Medical Documentation

1. Medical Documentation Avni Bhalakia, M.D. St. Barnabas Hospital July 29, 2009

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

3. 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

4. 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

5. 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

6. Importance of Documentation • Patient Care & Safety • Legal Implications • Financial Implications

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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!

15. 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

16. 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)

17. WHAT TO Document • Informed consent, risks and benefits explained • Incidents • Attempts at & communications with family members • Communications with primary care physicians & consulting services

18. 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.

19. DO NOT Document • False information • E.g. Part of the exam you did not perform • Personal opinions or judgments • Be objective

20. 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

21. Good Documentation • Promotes good physician-to-physician communication • Helps prevent medical errors • Enhances patient care • Has legal and financial impacts

22. Documents of the Inpatient Unit • Admission Note (H&P) • Progress Note • Discharge Summary & Patient Plan • Physician Orders

23. Must Have on EVERY Document • Patient label on every page • Time & Date all entries • Sign & Stamp all entries

24. Patient Label on EVERY page in chart

25. 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 Admission Note (H&P)

26. Example: Home Medications Write “unknown” or “unable to obtain.” Do not leave blank.

27. Progress Note • Means of communication between care providers • Convey thought process of decision making and plans • Record of events Patient Label Note Title (e.g. PGY1 Progress Note, Addendum, Event Note, etc) Date & Time Write Legibly Sign & Stamp

28. 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

29. 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

30. 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

31. 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

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

33. 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

34. “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” Example Department of Medicine, University of Florida

35. 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 for Post-Hospital Care

36. 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

37. Physician Orders • Care plan for hospital admission that includes • Nursing care: vitals, ins/outs, special instructions • Medications  Pharmacy • Circumstances to notify physician

38. Physician Orders • The Basics • Patient label • Diagnosis, allergies, & weight • Date & time order • Signature & stamp

39. 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

40. Official “Do Not Use” List by Joint Commission The Joint Commission, May 2005

41. Other “Do Not Use” Abbreviations The Joint Commission, May 2005

42. 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

43. Medication Reconciliation • Generates an accurate and complete medication list • Reduces • Inadvertent omission of home meds • Number of adverse medication events • Failure of restarting home meds • Errors associated with doses or dosage forms

44. 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

45. 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

46. 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.