Medical Documentation Rules. Medical Documentation Rules General principles The documentation of...

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Page 1: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation Medical Documentation RulesRules

Medical Documentation Medical Documentation RulesRules

Page 2: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation RulesGeneral principlesGeneral principles

The documentation of each patient encounter The documentation of each patient encounter should include:should include:

Chief complaintChief complaint Relevant history of present illness(HPI)Relevant history of present illness(HPI) Physical examinationPhysical examination FindingsFindings Prior diagnostic test resultsPrior diagnostic test results Assessment, clinical impression orAssessment, clinical impression or diagnosis.diagnosis. Plan for carePlan for care Date and legible identity of the observer.Date and legible identity of the observer.

Page 3: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation RulesGeneral principles…General principles…

The rationale for ordering diagnostic andThe rationale for ordering diagnostic and otherother ancillary services should be easily inferredancillary services should be easily inferred

Past and present diagnoses should be Past and present diagnoses should be accessible to the treating and/or consulting accessible to the treating and/or consulting physicianphysician

Appropriate health risk factors should be Appropriate health risk factors should be identifiedidentified

The patient’s progress,response to and changesThe patient’s progress,response to and changes in in treatment, and revision of diagnosis should betreatment, and revision of diagnosis should be documented.documented.

Page 4: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation Rulesgeneral principles…general principles…

Codes reported on the health Codes reported on the health insurance claim form or billing insurance claim form or billing statement should be documented in statement should be documented in the medical record.the medical record.

Patient’s confidentionalityPatient’s confidentionality Plan for care should be recorded and Plan for care should be recorded and

include patient teaching and include patient teaching and monitoring.monitoring.

Dosage and treatment scheduleDosage and treatment schedule

Page 5: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation Rulesgeneral principles…general principles…

Draw a line on mistakes, never erase Draw a line on mistakes, never erase the datathe data

Record Record counsulting:request,render,report.counsulting:request,render,report.

Page 6: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation Rulesdocumentation of historydocumentation of history

The levels of E/M services are based The levels of E/M services are based on four types of history:on four types of history:

Problem FocusedProblem Focused Expanded problem focusedExpanded problem focused DetailedDetailed comprehensivecomprehensive

Page 7: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation Rulesdocumentation of history…documentation of history…

Each types of history includes the Each types of history includes the following elements:following elements:

Chief complaint(CC)Chief complaint(CC) History of present illness(HPI):History of present illness(HPI): Past, family and/or social Past, family and/or social

history(PFSH)history(PFSH) Review of systems(ROS)Review of systems(ROS)

Page 8: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation Rules

Chief complaintChief complaint

Page 9: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation Rules Medical Documentation Rules chief complaintchief complaint

The CC is a concise statement The CC is a concise statement describing the describing the symptom,problem,condition,diagnosisymptom,problem,condition,diagnosis,physician recommended return,or s,physician recommended return,or other factor that is the reason for the other factor that is the reason for the encounter.encounter.

Page 10: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation RulesHistory of present illness(HPI)History of present illness(HPI)

HPI is a chronological description of HPI is a chronological description of the development of the patient’s the development of the patient’s present illness from the first and/or present illness from the first and/or symptom or from the previous symptom or from the previous encounter to the present. It includes encounter to the present. It includes the following elements:the following elements:

Page 11: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation RulesHPIHPI

Location Location QualityQuality SeveritySeverity DurationDuration TimingTiming context context

Modifying factorsModifying factors

Associated signs Associated signs and symptoms.and symptoms.

Page 12: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation Rulesdocumentation of historydocumentation of history

The levels of E/M services are based The levels of E/M services are based on four types of history:on four types of history:

Problem FocusedProblem Focused Expanded problem focusedExpanded problem focused DetailedDetailed comprehensivecomprehensive

Page 13: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Medical Documentation RulesMedical Documentation RulesPast, Family and/or SocialPast, Family and/or Social History(PFSH)History(PFSH)

Past: the patients experiences with Past: the patients experiences with illnesses,operations,injuries and illnesses,operations,injuries and treatments.treatments.

Family: review of medical events in Family: review of medical events in the family ,(hereditary or place the the family ,(hereditary or place the patient at risk)patient at risk)

Social; an age appropriate review of Social; an age appropriate review of the past and current activitiesthe past and current activities

Page 14: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.
Page 15: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.
Page 16: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of ExaminationDocumentation of Examination

InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation

Page 17: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of ExaminationDocumentation of Examination

Page 18: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of ExaminationDocumentation of Examination

Page 19: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of ExaminationDocumentation of Examination

Page 20: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of examinationDocumentation of examination

The levels of E/M servicesThe levels of E/M services Problem FocusedProblem Focused Expanded Problem Focused Expanded Problem Focused DetailedDetailed ComprehensiveComprehensive

Page 21: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of examinationDocumentation of examination P F:A limited examination of the body areaP F:A limited examination of the body area oror

organ system.organ system. Exp PF:Exp PF:AA limited examination of the limited examination of the affectedaffected

body area or organ system and otherbody area or organ system and other symptomatic or related organ system(s).symptomatic or related organ system(s).

Detailed: anDetailed: an extended examination of the extended examination of the affected body area(s) and other affected body area(s) and other symptomatic or related organ system(s).symptomatic or related organ system(s).

Com:a general multi-system examination or Com:a general multi-system examination or complete examination of a single organ complete examination of a single organ system.system.

Page 22: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of disease coarseDocumentation of disease coarse

Two methods:Two methods:11-admit note/follow-up -admit note/follow-up

note/treatment note/daily notenote/treatment note/daily note Progress noteProgress note Final noteFinal note

Page 23: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of Disease coarseDocumentation of Disease coarse

2-SOAP2-SOAP SubjectiveSubjective ObjectiveObjective AssessmentAssessment Plan of treatmentPlan of treatment

Page 24: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of the complexity of Documentation of the complexity of medical decision makingmedical decision making

The levels of E/M services recognize The levels of E/M services recognize four types of medical decision four types of medical decision making:making:

Straight-forwardStraight-forward Low complexityLow complexity Moderate complexityModerate complexity High complexityHigh complexity

Page 25: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of the complexity of Documentation of the complexity of medical decision makingmedical decision making

Page 26: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of Medical Documentation of Medical terminologyterminology

1-Diagnostic services1-Diagnostic services

2-Surgical services2-Surgical services

Page 27: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of Medical Documentation of Medical TerminologyTerminology

Do not use abbreviation in:Do not use abbreviation in: Final examinationFinal examination Management activitiesManagement activities External causes of emergenciesExternal causes of emergencies Death causesDeath causes

Page 28: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of Medical Documentation of Medical terminology…terminology…

It is recommended do not use It is recommended do not use abbreviations in:abbreviations in:

Discharge…(File summary sheet)Discharge…(File summary sheet) Surgical procedures…(Operation Surgical procedures…(Operation

report sheet)report sheet)

Page 29: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of Medical Documentation of Medical terminologyterminology

It is better to use the complete term It is better to use the complete term at first it appears then use the at first it appears then use the abbreviations for further refers.abbreviations for further refers.

Clarify precisely the anatomic site Clarify precisely the anatomic site and don’t use – or + for normal or and don’t use – or + for normal or abnormal findings.abnormal findings.

Page 30: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of Medical Documentation of Medical terminologyterminology

Surgical terms:Surgical terms: Simple lacerationSimple laceration Intermediate lacerationIntermediate laceration Complex lacerationsComplex lacerations

Page 31: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of MedicalDocumentation of Medical

Mention also:Mention also: Tools,facilities,and duration of their Tools,facilities,and duration of their

usageusage Kind of incisions; undermining, take Kind of incisions; undermining, take

down,lysis of adhesions( different down,lysis of adhesions( different tariff and codes).tariff and codes).

Patient Patient position;lithotomy,dorsal,vaginal…position;lithotomy,dorsal,vaginal…

Page 32: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation of Medical Documentation of Medical terminology…terminology…

RUQ,LUQ,RLQ,LLQRUQ,LUQ,RLQ,LLQ Right hypochondriacRight hypochondriac Left hypochondriac, epigastric,right Left hypochondriac, epigastric,right

lumbar, left lumbar,umblical,right lumbar, left lumbar,umblical,right iliac,left iliac,hypogastriciliac,left iliac,hypogastric

Page 33: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

Documentation RulesDocumentation Rules

Document while or just after Document while or just after performance.performance.

Do not ask the others to complete Do not ask the others to complete your document.your document.

Page 34: Medical Documentation Rules. Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint.

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