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)
