Clinical Documentation Flashcards
Purposes of Documentation
If not Documented, it Didn’t Happen
Establishes your credibility as a provider
Readers assume – right or wrong – that you practice in the same way you document
Communication tool between members of the team
Legal document that provides an account of any encounter
Evidence that appropriate care was given
Document patient’s response to the care
Impossible to fully capture all the nuance of a patient encounter
Many years can pass between the encounter and any legal action – so your notes are often the only record of what occurred
Only what is written is considered to have occurred
Strive for accuracy – document facts, not opinions
Primary audience will be other medical professionals who have a stake in the patient’s care
Principles of Documentation
Each entry should have the date, time, and author of the note/encounter
EMRs do this for you by creating a digital footprint
CMS = Center for Medicare/Medicaid Services
Part of HHS, create guidelines for documentation and billing/reimbursements
Record should be complete (and legible)
Do as much as possible during or right after the encounter
Hard to remember after a while!
Notes must be signed ASAP (every institution is different)
CMS Guidelines
Reason for encounter, relevant history, physical exam findings, and test results
Assessment, clinical impression, or diagnosis
Rationale for ordering tests (documented or easily inferred)
Past and present diagnoses should be readily available (importance of updating problem list/past history!)
Health risk factors should be identified
Patient progress, response to and changes in treatment
Diagnosis and treatment codes should be supported by documentation
*need to be able to give a reason for the orders
Key Concepts
Tests must be associated with an ICD-10
Use codes that align with the most specific diagnosis at the time
Primary code should be the chief complaint or reason for encounter
Do not use R/O
Signs and symptoms associated with a diagnosis shouldn’t be documented/coded separately (i.e., fever, cough, flu) Doc as influenza
Do not copy and paste from past records; looks bad and sloppy
Comprehensive History & Physical
Used when seeing a patient for the first time in a medical setting
Exception: when emergent condition surpasses need for treatment takes priority
Multiple providers are likely to read this note; make it accurate and thorough
Examples: new patient visits in primary care, admissions to the hospital
Review yearly at “annual physical” visits in primary care
Most other notes are a variation of the H&P
Tailored to specific specialty
Much of the history taking involves “building the chart”
Can then pull info into a note (depending on your system)
Problem Focused Note
Follows same pattern as H&P, but narrower in scope
Used when seeing a patient for follow up
Established patients in primary care for routine or urgent care visits
Addresses a focused concern (ankle sprain, hypertension, etc.)
Progress Notes
Daily notes used to document progress/changes over the course of an admission
Does not need to contain all the info in the H&P
Includes:
Day of hospitalization (e.g., HD #3) or post-operative day (e.g., POD #2)
How the patient is feeling
Events since the last note
Physical exam findings (including vitals, I&O)
Labs/diagnostics/other data
Assessment & plan of each problem
Operative Notes
Date of procedure
Name of procedure
Indication (reason for the procedure)
Surgeon
Surgical assistants, if any
Anesthesia type; who is delivering anesthesia
Pre-op diagnosis
Post-op diagnosis
Descriptions: specimens, EBL, drains
Complications
Disposition
SOAP Note General Outline
Subjective: what the Person Tells you
Objective: What you observe inculding test results
Assessment: What you think is going on
Plan: What you are going to do about it
Subjective: What the patient tells you
Identifying Info
CC/HPI
PMHx
- Meds
- Allergies
Family Hx
Social Hx
ROS
Identifying Information
Clinic or location
Date
Time
Patient Name
Patient DOB
Patient MRN
Source of Information
Patient, family member, friend, hospital staff, old records
Consider whether the source is reliable
Include two identifiers
Chief Concern
Why the patient is there
Can be in their own words – if so use quotes
“My head hurts”
“I twisted my ankle”
“I am having my gallbladder removed”
Can be a generalization
Follow up on chronic conditions of hypertension and diabetes
Here for an annual health maintenance visit
Avoid “no complaints”
History of Present Illness
For urgent or new issues, important to include:
OPQQRST
For chronic or old issues, include an interval update
Patient’s perspective: feelings, ideas, function, expectations
HPI
Most often documented in paragraph form, with chronological descriptions
Start with the story (location, quality, context, onset, timing), pertinent positives/negatives (associated symptoms), then on to non-symptom data (modifying factors, data related to presenting complaints)
It should read fluidly, like a narrative
Helps put the pieces together for the reader – by end of HPI you should know the differential diagnosis
Past History: Past and Current Health
Problem List vs Medical History in the EMR
Problem list includes active problems
History includes things that have occurred in the past and are over
For the purposes of writing notes for this course, PMHx includes both active and past problems
Should be documented as a list with headings
Include when the problem was diagnosed, the current status (stable, uncontrolled, resolved)
Past History
Medical History
Childhood illnesses
Adult illnesses
Hospitalizations
OB/GYN
Psychiatric
Surgical History
Medications
Allergies
Health Maintenance/Preventive Health
Immunizations
Social History
PMH: Medical: Childhood Illnesses
Include the typical illnesses depending on the age of the patient
Measles, mumps, rubella, Scarlet/rheumatic fever, polio
Varicella (most people born after 1990 were vaccinated as it was mandatory for school in 1995)
Does not have to include anything that is transient or self-limiting
Exclude common colds, GI illnesses, UTI – unless complications persist into adulthood
Surgeries as a child get documented in surgical history
Include age at diagnosis if known
PMH: Medical: Adult Illnesses
Include any diagnoses made as an adult that have considerable impact
No need to include every cold/URI/GI bug
Include age at diagnosis, diagnostic testing, management plan, complications, care team/specialists
Example:
Primary hypertension: diagnosed at age 50, managed with medications by PCP, no complications thus far
Hyperlipidemia: diagnosed at age 55, managed with mod-dose statin, initial ASCVD risk 30%, 1/2023 ASCVD risk 5%
PMH: Medical: Hospitalizations
Why
Where
How long
Outcome/complications
Example:
4-day hospitalization for bacteremia and sepsis secondary to complicated UTI at UMass Memorial, 09/2021. Full recovery without ongoing complication
Medications
Name, Str, route, formulation, freq
Reconciliation is big part of PC
Allergies
List medication or allergen and reaction – include environmental, latex, food
NKA = no known allergies
NKDA = no known drug allergies
Examples:
Penicillin (rash), bee venom (anaphylaxis)
Do not list adverse drug events or reactions as allergies!
Nausea or diarrhea from an antibiotic is to be expected
Can still document but be clear it’s an ADR
PMH: OB/GYN History
Only for patients assigned female at birth
Periods:
Menarche
LMP
Typical cycle duration, intervals, symptoms
Family planning
Desire for pregnancy/contraceptive method
Menopause (age for patient and for patient’s mother, if known)
DES exposure (if born before 1971)
Pregnancies:
G_P_, F-P-A-L
Delivery types (vaginal vs c-section vs others)
Complications
Gender identity & sexual orientation can be documented separately in social history
Some providers prefer to include sexual partners/practices in this section, but not every patient gets an OB/GYN history!
Cervical cancer screenings can go here, or in HM
If colpo/LEEP/other procedure, can document here
G = __________ (# pregnancies)
P = ____ (# deliveries after 20w)
F = ___________ (after 37w)
P = _______ (before 37w)
A = ___________ (both kinds)
L = ___________
*twins count as 1 pregnancy
Gravida, PAra, Fullterm, preterm, abortion, living children
PMH: Medical: Psychiatric
Can be a touchy subject
“I ask all my patients…” or “I believe mental health is an important part of overall health…” or “I see you have multiple specialists involved in your care…” “have you ever seen a counselor or psychiatrist, or been hospitalized for your mental health?”
Document dates, locations, provider names (if known and/or if still engaged in care), outcomes
Consider PHQ-2 or PHQ-9, GAD-7, PTSD-PC screening tools
Example:
Inpatient hospitalization in 2015 at Hospital for Behavioral Medicine for major depression. Discharged to IOP community counselor (Susie Q, LICSW) and psychiatrist (Dr. So-and-so)
Past History: Surgical
Procedure (including laterality)
Date
Surgeon/hospital
Outcome/complications
Both from the surgery or anesthesia
No family history of malignant hyperthermia is an important negative to document/include in pre-op clearance notes
Example:
Cholecystectomy, 2017, Dr. Cui, UMass Memorial. No complications.
Past History: Health Maintenance
Immunizations
CA screenings
Dz screenings/surveillance
Determinants of health
Advanced Care Planning
Past History: Health Maintenance, Immunizations
Immunizations: include dates (as exact as possible)
States participate in immunization information systems to make getting info easier
Screening and preventive measures: date and result
Cancers: Breast, lung, cervical, prostate, colorectal
Other screenings: DEXA (osteoporosis), metabolic (labs for DM, lipids, disease monitoring)
Advanced Care Planning
Health care proxy form
Any care planning documents on file? (i.e. MOLST)
(Social) Determinants of Health
Income and social protection
Education
Unemployment & job security
Working life conditions
Food insecurity
Housing, basic amenities, and the environment
Early childhood development
Social inclusion and non-discrimination
Structural conflict
Access to affordable health services of decent quality
