical Record Value in a Physician�s Practice & in Patient Care

4. The Medical Record The medical record should be viewed as an extremely important and valuable tool in patient management. All that happens to the patient; all things done to and done for the patient; all relevant professional plans, therapies, and advice; all invasive and noninvasive procedures; all working diagnoses and long term therapeutic plans and goals should be detailed in the record. It must contain all elements set forth by both the medical record committee and practice standards board of a given hospital. The medical record is viewed as the professional and legal record of a given patient's care. It should therefore be carefully maintained and all entries should be clearly legible. The medical record ( or chart ) should be a clear and accurate documentation of the complete clinical course of the patient. All entries should be legibly written, signed, dated, and timed. With the advent of the electronic medical record, legibility has become much less of an issue as are times and dates

5. Medical Records - Then & Now The Paper Record Readable Writing Availability Tracking Getting Data in to the Record in a Timely Manner Moves with Patient

6. Medical Records - Then & Now Where did that record go ? Putting in all the floating data slips ! Getting the record off to different clinics ! Doing chart reviews

7. Medical Records - Then & Now Where did all those records go after a patient died ? Can I find the record in the dead record file room ?

8. Medical Records - Then & Now The coding room jungle Getting the ICD-9 codes correct Setting up for billing Doctor, Medical Student & Resident Reviews & Sign-Offs

9. Medical Records - Then & Now The new medical filing room Where did all those folders go ? Hello Y2K !!!!

10. Medical Records - Then & Now Entering the lab data No longer by hand and floating files Direct data entry in to the electronic medical record

11. VA Medical Record

12. VA Medical Record

13. Medical Records - Then & Now Multiple access points - simultaneously Able to access via modem or Internet Can review data from outside hospital Remaining hurdles - Phys Ex & Progress Notes The Internet Medical Record � available from all locations one can access Internet

14. Medical Records - Then & Now The student and resident offices on the hospital wards and in the clinics Search and reviewing patient data Entering information

15. Medical Records - Then & Now At the Nurses�Station Students Residents Nurses Pharmacists Social Service Calling in from outside the hospital

16. Purposes of the Medical Record Record Data Outline Dx & Rx Opinions Interpretations of Findings Track Progress of Patient Keep Simplified Record � Family & Friends � for testing & Rx

17. Elements of the Medical Record History & Physical Review of Systems Problem List Orders Informed Consent Progress Notes Consultations Operative Report Discharge Summary Study Reports

18. The Problem List Diagnoses (Initial Date of Problem and Date Resolved). Surgeries/Procedures (Include Dates). What Constitutes a Problem ? Physical finding, a Symptom, an Abnormal lab result, or Disease process Personal and/or Social difficulty May include items like � Rising PSA �

19. PROGRESS NOTES ( S. O. A. P. FORMAT )  S = subjective � My chest pain is less today � O = objective � Improved deep breathing during exam with continuing left chest pleural friction rub with deep inspiration � A = assessment � Px is responding to steroid therapy � P = plan � I will begin to taper steroid dose over the next few days and observe impact on chest pain and left pleural friction rub �

20. Progress Notes in theElectronic Medical Record TOO MUCH copying and pasting Repeating lab and other studies needlessly Increases time in reviewing notes Copying information which is days old Plagiarizing others� notes - ? Ethics of this Moving �old� information forward

21. The Value of a Differential Diagnosis Explores the � what if�s � Reduces chance for a � missed � Dx The 9 /11 Scenario � Who ever thought they were going to crash planes into buildings � everyone thought �hostages� �

22. COMPLETION Requirements of the MEDICAL RECORD Incomplete Record Any record which does not have a completed (dictated and/or signed) Discharge Summary, History & Physical, Operative Report, Progress Note, Physicians Order, etc Must have all hospital required components completed JCAHO Standard - no more than the average of one months discharges listed as incomplete Delinquent Record Any record which is incomplete for over 30 days JCAHO Standard - no more than half of the average of one months discharges

23. System for Data Storage and Retrieval for the � Doc � Internet Searches Medline & PubMed Journals Textbooks Example ( using Harrison�s Textbook ) Use Index for page # , then Contents for Chapter ( folder # ) Chapter Title for Folder Name

24. Quality Improvement/AssuranceProcesses for Patient Care Occurrence Screens Readmit 10 days after Discharge Admit 3 days after Clinic Visit Transfer back to ICU within 3 days of being moved out Unscheduled Surgery Cardiac/Pulmonary Arrest All Deaths in Hospital or Clinic Continuous Monitors Tissue & Transfusion Comte Med Record Comte Pharm & Therapeu Comte including Drug Utilization Inf Dis Control Comte Peer Review Credentialing & Privileging Comte with National Health Data Bank

25. How to Fill Out aDeath Certificate Proper Diagnosis Cause of Death Related to What Underlying Disease Cardiac Arrest & Pulmonary Arrest NOT Used !!!!!!! Only in Limited Way Epidemiologist Review

26. HOSPITAL & PHYSICIAN ( $ ) CHARGES � How Calculated  Hospital Charges Fee-for-Service gone Negotiated Rates Discounts of Health Plans Px with & without coverage and impact of discount Community Comparisons Drop from Panel if not competitive in price Documentation needed from Medical Record Physician Charges DRG�s Discounting Fee-for-Service gone Documentation through Medical Record Complexity of Visit Number of elements of the Hx & Physical establishes part of the charges

27. The Medical Record The End

28. Instruments of / for Care(a) Progress Notes � date, time, clear signature 3 x 5 Cards Nurses� Notes What is the Plan of Care ? Is the Problem List Complete ?

29. Instruments of / for Care(b) Medical Alert Necklace / Bracelet Rx�s Complete at Discharge Px�s Address, Phone Number Up-to-date ? Filling Out Death Certificate Properly !!!