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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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ë


















3 / 29
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 methodð

±
 

 

± 


 

7 / 29
Ë 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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Ë 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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 Source Oriented Medical Record
„

Patient -Source-Oriented Medical Record
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.


21 February 1996: ESR 25 mm, Hb 7.8, Fecal occult blood +.
4 March 1996: Hb 8.2, Fecal occult blood :-.

21 February 1996: Chest x-ray: no atelectasis, light cardiac decompensation
findings 12 / 29
 Problem Oriented Medical Record

4


  4



!
  




dyspnea, coughing, fever.


pulse 95/min, Fever: 39.3 oC.
Rhonchi+. ESR 25 mm.
Chest x-ray: no atelectasis, light cardiac
decompensation findings.

Acute bronchitis.

Amoxicilline 500 mg 2x1.
!
" 




no coughing, slight dyspnea.


pulse 82/min. Slight rhonchi.

minimal bronchitis findings.
!
  




Dyspnea.


Rhonchi+, BP 150/90 mmHg.
Chest x-ray: no atelectasis, slight
cardiac decompensation findings.

Slight decompensation findings.
!
" 




slight dyspnea.


BP: 160/95, pulse 82/min.

No decompensation.

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4
 




!
  




Dark feces. Using Aspirin 64 mg/day.


No abdominal tenderness, rectal exam revealed no blood, Hb 7.8
mg/dl. Fecal occult blood +

Possible intestinal bleeding due to Aspirin.

Decrease Aspirin dose to 32 mg/day.

!
" 





Defecation normal.


Fecal occult blood -

No intestinal bleeding symptoms.

Continue Aspirin dosage 32 mg/day

14 / 29
 DOCUMENTATION

‡ Any printed or written record of activities.

‡ Recording and reporting are the major ways
health care providers communicate.
‡ The client¶s medical record is a legal
document of all activities regarding client
care.
PURPOSES OF DOCUMENTATION

‡ Communication
‡ Practice and legal standards
‡ Reimbursement
‡ Education
‡ Research
‡ Nursing audit
 COMMUNICATION

‡ Documentation confirms the care provided to

the client and clearly outlines all important
information regarding the client.
 PRACTICE AND
LEGAL STANDARDS

The legal aspects of documentation

require:
‡ Writing legible and neat
‡ Spelling and grammar properly used
‡ Authorized abbreviations used
‡ Time-sequenced factual and descriptive
entries
 PRACTICE
STANDARDS INCLUDE:

‡ State Nursing Practice Acts

‡ Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
‡ Confidentiality
‡ Informed consent
‡ Advance Directives
 REIMBURSEMENT

‡ The federal government requires monitoring

and evaluation of quality, appropriateness of
care provided.
‡ Documentation of intensity of services and
severity of illness reviewed.
‡ Failure to document can result in
reimbursement denied.
 EDUCATION

‡ Health care students use medical record as

tool to learn about disease processes, nursing
diagnoses, complications and interventions.
‡ Students can enhance critical-thinking skills
by examining the records and following
health care team¶s plan of care.
 RESEARCH

‡ The client¶s medical record is used by

researchers to determine whether a client
meets the research criteria for a study.
‡ Documentation can also indicate a need for
research.
 NURSING AUDIT

‡ Method of evaluating the quality of care

‡ Includes:
± Safety measures
± Treatment interventions and responses
± Expected outcomes
± Client teaching
± Discharge planning
± Adequate staffing
 PRINCIPLES OF EFFECTIVE
DOCUMENTATION

1. Document accurately, completely, and

objectively, including any errors.
2. Note date and time.
3. Use appropriate forms.
4. Identify the client.
5. Write in ink.
6. Use standard abbreviations.
 PRINCIPLES OF EFFECTIVE
DOCUMENTATION (continued)

7. Spell correctly.
8. Write legibly.
9. Correct errors properly.
10. Write on every line.
11. Chart omissions.
12. Sign each entry.
SYSTEMS OF DOCUMENTATION

‡ Narrative charting ‡ Focus charting

‡ Source-oriented ‡ Charting by exception
charting
‡ Computerized
‡ Problem-oriented documentation
charting
‡ PIE charting ‡ Critical pathways
 NARRATIVE CHARTING

‡ Traditional method of nursing documentation.

‡ Chronologic account in paragraphs describing
client status, interventions and treatments, and
client¶s response.
‡ The most flexible system.
‡ Usable in any clinical setting.
SOURCE-ORIENTED CHARTING

‡ Narrative recording by each member of the

health care team on separate documents.
PROBLEM-ORIENTED CHARTING

‡ SOAP, SOAPI, AND SOAPIER

± S: subjective data
± O: objective data
± A: assessment data
± P: plan
± I: implementation
± E: evaluation
± R: revision
 PIE CHARTING

‡ P: problem
‡ I: intervention
‡ E: evaluation
 FOCUS CHARTING

‡ System using a column format to chart Data,

Action, and Response (DAR).
 CHARTING BY EXCEPTION

‡ Only significant findings (exceptions) are

documented in a narrative form.
‡ Presumes that unless documented
otherwise, all standardized protocols have
been met and no further documentation is
needed.
 COMPUTERIZED
DOCUMENTATION

‡ Reduces time taken, increases accuracy.

‡ Increases legibility.
‡ Stores, retrieves information quickly.
‡ Improves communication among health care
departments.
‡ Confidentiality and costs can be problems.
 CRITICAL PATHWAY

‡ Also known as Care Maps.

‡ Comprehensive pre-printed standard plan
reflecting ideal course of treatment for
diagnosis or procedure, especially with
relatively predictable outcomes.
‡ Additional forms are needed to complement
the pathway.
 NURSE¶S PROGRESS NOTES

‡ Document client¶s condition, problems,

complaints, interventions, and client¶s
response to interventions.
‡ Include MAR, vital signs records, flow
sheets, and intake and output forms.
 DISCHARGE SUMMARY

‡ Client status on admission and discharge

‡ Brief summary of the client¶s care
‡ Intervention and education outcomes
‡ Resolved and unresolved problems
‡ Client instructions about medications, diet,
food-drug interactions, activity, treatments,
follow-up, and other needs
 DOCUMENTATION TRENDS

‡ Nursing Minimum Data Set (NMDS)

‡ Nursing Diagnoses
‡ Nursing Interventions Classification (NIC)
‡ Nursing Outcomes Classification (NOC)
 INFORMATION
FOR SHIFT REPORT
‡ Name, room and bed, ‡ General status, any
age, gender significant change
‡ Physician, admission ‡ New or changed
date, and diagnosis physician¶s orders
‡ Diagnostic tests or ‡ IV fluid amounts, last
treatments performed in PRN medication
past 24 hours (results if ‡ Concerns about client
ready)
 WALKING ROUNDS

‡ Members of the
care team walk
to each client¶s
room and
discuss progress
and care with
each other and
with the client.
 TELEPHONE ORDERS

‡ Date and time

‡ Order as given by the physician
‡ Signature beginning with t.o. (telephone
order)
‡ Physician¶s name
‡ Nurse¶s signature
‡ Physician must countersign
 INCIDENT REPORT

‡ May also be called a ³variance.´

‡ Informs administration of incident, allows risk
management personnel to consider ways to
prevent future similar occurrences.
‡ Alerts insurance company to potential claim
and possible need to investigate.


#
$ 

‡ It is practical to use follow-up charts for

chronic diseases
± DM,
± Hypertension
± Obesity
±«

42 / 29
 Rules in keeping medical records (NCQA)
1. Each page in the record contains the patient¶s 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 author¶s 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.
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http://www.ncqa.org/LinkClick.aspx?fileticket=dmQOrIgyvMQ%3D&tabid=125&mid=766&forcedownload=true
National Committee for Quality Assurance
(NCQA)
8. * 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.
9. 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).
10. The history and physical examination identifies appropriate
subjective and objective information pertinent to the patient¶s
presenting complaints.
11. Laboratory and other studies are ordered, as appropriate.
12. * Working diagnoses are consistent with findings.
13. * Treatment plans are consistent with diagnoses.
14. Encounter forms or notes have a notation, regarding follow-up care,
calls or visits, when indicated. The specific time of return is 44noted
/ 29
in
weeks, months or as needed.
 NCQA
15.Unresolved problems from previous office visits are addressed in
subsequent visits.
16.There is review for under - or over utilization of consultants.
17.If a consultation is requested, there a note from the consultant in the
record.
18.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.
19.* There is no evidence that the patient is placed at inappropriate risk
by a diagnostic or therapeutic procedure.
20.An immunization record (for children) is up to date or an appropriate
history has been made in the medical record (for adults).
21.There is evidence that preventive screening and services are offered
45 / 29 in
accordance with the organization¶s practice guidelines.
 „



‡ %


 &
%





46 / 29
 ë




 




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

47 / 29
Do not use vague expressions such as ³the 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

48 / 29
 -: Bibliography :-
1. B.T.Basvanthappa.
2. Wikipedia.org/Institutional Records.
3. Encyclopedia Encarta.
4. Britannica.
5. Google search.
6. Amazon.com

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p%'

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