Medical Documentation

Documentation:

• Anything written or printed that can be relied on as a record of proof for authorized persons
• Is a vital part of professional practice

Medical Documentation:

• Refers to any written or electronically generated information about a patient regarding history including past and present illnesses; examinations; tests; treatments; and outcomes
• Is a record of the patient’s health status and medical conditions
• Is a statement from a licensed physician or other appropriate practitioner providing information the agency considers necessary
• It should reflect the patient’s perspective on his/her health status and well-being, the care provided, the effect of care, and the continuity of care
• It is as important as the actual treatment rendered to the patient

'If it is not documented – it did not happen.'

Medical Documentation includes:

• A list of the patient’s problems and complaints
• All medications prescribed
• Adverse drug reactions and allergies
• Patient’s medical history/examination findings
• Laboratory tests
• Treatment plans
• Diagnosis and prognosis
• Screening and evaluations
• Referrals/Follow up visits
• Therapeutic treatment/services

Guidelines for Proper Documentation

• Factual
• Clear and concise
• Intact i.e., completed in accordance with standards of the healthcare facility
• Legible – using blue or black ink OR print
• Specific
• Timely – documented at the time the service was rendered

Terms to Remember

• A New Patient: is defined as one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group within the past three years
• An Established Patient: is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group within the past 3 years
• A Face Sheet, Cover, or Demographic Sheet: refers to a registration form when presenting for hospital care. Is a document that contains a summary of a patient’s personal and demographic information
• A document that gives patient’s information at a quick glance
• Can include contact details, a brief med history, level of functioning, along with patient preferences and wishes
• Consultation: Is the rendering of advice or professional opinion, followed by a report of findings to the referring physician
• When an ill person seeks the advice of a doctor whom he/she trusts
• It is a type of service provided by a physician whose opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician or other appropriate source.

Communication with other healthcare professionals concerning:

• Patient’s health status
• Quality of care
• Patient treatment and planning
• Guides decision-making processes
• Reimbursement – charges and payment
• To show progress or lack of progress
• Research purposes

Legislative Requirements

• Legal reasons
• Provides evidence that care (given) was necessary

Quality of Care

• Describes responses to care
• Describes any changes made in the plan of care
• Evaluation of patients progress

Coordination of Care

• Plan interventions

Accountability

• Decision making about ongoing interventions
• Billing - charges and payment
• Can be used by all health team members

FUNCTION OF MEDICAL DOCUMENTATION

• Important when referring patients
• Coordination of various aspects of treatment
• Increases legal protection
• Requirement for reimbursement
• Assures patient confidentiality
• Ensures the standard of care is being met
• New doctors would be able to follow what others have done:
• To prevent erratic and potentially deadly interventions
• Can serve as a source of medical data for researchers (CME/peer review)

• Subjective/Medical History
• Clinical (Objective) Findings and Results of Lab Tests; X-rays, ECG, MRI, CT scans, etc
• Assessment/Diagnosis
• Plan of Care/Medical Orders
• Progress Notes
• Discharge Summary

General Principles

• It should be complete and legible
• Documentation of each patient should include:
• Reason for the encounter and relevant history
• Physical examination findings and prior diagnostic test results
• Assessment, clinical impression, or diagnosis
• Plan for care
• Date and proper identity of the author/observer

DO's

• Check that you have the correct chart/form before writing
• Identify the patient by name and hospital number
• Make sure the documentation is within your scope of practice
• Use permanent black/blue ink
• Chart completely, concisely, and accurately (factual)
• Document immediately OR within one hour after encounter OR note late entry
• Cross out errors properly
• Make continued and addendum entries correctly
• Document a patient’s refusal to allow treatment and complete a refusal form (ask the patient to sign)
• Use only commonly used and approved abbreviations and symbols
• When documentation continues on the next page, write the date, time, and “continued from the previous page”
• Sign the bottom of the last page (ideally sign the bottom of each page and the top of the next)

DON'Ts Of Medical Documentation

• Chart a symptom, such as “c/o pain,” without also describing the pain, duration, previous relief measures, pain scale, and what you did about it
• Alter a patient record….THIS IS A CRIMINAL OFFENSE
• Use shorthands or abbreviations that are not universally accepted
• Write vague descriptions such as “drainage on bed” or “large amount”
• Give excuses as to why care was not provided as instructed “due to limited staffing”
• Bring special attention to anything in the medical record i.e. do not put an asterisk or star beside abnormal lab values
• Accept verbal orders unless it is an emergency
• Don’t chart your opinions
• Don’t use white out or an eraser
• A neat line should be drawn through the incorrect information with an explanatory note and date + signature
• Don’t use highlighter pens in the health record
• Don’t leave empty lines or spaces
• Don’t write sloppily or illegibly
• Don’t write in margins

RED FLAGS OF CHARTING THAT SHOULD BE AVOIDED

• Don’t add information at a later date without indicating that it is a late entry
• Don’t date the entry so that it appears to have been written at an earlier time
• Don’t add inaccurate information {FRAUD}
• Don’t destroy records

• Begin with accurate date and time of the event as it occurs and end with a signature
• Document omissions and reason and actions taken
• Do not leave blank spaces
• Record legibly in black/blue ballpoint pen
• Do not erase, scratch out or use whitener
• Draw a line through the mistake and put your initials/signature above the mistake
• Document the patient record with institutional protocols
• Chart only for yourself, avoid vague statements and use only standard abbreviations

• Progress Note
• Problem-Oriented Medical Record (POMR)
• SOAP (Subjective, Objective, Assessment, Plan)
• Narrative Format
• Data, Assessment, Plan (DAP)
• ADIME (Assessment, Diagnosis, Intervention, Monitoring, Evaluation)

Faulty record keeping can lead to:

• Failure to include necessary information
• Charting after the fact
• Misplaced records
• Poor communication
• Failure to follow set standards of care

Observe six “rights” of medical prescription:

1. Patient Identification: At least two identifiers - Name, Hosp no, Age, Sex
2. Medication(s)
3. Dose/Dosage Form
4. Timing/Frequency
5. Route
6. Right to Refuse

• Document response to medication
• Document medication allergies
• Remember it is a legal document
• Properly sign with names and initials
• Use only approved prescription form by the institution

The patient sometimes asks a colleague for advice, not directly to the consultant but to the referring physician.

• Consultant: Person who is consulted or to whom the patient is referred.
• The one who is consulted could be a specialist, a family physician, a member of the allied health profession (e.g., physiotherapist, speech therapist, dietitian, etc.)
• Models (Bio-medical; PHC; Expanded; Pendleton; Neighbour)

Recognizing Limitations and Referring Cases

A good doctor is the one who knows and appreciates his limitations and is able, in the nick of time, to refer the case to a more knowledgeable, more skilled, or better-equipped colleague.

Such an ability to recognize limitations enhances, rather than diminishes, the reputation of a doctor and offers the best possible service to the patient.

Types of Consultation

Informal (They should rarely be used)

• Telephone
• In the corridor
• Coffee room or dining room

Formal

• Often a crucial episode in the patient's management
• Communicate directly with the consultant
• Communication should be in writing (letter or note)
• May use telephone if consultation is urgent
• The consultant and the doctor requesting consultation should see the patient together

Is a request from one physician to another to assume responsibility for the management of one or more of a patient’s specific conditions. This represents a temporary or partial transfer of care to another physician for a specific time until resolved, or on an ongoing basis.

It is the responsibility of the physician accepting the referral to maintain appropriate and timely communication with the referring physician and to seek approval from the referring physician for treating or referring the patient for any other condition that is not part of the original referral.

Referral: Implies a transfer of responsibility to another physician for some aspect of the patient’s problem or care for a limited time. For the family physician, the transfer of responsibility is never total. It is a request to assume care of a patient.

Referring Physician

Referring physician: The physician initiating either consultation or referral.

The rule of three R’s of referral:

• Request services of consulting physician;
• Render opinion; and
• Response/report to requesting doctor.

Types of Referral

• Interval referral:
  • The patient is referred for complete care for a limited period.
  • The referring physician has no responsibility during this period.
• Collateral referral:
  • The referring physician retains all responsibility of care.
  • Only refers the patient for care of some specific problem(s).
  • Referral may be long term or short term.
• Cross – referral:
  • Patient is advised to see another physician.
  • The referring physician accepts no further responsibility!
  • Occurs after self-referral by the patient or even after referral by the family.
  • In either case, the practice must be condemned.
• Split referral:
  • Takes place under a multi-specialist practice.
  • Responsibility is divided evenly among two or more physicians.

Reasons for Referral/Consult

1. Diagnosis: History, physical exam, basic investigations.
2. Management: Treatment protocol generation, further special interventions.
3. Diagnosis and management.
4. Reinforcement or confirmation of a diagnosis or plan of management.
5. Whenever the patient or family expresses doubt or shows a lack of confidence in diagnosis or management.
6. Lacked required facility, equipment, or skill?
7. Dissatisfied with the patient’s progress/prognosis.

Transfer of Care

Consultations, referrals, and transfers of care are often used interchangeably, but they are different. Transfer of care occurs when one physician turns over responsibility for the comprehensive care of a patient to another physician. Referrals are more physician-driven, while transfer of care is patient-driven more than being physician-driven.

Responsibilities of Referring Physician

• Selection of the Consultant:
• Proper consultant for the particular patient
• The consultant must have knowledge and skill appropriate to the patient’s need
• Personality compatible with that of the patient
• Availability, competency maintained by frequent use of the skills required
• Ability to work well with the referring physician
• Adequate Transfer of Information:
• Letter should list all the patient’s significant problem(s), main findings, investigations, and medications.
• The referral contract should be clearly understood by the consultant (reason for referral)
• Patient Preparation and Compliance:
• Patient should be adequately informed and ensure his or her understanding and cooperation.
• Give the patient some choice of consultants if possible.
• Details about the appointment with the consultant may be helpful.
• Evaluation of Information:
• Continue interaction with the consultant.
• Newly discovered information needs to be coordinated with that already recorded.
• Regulate information to the patient.
• Evaluation of Information:Feedback to Consultants:
• Keep a log of all referrals.
• Give feedback to the consultant.
• Let the consultant know if the consultation was inadequate.
• Help young consultants improve their "art of consultation" and should accept this as a responsibility.

Responsibilities of the Consultant:

• Provide prompt and concise reports to the referring physician.
• When consultation involves an in-patient, provide opinion and avoid duplication.
• Remain in contact with the referring physician throughout the period of care and return the patient with a full written report.
• Should not refer the patient to another physician without the knowledge and consent of the referring physician.

• May be a result of an e-mail complaint made.
• May be a result of medical negligence.
• May be a result of lawsuits and other legal disputes.
• For official documentation – pre-employment, schooling, traveling, etc.

• Is a legal document presented by the government to certify the truth of a person’s death.
• It includes where the death occurred.
• Is a permanent record of the person’s death.
• Sometimes, often documented by a medical practitioner and issued by the country coroner.
• Can be obtained by the next of kin of the deceased.

• Medical documentation is an important aspect of practice.
• Referral also adds to the quality of care for patients and the referring doctors.
• Proper entry of all necessary medical documentations with dates and the signature of the author must be ensured at all times.
• Documentation of a medical condition means a statement from a licensed physician or other appropriate practitioner providing information the agency considers necessary.