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Chapter 9 PowerPoint
- 1. The Health Record Chapter 9 Copyright © 2020 by Elsevier, Inc. All Rights Reserved
- 2. Learning Objectives 1. List the information found in the record. 2. List the uses of the information in the health record. 3. Discuss ownership of the health record and the release of information. 4. Explain the features and benefits of EHR technology. 5. List best practices for documenting patient care. 6. Define the government’s involvement in the promotion and oversight of EHR technology. 7. Explain the purpose of medical coding and list the transaction code sets required by law. Copyright © 2020 by Elsevier, Inc. All Rights Reserved
- 3. Introduction Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Documentation – Health record • the primary means by which HCPs communicate info about pt care to one another • Providers to nurses, nurses to providers • Providers to payers • Used by oversight agencies to ensure compliance • Central to health care industry and affects all areas
- 4. The Health Record Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Consists of all the information from the initial pt interview, findings and orders of the provider, and all instructions given to pt over course of care • Assembled chronologically • Failure to properly document in the health record can result in fines and loss of licensure • Paper files and charts have been mostly replaced by Electronic Health Records (EHR) • There are many advantages to EHR over paper
- 5. Clinical Content (1 of 2) • SOAP method of documentation • Subjective – pts version of symptoms • Objective – provider observations, measurements • Assessment – provider diagnosis • Plan – plan of treatment/action/medications • Authentication signifies provider responsibility • Countersignature - additional signature by a supervising provider to be compliant • Imaging and Laboratory Documentation • Image studies like x-rays, MRIs are digitally added to record and can accessed from a facility terminal • picture archiving and communication system (PACS)
- 6. Clinical Content (2 of 2) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Operative Reports • Findings during surgical procedure, pre-operative assessment and post-operative instructions • Including images or biopsy results, entire record is reviewed and signed by the physician responsible • Patient Education • Any pt education sessions, even informal, must be documented and entered into medical record • Discharge Summary • Provided to pt when discharged after medical visit • Includes studies, procedures, instructions, etc
- 7. Legal Forms (1 of 2) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Includes pt’s consent to receive treatment and to send PHI to payer, and any advance directives • Informed consent form must be signed showing pt agrees to be treated by the provider • HCP to ensure pt understands treatment • Without consent to treat, provider could be charged with the crime of battery. • Notice of Privacy Practices (NPP) details a health care organizations policies on privacy • NPP required to be clearly written
- 8. Legal Forms (2 of 2) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Advance Directive • Communicates pt’s wishes if they are unable to • Feeding, mechanical ventilation, pain relief, etc. • Do not resuscitate (DNR) order – states whether to initiate life-saving measures (e.g., CPR) • Durable power of attorney (DPOA) – specifies who makes medical decisions for pt • Each document maintained in pt health record
- 9. Uses (1 of 3) • Patient Care • Continuity of care – pt’s health care over time • Pt’s previous disgnoses and treatments crucial for quality pt care • Accurate record essential when pt sees multiple physicians, all providers on same page • Billing • “If it wasn’t documented, it wasn’t done” • peer review organizations (PROs) review services for necessity • Medicare, insurers use prospective payment system based on diagnosis • Insurers may deny claim and refuse to pay
- 10. Uses (2 of 3) • Legal Matters • A pt’s health record is considered a legal document and evidence in court if pt files malpractice lawsuit • Risk Management • Documents pt-related incidents that occur in the facility as they relate to pt care • Management/Administration • Administrators monitor compliance, staff resources, pt care, and use of equipment and technology • Information used to make pt services, staffing and budget decisions
- 11. Uses (2 of 3) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Quality Improvement • Identifying a problem, educating staff, then reevaluating if issue has improved or been solved • QI programs required by many agencies • Research and Public Policy • Pt’s diagnosis documented in medical record and translated into ICD-10-CM codes • show health data and health of a population
- 12. Ownership and ROI • Ownership • Pt owns information, but not medium it’s kept on • Data is owned by pt; however, storage and maintenance of data is facility responsibility • Release of information (ROI) • Nobody has access to pt’s PHI unless pt allows it • Pt must sign ROI form authorizing disclosure to others • Even if pt wishes to see their own records • All signed ROIs are kept in pt’s health record
- 13. Electronic Health Records (1 of 3) • Electronic health record (EHR) - digital version of pt’s paper chart • Record viewed/shared with by multiple parties • Data recorded in real-time • Send prescriptions directly to pharmacies • Standardized data input • Using drop-down menus instead of freely typing • Alerts for allergies/contraindications • Secure messaging • Record completion reminders and other tools for compliance
- 14. Electronic Health Records (2 of 3) • Computer-assisted physician order entry (CPOE) – allows providers to select and digitally transmit orders/meds • Reduces errors • Most systems will not allow ‘out of range’ values • Clinical decision support (CDS) system – evidence- based approaches and treatments • More secure than paper records, using passworded logins that track identity of user • Audit trail - tracks the identity and time each user viewed the medical record
- 15. Electronic Health Records (3 of 3) • Health Information Exchange • Sharing pt data with other providers from other health care facilities or networks • Software must be interoperable, or have the ability to communicate, exchange data, and use the information that has been exchanged across clinicians, lab, hospital, pharmacy, and patient regardless of the EHR system • Patient portal – pt access to EHR • Lab/test results • Problem list • Communicate with staff and physician (scheduling)
- 16. Documenting Guidelines (1 of 4) • Military Time • Using military time (1200 hours instead of noon) helps eliminate a.m./p.m. miscommunications • Approved Abbreviations and Symbols • The Joint Commission (TJC) developed standards for using abbreviations in health care setting, since misunderstandings have led to injury or death • Correct Punctuation • Comma or period can completely change message • Foley catheter removed in cardiac chair reading. • Foley catheter removed, in cardiac chair reading.
- 17. Documenting Guidelines (2 of 4) • Active Voice • Conveys events more concisely, who did what • Passive: “family notified” (omits who did it) • Active: “Notified family” (recorder notified) • Spelling • Errors in spelling are unprofessional and lazy • Spell checkers will not catch a correctly spelled word that is used wrong (...a fowl smelling odor) • Seems obvious, but could endanger a legal case • Being Concise • Not recommended that you record lengthy narrative notes about normal events in pt care
- 18. Documenting Guidelines (3 of 4) • Being Specific • Be careful when using words like large and small • Use measurements, as they are not subjective • Large laceration vs. three-inch laceration • Sticking to the Facts • Do not put personal assumptions in the health record • Never use health record to criticize other HCP • Corrections • Follow your office’s policy for making corrections • Never completely black out mistaken entry, put line through it so it is still legible • Most EHR software has its own correction functions
- 19. Documenting Guidelines (4 of 4) • Late Entries • Follow office procedure to make late entry • Make them as soon as possible • Emergency Care • Always treat the pt first, then document event • Patient Noncompliance • Must be reflected in record as factual information • Missing appointments is considered noncompliant • Missing follow-up visits is failing to follow medical instructions. Documentation will help in a legal case
- 20. Coding Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Coding translates diagnoses and procedures into a short numeric or alphanumeric code • HIPAA requires use of specific codes for billing • Standardizing clinical data increases clarity • Medical coders and billers specialize in assigning codes • They review record to determine applicable code(s)
Editor's Notes
- subjective section includes the symptoms that the patient is experiencing—such as nausea, pain, confusion—that cannot be objectively measured. Objective signs are the other piece of the complaint—those that can be measured or observed, such as fever, weight gain or a rash. The assessment piece is the provider’s compilation of signs and symptoms and evaluation to determine a diagnosis. The plan is the provider’s action plan or treatment regimen to the given diagnosis. As part of the treatment, documentation for any medications prescribed will be made in the health record, along with prescribing order to the pharmacy, and any consultations or referrals.
- The discharge summary, also called a discharge report, is provided to the patient when he or she is discharged or checks out after the medical visit. The discharge summary includes the patient’s diagnoses; any procedures that were performed; the patient’s diagnostic studies, including laboratory and imaging; progress notes; physician’s orders, consultation reports; and any discharge instructions.
- Informed consent involves a full explanation of the plan for treatment; the potential for complications, risks, and side effects; a discussion of alternate treatments, if any; and the consequences of not performing the treatment at all Battery can mean the patient was physically harmed or injured, developed an illness because of the provider’s intervention, or even felt violated because they did not consent to the provider’s touch. If the patient refuses to consent to treatment – and the treatment is performed anyway – the patient can then sue for battery. NPP How a health care organization may disclose or use a patient’s protected health information (PHI) both with and without her authorization, the patient’s rights concerning her privacy, and the organization’s responsibility to safeguard her information.
- Using an advance directive, patients may elect, in advance, to forego feeding or breathing tubes when, for example, they are in an irreversible coma or a condition that requires life support. A DNR order is a document signed by the patient specifying that, if the patient has no heartbeat or is not breathing, no life saving measures should be performed, such as CPR
- Managements use of documentation: For example, the health services administrator may look at records to identify the sources of revenue for the clinic. The health services administrator may also use the data in medical records to track the number and types of patients seen in the clinic to help negotiate contracts with insurance companies and monitor the number of referrals to determine whether an in-house service is cost-effective or not.
- ICD Codes and impact on Research/Public Policy For example, if data from the ICD codes show an increase in the new cases of a sexually transmitted infection, such as syphilis, the state or county health department may increase funding to the health departments to hire more staff and provide free testing services to the community.
- Ownership: For example, in the case of paper records, the physical paper belongs to the health care organization, while the information belongs to the patient. This means that the patient may request certain changes be made to the information in the medical record, such as change of address and name, and how this information is used and shared outside of the health care organization. However, the organization owns the medium that the patient’s information is on When will pt need to sign ROI? (examples) A patient will also be asked to sign an ROI if she is being transferred to another facility so that the new provider can see her history and plan of care. If a patient is hospitalized, she may be asked to sign an ROI on her discharge to have the records from her hospital stay sent to her primary care provider (PCP). Even if the patient wishes to view her own records, she must sign an ROI form.
- Features of a fully functional EHR system: Store and access patient data from any location instantly Order tests and medications (known as computer-assisted physician order entry [CPOE]) Suggest plans of care and treatment protocols to providers Print information for patients about specific diseases and treatments Generate care and discharge instructions specific for the patient Present results of laboratory and diagnostic testing Alert providers to drug allergies and interactions Prompt wellness screenings and other reminders for preventative medicine Assign and track tasks among various health care providers Facilitate messaging and communication between health care practitioners Generate correspondence to patients and their families Track authentication of the record and audit users who accessed the record Schedule patients Generate reports Support billing functions
- Both private and governmental agencies have recognized the benefits of widespread interoperable EHR systems - would reduce inefficiencies like duplicate tests and imaging. Despite initiatives from both public agencies and private sector groups, the United States has not yet achieved interoperability across organizational boundaries.
- Military time: Military format is a 24-hour-clock system wherein each of the 24 hours in the day are counted, rather than repeating twelve hours and separating them with the a.m. and p.m. denotation -In this system, 11:00 a.m. is written as 1100; 11:15 a.m. is written as 1115; 12:00 p.m. (noon) is written as 1200, and so on. Instead of starting the hour after noon as 1:00 p.m., however, this hour is 1300, 2:00 p.m. is 1400, and on until midnight (2400), after which the day begins again with 0001 Abbreviations approved by TJC: Do Not Use Potential Problem Use Instead U, u (unit) Mistaken for “0” (zero), the number “4” (four) or “cc” Write "unit" IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten) Write "International Unit" Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d, qod Mistaken for each other Write "daily“ Write "every other day" Trailing zero (X.0 mg)* Lack of leading zero (.X mg) Decimal point is missed Write X mg Write 0.X mg Can mean morphine sulfate MS or magnesium sulfate Write "morphine sulfate" MSO4 and MgSO4 Write "magnesium sulfate"
- Being Specific: It can be easy to be unspecific. For example, the progress note states: “patient was uncooperative.” This phrase leaves many questions in the mind of the reader: What were the uncooperative actions—spitting, pushing, or fighting? Why was the patient uncooperative? Was he in pain? Were you giving him an injection? Was he confused? Did his actions affect patient care—did he refuse his pills, pull off his dressings, or refuse blood work? Was he uncooperative at every visit, or on every shift, or just this one time? A better sentence to communicate would be, “Patient stated that he didn’t want to have any more finger sticks,” and then record that the importance of blood sugar testing was explained to the patient and the provider was notified Sticking to the facts: “Pt collapsed in parking lot. Brought back into clinic. Contacted Dr. Brown.” or “Patient felt weak before discharge but was told by Dr. Brown to go home. He collapsed in parking lot.” The first statement is accurate and honest. The second statement implies friction between the team members and accuses the provider of poor judgment. An attorney for the patient would be very excited to find discrepancy or fighting among team members.
- Box 9-2 The Five Nevers of Documenting Never document for someone else. Never give anyone your username and password. Never ask someone else to document for you. Never document false information. Never delete, erase, scribble over, or white out. Never tamper with the medical record.
- Example code sets: Coding System Description Sample Code Code Meaning ICD-10-CM Used for chief complaints A92.3 West Nile virus infection Diseases and diagnoses ICD-10-PCS Inpatient procedures BT0B0ZZ X-ray of bladder/urethra with high osmolar contrast Procedures Health Care Nonphysician services J0897 Injection, denosumab, 1mg Common Procedure (ambulance, DMEs, meds) Coding Sys. (HCPCS) (supplies) Current Procedure HCP services 59400 Routine obstetric care… Terminology (CPT) Code on Dental Dental procedures D3348 Retreatment of previous root canal Procedures (CDT) National Drug Code Product ID for every med 54092-383 Adderall XR (NDC) sold for use in humans