The Problem Oriented Medical Record

1. The Problem OrientedMedical Record Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

2. Aim-Objectives • Objectives: • be able to define source oriented medical record • be able to define problem oriented medical record • be able to list items to be included in the medical record • be able to discuss reasons for keeping medical records • be able to explain the PSOAP acronym for keeping records

3. It is always easier to find your way if you have a road map!

4. Which data are we recording in practice?

5. 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

6. Why to keep records? • Has economic benefits • Useful to produce health statistics • Provides epidemiological data • Assists practice management • Useful in QI activities • Is a communication tool • Useful in medical education

7. Types According to the method; • Source oriented • Problem oriented

8. Source oriented medical recordData 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

9. Problem oriented medical record • Structure is defined in advance. • The patient with problem is in the focus • It is systematic • Data is easily accessible • Starts with a problem list • Progress notes are according to the PSOAP acronym • Patients problem is in the front line • Not flexible. Recording information is difficult and time consuming

10. Which data to record? / 29

11. PSOAP

12. Source Oriented Medical Record Patient -Source-Oriented Medical Record Visits : 21 February 2006: 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 2006: no cough, slight dyspnea, defecation normal.PE: light rhonchi, BP 160/95, pulse 82/min.Rx: Aspirin 32 mg/day. Lab : 21 February 2006: ESR 25 mm, Hb 7.8, Fecal occult blood +. 4 March 2006: Hb 8.2, Fecal occult blood :-. X-ray 21 February 2006: Chest x-ray: no atelectasis, light cardiac decompensation findings / 29

13. Problem Oriented Medical Record Problem 2: Dyspnea 21 February 2006 S:Dyspnea. O:Rhonchi+, BP 150/90 mmHg. Chest x-ray: no atelectasis, slight cardiac decompensation findings. A:Slight decompensation findings. 4 March 2006 S:slight dyspnea. O:BP: 160/95, pulse 82/min. A:No decompensation. Problem 1: Coughing 21 February 2006 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 2006 S: no coughing, slight dyspnea. O: pulse 82/min. Slight rhonchi. A: minimal bronchitis findings. / 29

14. Problem 3: Dark colored defecation 21 February 2006 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 2006 S:Defecation normal. O:Fecal occult blood - A:No intestinal bleeding symptoms. P:Continue Aspirin dosage 32 mg/day

15. Rules in keeping medical records (NCQA) • Patient’s name or ID number. • Personal biographical data • Author’s identification • All entries are dated. • The record is legible to someone other than the writer. • *Problem list. • *Medication allergies and adverse reactions http://www.ncqa.org/LinkClick.aspx?fileticket=dmQOrIgyvMQ%3D&tabid=125&mid=766&forcedownload=true

16. National Committee for Quality Assurance (NCQA) • * Past medical history • For patients 12 years and older, there is appropriate notation concerning the use of cigarettes, alcohol and substances • The history and physical examination • Laboratory and other studies are ordered, as appropriate. • * Working diagnoses are consistent with findings. • * Treatment plans are consistent with diagnoses. • Encounter forms or notes have a notation, regarding follow-up care, calls or visits, when indicated.

17. NCQA • Unresolved problems from previous office • There is review for under - or over utilization of consultants. • Note from the consultant in the record. • Consultation, laboratory and imaging reports filed in the chart are initialed by thepractitioner who ordered them, to signify review. • * There is no evidence that the patient is placed at inappropriate risk by a diagnostic ortherapeutic procedure. • Immunization record • Preventive screening and services

18. Legal Problems • Not recorded = Not done !

19. In order to prevent legal problems: • Record everything you do (including phone consultations) • Apply guidelines (e.g.: NCQA) • Don't use erasable pencils • Don’t use humiliating expressions

20. 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

21. Follow-up Charts • It is practical to use follow-up charts for chronic diseases • DM, • Hypertension • Obesity • …

22. Charts - Obesity

23. Medical Records are Our Road Maps

30. Summary • What are the benefits of keeping records?

31. Can you explain the meanings of PSOAP in the medical record?

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

33. THANK YOU www.themegallery.com / 29 33