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Medical Documentation
Avni Bhalakia, M.D.
St. Barnabas Hospital
July 29, 2009
Objectives
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Purpose of the Medical Record
Importance of Documentation
HOW TO Document
WHAT TO Document
Medical Student Documentation
Inpatient Documents
Medication Reconciliation
Summary
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
The Medical Record
 As outlined by Medicaid
 Chronological record of pertinent facts, findings, and
observations about an individual's health history
 Means to:
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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
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
Importance of Documentation
 Patient Care & Safety
 Legal Implications
 Financial Implications
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
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
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
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
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
Medical Documentation
HOW & 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
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
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!
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
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)
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WHAT TO Document
 Informed consent, risks and benefits
explained
 Incidents
 Attempts at & communications with family
members
 Communications with primary care
physicians & consulting services
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.
DO NOT Document
 False information
 E.g. Part of the exam you did not perform
 Personal opinions or judgments
 Be objective
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
Good Documentation
 Promotes good physician-to-physician
communication
 Helps prevent medical errors
 Enhances patient care
 Has legal and financial impacts
Documents of the Inpatient Unit
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Admission Note (H&P)
Progress Note
Discharge Summary & Patient Plan
Physician Orders
Must Have on EVERY Document
 Patient label on every page
 Time & Date all entries
 Sign & Stamp all entries
Patient Label on EVERY page in chart
Admission Note (H&P)
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
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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
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Example: Home Medications
Write “unknown” or “unable to obtain.” Do not leave blank.
Progress Note
• Means of
communication
between care
providers
• Convey thought
process of decision
making and plans Date & Time
Patient Label
Note Title (e.g. PGY1 Progress Note,
Addendum, Event Note, etc)
Write
Legibly
• Record of events
Sign & Stamp
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
PMD rated D/C summaries as useful
IF 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
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
Discharge Summary
Hospital 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
Discharge Summary
Hospital 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
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
Example
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“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…”
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“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”
Department of Medicine, University of Florida
Patient Plan for Post-Hospital Care
 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
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
Physician Orders
 Care plan for hospital admission that
includes
 Nursing care: vitals, ins/outs, special
instructions
 Medications  Pharmacy
 Circumstances to notify physician
Physician Orders
 The Basics
 Patient label
 Diagnosis,
allergies, &
weight
 Date & time
order
 Signature &
stamp
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
Official “Do Not Use” List by
Joint Commission
DO NOT USE
USE INSTEAD
QD or Q.D.
Every day or daily
QOD
Every other day
U
Units
IU
International Units
MgSO4
Magnesium Sulfate
MS or MSO4
Morphine Sulfate
Trailing zero (X.0 mg)
Write “X mg”
Lack of leading zero (0.X mg)
Write “0.X mg”
The Joint Commission, May 2005
Other “Do Not Use” Abbreviations
DO NOT USE
USE INSTEAD
µg
Mcg or micrograms
BT
Bedtime or QHS
SS
Sliding Scale
CC
Cubic Centimeter
>
Write “greater than”
<
Write “less than”
The Joint Commission, May 2005
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
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
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
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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
References
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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.