Medical Documentation

Avni Bhalakia, M.D.St. Barnabas HospitalJuly 29, 2009

Objectives Purpose of the Medical Record Importance of Documentation HOW TO Document WHAT TO Document Medical Student Documentation Inpatient Documents Medication Reconciliation Summary

The Medical Record As defined by the AHIMA (American Health

Information Management Association) Record of the patient’s health history

Care provided Evidence that the care was necessary Patient’s response to care Standards of care delivered

Method of communication among practitioners Supporting documentation for reimbursement

www.ahima.org

The Medical Record As outlined by Medicaid

Chronological record of pertinent facts, findings, and observations about an individual's health history

Means to: Evaluate and plan for patient’s care Monitor patient’s health over time Communicate with others involved in the care Review claims and payment (reimbursement) Review quality of care Collect data for research and education

May serve as a legal document

Medicaid, Documentation Guidelines for E/M Services, 1997

Documentation in the Medical Record

Documentation is a big failure in most institutions and practices

Documentation should be a means to justify decisions more than to recall events

Good documentation enhances communication among physicians

Medical Records are a “running dialogue between involved clinicians on the patient’s management and progress” (Panting, Postgrad Med J, 2004))

Physician Documentation Expert Panel Ontario, 2006

Importance of Documentation

Patient Care & Safety Legal Implications Financial Implications

Documentation Impacts Patient Safety

Improper documentation can lead to errors in patient care & jeopardize patient safety

Medical Errors 20% of patients will have an adverse

outcome in first several weeks after discharge

1/3 of those errors were preventable

Physician Documentation Expert Panel Ontario, 2006

Patient Safety 1999, Institute of Medicine

44,000-98,000 people die in hospitals each year because of preventable medical errors

Estimated cost between $17-29 billion per year in hospitals nationwide Includes the expense of additional care

necessitated by the errors, lost income and household productivity, and disability

Movement began for patient safety goals Joint Commission, Hospital administration

Institute of Medicine, 1999

Legal Impact of Documentation Improper documentation can cause trouble

for the healthcare worker Joint Commission (loss of hospital accreditation) Lawsuits and loss of professional standing, job

& savings “Clinical negligence cases are won on the

evidence” If not documented completely, failing memories

may lead to an inability to rebut the claim

Panting, Postgrad Med J, 2004

Financial Impact of Documentation

Insurance companies have standards that must be complied with to be paid Reimbursed for the work that is

documented

Inadequate documentation can lead to improper allocation of resources E.g. Hospital loses accreditation and

funding decreases

The Barriers to Good Documentation

Redundant information Writing the same thing in multiple

places

Time constraint Legibility (Hand Written Chart) Inaccurate problems & plan/ status

not updated (EMR)

Physician Documentation Expert Panel Ontario, 2006

Medical DocumentationHOW & WHAT TO DOCUMENT

Know that there is a standard for what is acceptable documentation

Must know the standards for all the reasons we just mentioned

HOW TO Document Document in Black pen

Never use blue pen Never use pencil

Do not leave spaces between entries to allow for chronological order

Deletions or Alterations Should be crossed out with a single line

and co-signed/initialed Never use white out

HOW TO Document Every entry should be signed by the

author with legible print of name & title below signature or stamp Includes Medical Students

Resident physicians must co-sign student notes Addend what is incorrect or different to

their note as now you are signing your name!

HOW TO Document

Be specific, objective, and complete Write legibly Avoid abbreviations

When in doubt, write it out DO NOT USE abbreviations

It is illegal and unethical to pre-time/date or back-time/date an entry in the chart Add an addendum

WHAT TO Document

Each entry in the chart must have Patient label on every page Date (month, date, and year) Time of entry Title of entry (e.g. PGY-2 Addendum,

Daily Progress Note) Signature and authentication (stamp)

WHAT TO Document

Informed consent, risks and benefits explained

Incidents Attempts at & communications with

family members Communications with primary care

physicians & consulting services

WHAT TO Document

Events Change in clinical status, intervention, and

outcome E.g. Patient became hypoxic, portable CXR done and

shows RML pneumonia. Antibiotics added. Patient is currently comfortable on 1L NC, sats>98%, RR 18.

Significant change in plan E.g. Patient was not discharged today as planned

because the blood culture grew positive at 36 hours. A repeat culture was drawn and antibiotics were continued. Patient remains afebrile and well-appearing. Anticipate ID of organism tomorrow and possible discharge if it’s a contaminant species.

DO NOT Document

False information E.g. Part of the exam you did not

perform

Personal opinions or judgments Be objective

Medical Student Documentation

Review the students’ notes Co-sign the note and add an addendum Sign and stamp below addendum

ALL student notes should be co-signed Residents’ responsibility that the student

documentation is complete and accurate Should uphold all documentation standards

Good Documentation

Promotes good physician-to-physician communication

Helps prevent medical errors Enhances patient care Has legal and financial impacts

Documents of the Inpatient Unit

Admission Note (H&P) Progress Note Discharge Summary & Patient Plan Physician Orders

Must Have on EVERY Document

Patient label on every page Time & Date all entries Sign & Stamp all entries

Patient Label on EVERY page in chart

Admission Note (H&P) Patient Label Time & Date PMD & phone number Chief complaint History of Present

Illness Past Medical History Birth History Immunizations Home Medications

Dose, Route, Frequency, Last dose

Allergies

Dietary History Developmental History Family History Social History Review of Systems ER course Exam on Pediatric

Unit Assessment Plan Growth charts

(including BMI) Sign & Stamp

Example: Home Medications

Write “unknown” or “unable to obtain.” Do not leave blank.

Progress Note

Write Legibly

Patient Label

Sign & Stamp

• Means of communication between care providers

• Convey thought process of decision making and plans

• Record of events

Date & Time

Note Title (e.g. PGY1 Progress Note, Addendum, Event Note, etc)

Discharge Summary

Summarizes the hospital course Brief & complete account of what

happened during admission, problems and new findings, intervention, outcome, and follow-up

Means to communicate with the primary care physician and help with transfer of care and follow-up needed

Include the basics: patient label, date, time, signature, and stamp

PMD rated D/C summaries as usefulIF concise, complete & included:

Admitting diagnosis Relevant physical findings and labs Brief account of procedures and/or

complications during admission Discharge diagnosis Discharge meds & planned length of

treatment Active problems at discharge Arrangements for follow up

Physician Documentation Expert Panel Ontario, 2006

Discharge Summary

A summary of hospitalization to the primary care physician

HPI Do not need to rewrite entire H&P List pertinent positives and negatives on

physical exam and lab values

Hospital Course & Treatment Appropriate details with conciseness

Discharge SummaryHospital Course & Treatment

List hospital course by problem or organ system

Report interventions, rationale, outcomes

Report remarkable events and complications

Date important events E.g. Patient had surgery on 7/5/2008 vs.

Patient had surgery on hospital day #32

Discharge SummaryHospital Course & Treatment

Report remarkable labs and physical findings Avoid a laundry list of lab values; say what is

pertinent E.g. CXR was unremarkable, serum chemistry

unremarkable except for glucose of 58

Include lab values & data pertinent to follow up E.g. discharge weight in FTT patients, HgbA1C in

diabetic patients, Range of documented blood pressure in patient with noted hypertension in the hospital

Discharge Summary Patient condition upon discharge: stable Discharge diagnosis (not a symptom) Discharge medications

Length of therapy Reconcile with admission H&P and hospital

medications

Discharge instructions: be specific Pending labs Follow-up appointments

Date, time, location, & phone number

Example “he appeared to have

pneumonia at the time of admission so we empirically covered him for community-acquired pneumonia with ceftriaxone and azithromycin until day 2 when his blood cultures grew out strep pneumoniae that was pan sensitive so we stopped the ceftriaxone and completed a 5 day course of azithromycin. But on day 4 he developed diarrhea so we added flagyl to cover for c.diff, which did come back positive on day 6 so he needs 3 more days of that…”

“Completed 5 day course of azithromycin for pan sensitive strep pneumoniae pneumonia complicated by c.diff colitis. Currently on day 7/10 of flagyl and c.diff negative on 9/21”

Department of Medicine, University of Florida

Patient Plan for Post-Hospital Care Patient label, date, time Discharge diagnosis Discharge teaching: special instructions

Write when patient should return to ER or to see their physician

Discharge medications Reconcile with H&P and hospitalization Write instructions using language that the patient

to understand E.g. Twice a day (not BID)

Follow up Clinic name, address, date, time, and phone

number

Patient plan at discharge

Complete all sections of document Write n/a or Ø if not

relevant Write for the patient

to understand Normal vital signs at

discharge Be specific with

follow-up appointment information

Physician Orders

Care plan for hospital admission that includesNursing care: vitals, ins/outs, special

instructionsMedications PharmacyCircumstances to notify physician

Physician Orders The Basics

Patient label Diagnosis,

allergies, & weight

Date & time order

Signature & stamp

Physician Orders

DO NOT use abbreviations Write legibly If an order needs to be changed,

cross out the order & re-write it to avoid errors

Official “Do Not Use” List by Joint Commission

DO NOT USE USE INSTEAD

QD or Q.D. Every day or daily

QOD Every other day

U Units

IU International Units

MgSO4 Magnesium Sulfate

MS or MSO4 Morphine Sulfate

Trailing zero (X.0 mg) Write “X mg”

Lack of leading zero (0.X mg) Write “0.X mg”

The Joint Commission, May 2005

Other “Do Not Use” Abbreviations

DO NOT USE USE INSTEAD

µg Mcg or micrograms

BT Bedtime or QHS

SS Sliding Scale

CC Cubic Centimeter

> Write “greater than”

< Write “less than”

The Joint Commission, May 2005

Note when Writing Medication Orders

Write medications in mg/kg/dose or day Nursing and Pharmacy should not accept orders

without this

SBH Med dosing Daily = 9 am (NOT Q24 hrs) BID = 9 am, 5 pm (NOT Q12 hrs) TID = 9 am, 1 pm, 5 pm (NOT Q8 hrs)

SBH Pharmacy requires insulin units be written out in numeric form E.g. Humalog 5 (five) units SQ injection

Medication Reconciliation

Generates an accurate and complete medication list

ReducesInadvertent omission of home medsNumber of adverse medication events Failure of restarting home medsErrors associated with doses or dosage

forms

Medication Reconciliation Obtain medication history on admission Record current medications on H&P form Use medication list while writing orders Reconcile orders with med list during

admission, transfer, post-op care, and discharge

Communicate list of meds to next health care provider

Summary Documentation is important for provider

communication and patient safety Medical Record serves as a legal record of

the patient’s care Adhere to standards in documentation Write legibly Know which abbreviations are acceptable Reconcile home medications

References Altman, D. et al. Improving Patient Safety—Five Years after the IOM

Report. NEJM 2004; 351(20): 2041-43. American Health Information Management Association. Long Term Care

Health Information Practice and Documentation Guidelines, www.ahima.org, Sept 2001, downloaded on December 2, 2008.

Department of Internal Medicine, Oklahoma University. Discharge Summary Guidelines. http://tulsa.ou.edu/im/Discharge%20 Summary%20Guide.pdf, downloaded on December 4, 2008

Institute of Medicine. To Err is Human. Nov 1999. Panting, G., MD. How to avoid being sued in clinical practice. Postgrad

Med J 2004; 80:165-168. Physician Documentation Expert Panel Ontario. A Guide to Better

Physician Documentation, November 2006. Ross, Martie, Esq. Ten Commandments of Medical Record

Documentation. www.lathrophealthlawyers.com, downloaded on December 2, 2008.

University of Florida, Department of Medicine, Medical Clerkship, 4th year medical student information. http://www.medicine.ufl.edu/ 3rd_year_clerkship/documents/Discharge%20Summary.pdf, downloaded on December 12, 2008.