medical record documentation n.
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MEDICAL RECORD DOCUMENTATION. 2007/2008. OBJECTIVES. At the end of this presentation, participants will be able to: Define documentation Explain the importance and purpose of documentation Identify the basic information that is required when documenting in the medical record

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    2. OBJECTIVES • At the end of this presentation, participants will be able to: • Define documentation • Explain the importance and purpose of documentation • Identify the basic information that is required when documenting in the medical record • Discuss do’s and don’ts of documentation • Discuss concerns regarding faxing • Discuss do’s and don’ts of computerized charting • Explain SOAP charting • Document satisfactorily in a medical record

    3. Definition • Documentation is a record of the patient’s health status and medical conditions. Documentation should reflect the patient’s perspective on his or her health and well-being, the care provided, the effect of care and the continuity of care.

    4. Documentation • Factual • Clear and concise • Intact • Specific

    5. Purpose of Documentation • Communication • Accountability • Legislative requirements • Quality Improvement

    6. The best defense is a good documentation offense…..Welter, Dana, Med, RN, C….good documentation not only can help you in court, but it also can keep you out of court

    7. Good documentation reflects the quality of care that you give your patients and is evidence that you acted as required or ordered.

    8. “If it’s not in the medical record, it didn’t occur.”CALFEE, BARBARA E, 1993

    9. Legibility • Documentation has to be legible to anyone who may read it. If you have poor penmanship …… print.

    10. ESSENTIAL INFORMATION TO INCLUDE IN THE MEDICAL RECORD • Date and time (military time) of entry • Patient identification on every page • Documentation of your full name, credentials and job title in the required sections with signature.

    11. ESSENTIAL INFORMATION TO INCLUDE IN THE MEDICAL RECORD • Medical/Dental Provider Orders: • Date and time of call • Provider’s name and verbal/telephonic order • Signature with a complete date, year and military time • Document every attempt to contact a medical/dental provider • Verbal or telephonic order or telephonic reporting of critical test results written • The receiver of the information writes down the information or results and enters it into a computer • The receiver of the information “read back “ the order or test results • The receiver of the information receives confirmation from the individual who gave the order or test results • Document your name and title • Ensure provider countersigns order within the designated time of your organization

    12. DO’S AND DON’TS OF DOCUMENTATION • DO’S….. • Check that you have the correct chart before you begin writing • Identify patient by name and A# • Make sure the documentation is within your scope of practice • Use permanent black ink • Chart completely, concisely and accurately (tell the facts) • Document within one hour after encounter or note late entry • Cross out errors properly • Make continued and addendum entries correctly

    13. DO’S AND DON’TS OF DOCUMENTATION • DO’S….. • Document a patient’s refusal to allow treatment and complete a refusal form (Complete DIHS 820). It is important to note that even if a patient refuses the same medication three times a day, a refusal form must be for each time the patient refused the medication. • Use only commonly used and approved abbreviations and symbols from the DIHS Approved Abbreviation List • When documentation continues on the next page, sign the bottom of the first page and at the top of the next, write the date, time and “continued from previous page”

    14. DO’S AND DON’TS OF DOCUMENTATION • DON’TS… • 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’s record…THIS IS A CRIMINAL OFFENSE • Use short hand or abbreviations that are not accepted by your organization. If you do not know the abbreviations, write it out • 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

    15. DO’S AND DON’TS OF DOCUMENTATION • DON’T…..- Chart your opinions • - Don’t be vague or indecisive. (Avoid terms like “appears to be” or “apparently” which can seem as though you are not sure of what you are describing)

    16. DO’S AND DON’TS OF DOCUMENTATION • DON’TS….. • Don’t use white out or an eraser • A neat line should be drawn through the incorrect information with an explanatory note (i.e. error, wrong chart) and the date of correction and initials added to the correct entry) • Document correct entry in accordance with national policy • Don’t use highlighter pens in the health record • Don’t leave empty lines or spaces • Don’t write in margins • Don’t mention incident or accident reports in the medical record

    17. Documentation Don’ts • Chart staffing problems • Leave empty spaces • Chart before the fact • Write sloppily or illegibly • Argue/criticize in the chart • Use abbreviations which have not been approved by DIHS

    18. Prohibited Abbreviations • Don’t use abbreviations which are found on DIHS’ list of abbreviations to avoid: • U,u • IU • Q.D., QD, q.d., qd • Q.O.D., QOD, q.o.d., qod • Trailing zero (X.0 mg)1 • Lack of leading zero (.X mg) • MS • MSO4 • MgSO4 • DC

    19. RED FLAGS OF CHARTING THAT SHOULD BE AVOIDED • Don’t add information at a later date without indicating in the record 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. Charting information that you have not performed is considered FRAUD • Don’t destroy records

    20. Risky Business • Failure to document or faulty documentation on your part is risky behavior that should be avoided at all costs

    21. FAXING AND COMPUTERIZED RECORDS • According to the American Health Information Management Association, there are certain safeguards that you should take to protect the confidentiality of your clients when you are faxing their records

    22. EMAIL • No Expectation of privacy • Does not go away • Procedure to protect privacy

    23. Confidentiality Faxing Documents • Before faxing, call the intended recipient; ask the recipient to send a return fax verifying receipt of the information • On the fax cover, clearly note that the information is confidential • If you do not receive fax verification, check the fax machine’s internal log to determine where the fax was sent • If it went to the wrong number, send another fax to that number requesting the recipient to destroy the information

    24. Electronic Medical Record Documentation Guidelines • Double check the information before you enter it • Indicate if a provider’s order is written or verbal (in person or via phone) • Never share your password • Always change your password every 45-90 days

    25. Electronic Medical Record Documentation Guidelines • Do not leave patient information displayed on the screen • Log off the computer when you are not using it • Retrieve any printouts immediately • Ensure that proper backup files are kept

    26. Electronic Medical Record Guidelines • Familiarize yourself with your state’s rules and regulations and your organization’s policy and procedures for patient data, confidentiality and disclosure • Once notes are entered into the computer, they become part of the permanent medical record and should not be deleted or edited at a later time without an explanation that is documented, signed and dated

    27. Soap Documentation • SOAP CHARTING • This is an acronym for: • Subjective data • Objective data • Assessment • Plan

    28. Subjective • Subjective observations are what the patient states • State purpose of visit • Important and relevant positives and negatives from a focused history

    29. Objective • Measurable observations such as senses: seeing, touching, hearing, and smelling. Examples include rash, heart rate, and halitosis • Important and relative positive and negative physical findings, test results

    30. Assessment • Analysis/conclusion based on the subjective and objective findings • Document approved nursing diagnosis within your scope of practice (medical diagnosis for mid levels and MDs)

    31. PLAN • Planning of management and treatment, both present and future • Include: • Patient health teaching • Medications and treatments • Referrals as appropriate • Patient verbalization of understanding (need to be specific about what patient verbalized understanding of, i.e. patient verbalized understanding of medications • Follow up • Diagnostic work-up • Patient’s questions answered

    32. Documentation Habits • Avoid handwriting that is illegible or incomplete in documentation • Avoid using abbreviations that are not approved in DIHS Policy. Abbreviations to Avoid can be found on DIHS’ Global Drive:G:\DIHS Policy and Procedures\Current Approved and Prohibited Abbreviations\Abbreviations to Avoid Poster final Color_DIHS.doc • Use approved abbreviations, which can be found on DIHS’ Global Drive: G:\DIHS Policy and Procedures\Current Approved and Prohibited Abbreviations\Approved Medical Abbreviations.doc • Avoid using unapproved forms. DIHS’ approved forms can be found on the official DIHS website at: • Use only SOAP format for documentation • Avoid personal opinions, vague entries, and unauthorized entries

    33. Hazards of Improper Documentation • Faulty record keeping • Failure to include information • Charting after the fact • Misplaced records • Poor communication • Failure to follow set standards of care

    34. Medication Documentation • Observe six “rights” of medication administration: • Patient- 2 identifiers • Medication • Dose/Dosage form • Time • Route • Right to refuse

    35. Medication Documentation- continued • Document medications that are held • Document route of medication administration • Document response to medication • Document medication allergies

    36. REFERENCES • Calfee, Barbara E., “Documentation and Medical Record Problems in Court”, Nurses in the courtroom: Cases for commentary for Concerned Professionals. Cleveland, OH: ARC Publishing, 1993 • McGinnis, Jerri “Documentation/S.O.A.P. notes” power point presentation, Oct 2006 • Welter, Dana, “The Best Defense is a Good Documentation Offense” COEXCEL: Linking Learning to Performance • Williams and Wilkins “Nurses Legal Handbook”, 5th edition • • Keenan, Joseph M., “Review of SOAP Note Charting” • Hospital Documentation: Sample Policies, Procedures, and Forms, Joint Commission Resources

    37. REMEMBER….. Good documentation not only can help you in court, but it also can keep you out of court

    38. AND…… If it’s not in the medical record, it didn’t occur”CALFEE, BARBARA E, 1993


    40. Example SOAP Note • A: Fasting labs CBC, SMAC -20 RPR and HGB-A1C • S: Routine Labs • O:

    41. Example SOAP Note FBS • S: Fasting Blood Sugar • O: FBS 88, Normal Values 80-120 • A: Health maintenance • P: Follow-up as scheduled

    42. Example SOAP Note PPD Read • S:PPD read: “this itches and my arm pained me yesterday.” • O: 18 mm induration with erythema • A: Potential for infection • P: HCA 1% given by RN X. Educated on symptoms of tuberculosis, getting annual CXR, not to get anymore PPD tests. Verbalized understanding. CXR scheduled.

    43. Example SOAP Note Sick Call • S: “I’m having chronic back pain for several days.” • O: New detainee complain of chronic back pain; transfer paperwork showing Rx for naposyn for pain management . Pain is a 3-4 on a ten point scale. Vital signs are within normal limits; assessment stable; zero signs/symptoms of bruising or new trauma. • Alteration in comfort • P: OTC Motrin 200mg 1 tab tid prn with food • Follow-up with further pain management options at scheduled PE. • Encouraged to refrain from excessive physical activity • Educated on stretching exercises • Verbalized understanding of above instructions and follow-up as needed.

    44. Example SOAP Note • S: dusa • O: shows glucose • A: deferred • P: result to provider, advised to increase water.

    45. More Examples of Documentation Sick call: • S: "My lips have a lesion" • O: A/O x3, show on the lower lip an open lesion, no s/s of infection • A: Discomfort related to condition • P:Chapstick to apply to affected area, increase water intake • Return to clinic prn

    46. More Examples of Documentation • S: "I have a wound that never heals" "I have had this wound x 6 months, it started as local itch and I scratched it and it turned like this". "This is the first time I have had a wound like this, I took pills but only half of what was prescribed. I work in a restaurant and I stand all day" • O: A/Ox3, VS: 130/79 79 18 99.9 • Show on his left leg ankle an ulcer 60mm open wound. Dry skin surrounding it, dark filthy. Gauze show yellowish secretion, slight amount of blood, no pain. Refer itiching around. Varicose vein. Multiple fungal lesions on feet as well as contact dermatitis • A: Discomfort related to condition r/o stasis ulcer • P: Referral to hospital ER for evaluation and further care. Informed CD

    47. More Examples of Documentation Sick Call: • S: c/o "bump" on leg since 11/20. Denies etiology, does not recall being bitten by inset. States "bump" was larger initally but has been squeezing pus out". Current pain level-0/10. Denies h/o chronic diseases, denies prior symptoms • O: VS: 99.2 129/82 66 18 • left lower extremity outer aspect below knee • 22cm size round erythemic firm lesion, negative tenderness, manually expressed copious amount of sero-sang • drainage without odor • left extremity: Nl color, +distal pulses, +cap refill<3sec, warm to touch, +FROM, NL gait, cleansed area with betadine, applied bacitracin and bandage • wound culture obtained • A: Skin lesion of unknown etiology • P: Keflex 500mg 2 PO now, then 1 q6 hours x 7 days • Tylenol 325mg 2 PO now • Lab: wound culture • Return to clinic 11/10 for follow up • Pt Ed: diagnosis, treatment plan, medications/SE, follow up • Verbalizes understanding