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Effective Medical Documentation in Healthcare

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  1. Chapter 19 Documentation and Medical Records

  2. Definitions • Medical documentation • Medical record • Charting

  3. Purposes • Contributes to good patient care • Provides legal protection • Helps ensure regulatory compliance • Improves cost control • Decreases denials from insurance companies

  4. Characteristics • Complete with all requested information • Concise and factual • Properly identified • Legible • Correct spelling, terminology, punctuation, and grammar

  5. Characteristics • Clearly and objectively expressed • Findings not duplicated • Approved abbreviations listed in facility’s policy used • Time and date given for all entries

  6. Characteristics • Signed by proper person • Completed without leaving empty lines • Always charted after giving medication or performing procedure • Written with black or blue ink

  7. Making Corrections • Draw single line through error • Write in correct information • Note error per facility policy • Date and initial correction • Correct immediately on computer • If discovered later, correct as above

  8. Question • Which of the following is the recording of observations and information about patients? • Charting • Medical documentation • Medical record

  9. Answer • A. Charting • Charting • Recording of observations and information about patients • Medical documentation • Notes and documents that health care professionals add to medical record

  10. Answer • A. Charting • Medical record • Collection of all documents filed together • Form complete chronological health history

  11. Medical Records • Organized per facility policy • All health care workers responsible to maintain records per facility policy • Chronological or source-oriented

  12. Medical Records Content • History and physical (H&P) • Physician’s orders • Diagnostic tests • Admissions • Surgical procedures

  13. Medical Records Content • Graphics • Flow sheets • Medications record • Progress notes

  14. Medical Records Content • Reminder: • Verify correct form in chart by ensuring patient’s name on each document • Each section chronological • Thinning a chart • Security of files

  15. Question • Which of the following is a form used for specialty needs? • Progress notes • Graphics • Flow sheets

  16. Answer • C. Flow sheets • Flow sheets • Forms for specialty needs • Progress notes • Written chronological statements about patient’s care

  17. Answer • C. Flow sheets • Graphics • Graphed forms for vital signs

  18. Progress Notes • Primary tool • Recording, communicating, and coordinating care of patient • May include the following: • Observations • Treatments • Patient response

  19. Progress Notes: Formats • Problem-oriented charting • Narrative charting • Charting by exception • Computerized

  20. Question • True or False: • The chief complaint is the reason the patient is seeking medical care.

  21. Answer • True • Chief complaint • Reason patient seeks medical care

  22. EMRs • EMR systems can go far beyond core charting • Coordination tools • Information • Safety tools • Scanned documents

  23. EMRs • Can only communicate within same health care system

  24. Personal Health Record (PHR) • Recommended for patients • Due to mobility of individuals • Frequent changes in providers • Frequent changes in insurance coverage • Assists patient to recall events and dates

  25. Personal Health Record (PHR) • Prevents long delays in requesting information • Types of information to include • Demographics, such as name, address, contact information, etc • Emergency contacts • Name, specialty and contact information of previous providers • Insurance provider(s)

  26. Personal Health Record (PHR) • Types of information to include • Medical directives, living will, organ donation, etc. • General medical information: height, weight, blood type, vital signs, etc. • Allergies and drug sensitivities • Current conditions and date of diagnosis • Previous surgeries, including date and results

  27. Personal Health Record (PHR) • Types of information to include • Medications (prescription and nonprescription) • Immunizations and when last received • Any relevant health care visits, such as hospitalizations, other specialists or therapists • Pregnancies • Medical devices

  28. Personal Health Record (PHR) • Types of information to include • Foreign travel • Family history information

  29. Question • True or False: • EMRs have about the same capabilities and limitations as written charting.

  30. Answer • False • EMR systems can go far beyond core charting

  31. HIPAA • The Privacy Rule • The Security Rule • Possible consequences of not following HIPAA regulations

  32. Question • Which of the following is true about HIPAA? • It protects the health care facilities • It protects patients • It protects the safety of health care professionals

  33. Answer • B. It protects patients • HIPAA Privacy Rule gives patient specific rights related to medical records • HIPAA Security Rule requires administrative, physical, and technical safeguards be developed by facilities to protect patient information

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