Documentation Of Medical Records - Veterans Affairs

Documentation ofMedical Records

Documentation of MedicalRecordsIntroduction: In a continuous care operation, it is critical to documenteach patient’s condition and history of care. To ensure the patient receives the best available care,the information must be passed among all members ofthe interdisciplinary team of caregivers. Proper documentation is always important in ahealthcare setting. Incorrect information, or no information at all, mayresult in serious injury or death of a patient. Negative legal repercussions are often avoidedbecause of proper documentation and appropriatecommunication of patient information.

Documentation of MedicalRecordsObjectives: Recognize opportunities for documentation Apply electronic charting guidelines Locate appropriate documentation resources Understand staff’s responsibility to provideand document patient education resources Identify the medical record as protected andconfidential information Identify legal aspects of properdocumentation

Documentation of MedicalRecordsTopics:1. Overview2. Opportunities for Charting3. CPRS (Computerized Patient RecordSystem)4. Patient Education5. Legal Aspects

Documentation of MedicalRecords - OverviewWhat is documentation and why is it important? Medical record documentation is required to recordpertinent facts, findings, and observations about aveteran’s health history including past and presentillnesses, examinations, tests, treatments, andoutcomes. The medical record documents the care of thepatient and is an important element contributing tohigh quality care. An appropriately documented medical record canreduce many of the hassles associated with claimsprocessing. Medical Records may serve as a legal document toverify the care provided.

Documentation of MedicalRecords - Overview The medical record facilitates:– The ability of the physician and other healthcareprofessionals to evaluate and plan the veteran’s immediatetreatment, and to monitor his/her healthcare over time.– Communication and continuity of care among physicians andother healthcare professionals involved in the patient’s care.– Accurate and timely claims review and payment.– Appropriate utilization review and quality of care evaluations– Collection of data that my be useful for research andeducation.

Documentation of MedicalRecords – OverviewWith documentation of medical records,particular emphasis must be placed on thefive factors that improve the quality andusefulness of charted tenessTimelinessConfidentiality

Documentation of MedicalRecords – OverviewAccuracy Each individual medical record MUST becorrect. Information in the medical record is reliedupon for accuracy throughout theveteran's lifetime. Inaccuracies (either commission oromission) lead to improper medical advicebeing provided in error and may result inadverse healthcare outcomes or in legalproceedings.

Documentation of MedicalRecords – OverviewRelevance It is important that medical records containonly information relevant to the patient’shealthcare. Inclusion of inappropriate and irrelevantinformation could result in damaging legalaction.

Documentation of MedicalRecords – OverviewCompleteness ALL documentation, including that from theclinics, hospital and TLC, must be included inmedical record. Every document should be free from omissions. Documentation is sent to CPRS which maintainsa complete record for each patient. The Joint Commission requires continuousreview of medical record documentationthroughout the year.

Documentation of MedicalRecords – OverviewTimeliness – There are specific time requirementsfor completion of the medical record: History and Physical – completed and signed within24 hours of admission Post-Operative Note – written immediately followingsurgery Operative Note – dictated and signed within 24hours of operation/procedure Medical Record – must be completed within 7 daysof discharge or outpatient visit

Documentation of MedicalRecords – OverviewConfidentiality Medical records are confidential andprotected by authority of the Privacy Act of1974, its amendment and HIPAA. Don’t leave patient-identifiable information onyour computer screen or exposed in yourwork area. Shred papers containing patient informationthat is not relevant to medical documentation. Don’t talk about patients or families inhallways, elevators, or in other public places. Don’t release medical record informationwithout the patient’s consent.

Documentation of MedicalRecords – OverviewLegibility – physicians get a bad rap aboutnotes and prescriptions being unreadable andillegible. CPRS makes medical records easyto read.Omissions – Seemingly innocent omissions inmedical record documentation can have direconsequences.

Documentation of MedicalRecords – OverviewPhysician problem areas and consequences: Failing to write a note:– Some physicians make rounds and pass thenurses' station shouting out verbal orders andnot placing a progress note – not even ahistory or physical – on the chart until dayslater, often well after the patient has beendischarged.

Documentation of MedicalRecords – OverviewPhysician problem areas and consequences: Forgetting to place an operative note on thechart the instant after a procedure or operationis performed:– The surgeon may dictate the operative note, but willwrite a postoperative note so there isdocumentation on the chart when the patient getscare elsewhere, i.e. recovery room, on the medsurg unit, or at home if discharged.– When the hospital is called for information aboutwhat procedure was done and the surgeon cannotbe reached, there is no way to find out unless thereis a written post-op note.

Documentation of MedicalRecords – OverviewPhysician problem areas and consequences: Not entering the time and date that thenote was developed, whether written ordictated:– Doctors cannot defend the timeliness of theiractions if they don’t tell anyone what time theaction was taken.– If the note is not written on the day of theservice, the note must start with “Late Note forvisit on date of service”.

Documentation of MedicalRecords – OverviewPhysician problem areas and consequences: Using the phrases, “Doing Well” or “NoChange.”– This does not tell anyone what happened onthat visit.– It is unreasonable to bill and expect to be paidfor such a vaguely described service.

Documentation of MedicalRecords – OverviewPhysician problem areas and consequences: Not writing down and getting credit for thingsdone on rounds to non-surgical patients. Providers conduct fairly extensive evaluationsbut only dictate minimal portions ofobservations made.– Fail to mention all organ systems examined– Forget to describe how patient answered questionsabout new medications or new diagnoses– Fail to note they spoke to relatives or family aboutfindings

Documentation of MedicalRecords – OverviewPhysician problem areas and consequences: Neglecting to do a proper History andPhysical on every patient.– NEVER an excuse for provider not todocument a good evaluation of the wholepatient.

Documentation of MedicalRecords – OverviewPhysician problem areas and consequences: Not naming a diagnosis (or presumeddiagnosis) when ordering studies ortreatments.– Always name the problem that is beingevaluated or treated when prescribingmedication (even over the phone), sendingpatient to lab or x-ray, or starting a treatment.

Documentation of MedicalRecords – OverviewNursing and Interdisciplinary Team MemberNote Problem Areas and SubsequentConsequences: Using the phrases, “Doing Well” or “WithinNormal Limits.”– This does not tell anyone what happened onthat visit.– It is unreasonable to bill and expect to bepaid for such a vaguely described service.

Documentation of MedicalRecords – OverviewNursing and Interdisciplinary Team MemberNote Problem Areas and SubsequentConsequences: Not entering the date on which the notewas developed, whether written ordictated.– Timeliness of actions cannot be defended ifdocumentation of when the action was takenis not provided.

Documentation of MedicalRecords – OverviewNursing and Interdisciplinary Team Member NoteProblem Areas and Subsequent Consequences: Failure to chart each shift on patient condition.– Patient’s condition MUST be charted at theend of each shift to provide continuity of carefrom shift to shift.– If the note is not written by the end of theshift, the note must start with “Late Note forvisit on date of service”.

Documentation of MedicalRecords – OverviewDefensive Charting Documentation reflectsprofessionalism and competence.– Appearance counts – including legibility.– Documentation – if it’s not documented, itwasn’t done.

Documentation of MedicalRecords – Opportunities for ChartingAdmission – This process: activates creation of, or access to, veteran’s databaserecord. initiates a generic Admission Form. captures a snapshot of patient upon admission. identifies patient’s needs, strengths, problems,limitations, support systems, and Advance Directives. identifies and screens for further assessment ofpatient’s physical, nutritional, and functional behavior,spiritual, environmental, and psychosocial needs. identifies and assesses any incidents of abuse: elder,child, sexual, physical assault, rape, or domesticviolence.

Documentation of MedicalRecords – Opportunities for ChartingAssessments/Reassessments: Performed according to each discipline'sspecific protocol, policy, standards, orguidelines. Should be conducted according to intensityand scope of care. Should be initiated whenever there is achange in patient’s diagnosis or condition. Data is used to formulate or update patient’splan of care. Patient responses to previous interventionsmust be charted.

Documentation of MedicalRecords – Opportunities for ChartingInterventions performed or administered: MUST be accurately documented in themedical record on appropriate forms,flow sheets, or in the Progress Notes. Includes:– Treatments or procedures rendered– Medications or therapies administered– Education or instructions provided toPatient/Family/Significant Other– Referrals or Consults Initiated

Documentation of MedicalRecords – Opportunities for ChartingOther opportunities for charting: Regular Discharge Interservice Transfer Interservice Receiving Against Medical Advice (AMA) Unauthorized Absence (UA) Irregular/Disciplinary Discharge Death Notes

Documentation of MedicalRecords – Opportunities for ChartingEstablishing and Documenting a Plan of Care: Written Plan of Care is established by theInterdisciplinary Team for each patient. Plan of Care:– includes establishment of treatment and dischargeplan.– includes education of Patient, Family, and/orSignificant Other.– is reviewed and updated throughout the continuumof care .– becomes part of the patient record.

Documentation of MedicalRecords – Opportunities for ChartingPositive Outcomes resulting from timely,appropriate charting:1. Stable Condition2. Improving and progressing3. Moving towards discharge goals4. Absence of problems or complications(infections, falls, adverse reactions, orsentinel events).

Documentation of MedicalRecords – Opportunities for ChartingNegative Outcomes resulting from poorcharting:1. Unstable condition2. Decompensating or worsening3. Moving away from discharge goals4. Presence of problems orcomplications (falls, infections,adverse reactions, or sentinel events)