Medical documentation

Medical DocumentationMedical Documentation
Prof. AMER ELTWATI IRHUMA M.B.ch.B FRCS
Consultant Surgeon

QuoteQuote
"Knowing is not enough;
we must apply.
Willing is not enough;
we must do.
“ -Johann von Goethe “

Lecture objectivesLecture objectives
By the end of this talk attendant must be able to :
– Define the medical documentation
– Understand the importance of documentation
– Identify the Purposes of documentation
– Recognize the documentation principle in general
terms
– Differentiate between different types of data
– Write quality documentation

DEFINTIONDEFINTION
documentation of a medical condition mean
a statement from a licensed physician or
other appropriate practitioner that provides
information

INTRODUCTIONINTRODUCTION
Doctors and other providers should remember that the first and
primary purpose of a medical record is to accurately and
completely document patient-status and care.
The medical record is a communication amongst health care
providers to document type of care, quality of care, patient progress,
and patient status. It is important to remember the intended
purpose of medical records.
Records that are kept solely because of their legal significance will
appear to be self-serving and defensive.
Improper or biased documentation can hurt a cause just as much,
if not more, than proper documentation can help.

INTRODUCTIONINTRODUCTION
Medical records are one of the primary sources of evidence
used by the court in deciding whether a physician is liable for
malpractice. Incomplete records can be devastating to the
defense of a claim; as far as the court is concerned, if it’s not in
the medical record, it simply did not happen. Sloppy or
inaccurate documentation can create the impression that the
medical care rendered was less than professional.
Accurate and legible entries are mandatory for appropriate
patient management, continuity of care, coding procedures, and
appropriate risk management.
Documentation of patient evaluations and treatment must be
completed at the time the service is performed.

Importance of the Medical RecordImportance of the Medical Record
 The medical record you prepare today may be
reviewed by others, both within and outside
the hospital or practice.
 The accuracy and completeness may be
questioned or discussed and you may be
asked to justify your record-keeping methods
and practices by non-medical personnel.

Importance of the Medical RecordImportance of the Medical Record
Protection for medical personnel
Reflection of good patient care
– It provides for continuity of care and promotes patient
safety
– It provides written evidence of the care provided,
interventions, interactions, etc
– It is a source of information for risk identification and
quality improvement
– It is essential for coding
– It may be the best defense if a claim is filed

DocumentationDocumentation
Purposes
Preserves basic patient information
Justifies treatment
Allows continuity of care
Satisfies regulatory requirements
Provides data for quality control and research
Is documentary evidence of evaluation,
treatment, change in condition, etc
Is a communication tool between clinicians

The general principles of documentation
The medical record should be complete and legible.
The documentation of each patient encounter should
include:
- the chief complaint and relevant history
- physical examination findings
- prior diagnostic test results; assessment
- clinical impression or diagnosis
- plan for care
- date and a verifiable legible identity of the health care professional
who provided the service.

If not specifically documented, the rationale for ordering
diagnostic and other ancillary services should be able to be easily
inferred.
To the greatest extent possible, past and present diagnoses and
conditions, should be accessible to the treating and / or consulting
physician.
Appropriate health risk factors should be identified.
The patient's progress, response to and changes in treatment, planned
follow-up care and instructions, and diagnosis should be documented.

The ICD-9-CM codes( International Classification of Diseases - Clinical
Modification (ICD-CM). should be followed
An addendum to a medical record should be dated the day the
information is added to the medical record and not dated for the
date the service was provided.
A service should be documented during, or as soon as practicable
after it is provided in order to maintain an accurate medical record.
The Confidentiality of the medical record should be fully
maintained consistent with the requirements of medical ethics and
of law.

What Is Good Documentation?What Is Good Documentation?
Good Documentation is:
 Timely
 Accurate
 Complete
 Legible
 Free of Extraneous Information
 Objective
 Comprehensive
 Signed, Timed, and Dated

AA POORPOOR Medical Record Is:Medical Record Is:
Blaming or accusatory
Stated with innuendo
Incomplete
Inconsistent
Falsified
Illegible

An accurate, complete, legible medical record
IMPLIES
accurate, complete, organized assessment and
management

AccurateAccurate
Document facts, observations only
Do NOT speculate about patient or incident
Double-check numerical entries
Recheck spellings of:
• Persons
• Locations
• Medical terms

AccurateAccurate
 If you make a mistake, document it.
 It is better to record your own mistakes that
for someone else to uncover them.

AccurateAccurate
How to Correct a Medical Record
 Draw a single line through the
inaccurate material
 Date & initial the correction
 Add a note regarding the correction
 Enter the corrected statement in
chronological order

AccurateAccurate
How to Correct a Medical Record
An easy way to remember is by using the
S.L.I.D.E. rule
 S = Single
 L = Line
 I = Initial
 D = Date
 E = Error

When in doubt.....
AccurateAccurate

CompleteComplete
Include all requested information
If information requested does not apply,
note “not applicable” or “N/A”
If you look for something and it isn’t there,
document its absence
Failure to document implies failure to
consider

CompleteComplete
Documenting Patient Education
 Specific information given to the patient
 List any handouts by name that you give
the patient
 Document patient understanding of
instruction, information, etc. such as
“patient verbalized understanding”
 Documenting “ the patient understood” is
not appropriate and is poorly defensible

If you have a long report, don’t
hesitate to use additional pages
CompleteComplete

CompleteComplete
IF IT ISN’T DOCUMENTED,
IT WASN’T
DONE!

LegibleLegible
If you cannot read the report, you
may be unable to determine what
happened
Documents presented in court must
“speak for themselves”
If a document cannot be deciphered,
the court has the right to ignore it
altogether

LegibleLegible
 Legible Charting It is the single most effective
way to improve medical records!
 Writing legibly requires little or no additional
time
 When defending malpractice actions, an
illegible record is of no help

LegibleLegible
If the report is sloppy, others
will assume that the care was
equally sloppy

Free of Extraneous InformationFree of Extraneous Information
Avoid labeling patients (“drunk”,
“psych patient”)
Describe the observations you made
Preface comments made by the patient
with “per the patient” or “patient
stated”

Record hearsay only if applicable
Do NOT record hearsay as facts
Use quotation marks only if a
statement is accurate word-for-word

Avoid interjecting humor The public
does not regard medicine as a funny
business

Types of DocumentationTypes of Documentation
The type of documentation that you use will
depend on the facility policy
Regardless of the type of documentation
you use, there are several key components

OBJECTIVE DATAOBJECTIVE DATA
SUBJECTIVE DATA
vs

ObjectiveObjective vsvs.. SubjectiveSubjective
 Objective documentation is based in fact.
It is:
 Measurable
 The examiners assessment findings
 Includes results of diagnostic tests
 Is non-judgmental

Objective data is what you:
See
Hear / auscultate
Smell
Palpate

Objective data also includes what you don’t find
 Statements of non- findings:
 May be what leads you to consider a
differential diagnosis
 Indicates that thorough exam was
completed, that you didn’t overlook
anything
 May eliminate the potential for your word
against theirs situations if you find yourself
in court

 Subjective data is information received
from the patient/family and includes:
Chief complaint
History of present illness
History of past illnesses
Systems review
Family and social histories

Informed ConsentInformed Consent
Informed consent is a dialog; an
exchange of information, between the
physician and the patient .
The purpose is to provide adequate
information to the patient so the patient
can make an informed choice regarding
their health care

Informed consent is a process, it is
NOT a piece of paper
Informed consent occurs as the
physician discusses with the patient
–The disease/diagnosis
–Proposed treatment with other
options
–Risks and benefits

This implies:
–The patient is given objective
medical information related to their
state of health in language they can
understand
–The patient is allowed to ask
questions and have them answered
to their satisfaction before making a
decision

Sign Your Notes!Sign Your Notes!
 Sign every entry
 Every entry must have a date and time
 Never sign someone else’s notes
 Countersign someone else’s notes only as
verification

Recording of TimeRecording of Time
Record Date and Time of:
 All entries
 Consultation notification
 All orders
 Securing of all consents, authorizations,
releases
 All informed consents
Failing to document times implies lack of
concern about the time factor

Protect YourselfProtect Yourself
 Never alter medical records
 Never skip lines or leave blanks
 Never obliterate
 Document only with ink

Select Your Words CarefullySelect Your Words Carefully
 Selecting your words carefully and
thoughtfully is very important. You want to
state your documentation with confidence
and without hesitation.
 Don’t use vague words

Select Your Words CarefullySelect Your Words Carefully
 Avoid using vague words such as:
“Unintentionally”
“Inadvertently”
“Somehow”
“Unexplainably”
“Unfortunately”
“Apparently”

Medical Records & Confidentiality &Medical Records & Confidentiality &
SecuritySecurity
 Maintain physical security of records
 Never remove records from the facility /office
 Release records only through proper
procedure
 No unauthorized copying of records
 No access to records by unauthorized
individuals

In SummaryIn Summary
Remember…………………
POOR DOCUMENTATION MAKES
GOOD CARE LOOK BAD!!!!

In SummaryIn Summary
REMEMBER……..DOCUMENT
OBJECTIVELY
Good documentation may be your best
defense in a malpractice claim

COMMITMENTS
HONESTY
PROFESSIONALISM

CONCLUSIONCONCLUSION
 As responsibility grows so does accountability.
There are few, if any, professions that bear more
responsibility than the medical profession. With this
huge responsibility there is strict accountability.
 What does this accountability mean to the average
physician, nurse, hospital, or other health care
provider ?
 It means that proper documentation and record
keeping can be as important as providing proper
care.

THE MESSAGETHE MESSAGE
Better SAFE
than SORRY

Medical documentation

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