Inpatient Documentation Flashcards
Why document?
- To communicate to the others:
- what is wrong
- what has happened
- what are your thoughts
- who you talked to
- what you did - Medicolegal requirements - It did not happen if you did not write it down
- Complete documentation is your best defense
Outpatient services (6):
- Cardiac diagnostic procedures
- Radiation Oncology
- Radiation
- Infusion - chemo or other
- Medical practices
- Surgery
Inpatient services (4):
- Emergency department
- Labor and delivery
- Medicine
- Surgery
How do you get into the hospital?
- Direct admission - scheduled or from the office
- Emergency department
- Labor and delivery
- Outpatient area - I.e., surgery & infusion services
Why admit to the hospital?
For care that cannot be delivered elsewhere (aka “cheaper”
1. Medical necessity:
- How sick is the patient? - acuity
- What is the risk to the patient?
2. Intensity of services:
- IV medications
- Monitoring requirements
- Intensive care
- Procedures or treatments
What happens in the hospital?
- Admission
- Stay
- Discharge
How do you leave the hospital?
- Front door - Home
- Side door - going/being transferred to somewhere else (I.e. Transfer (hospital), nursing home, rehab center, prison, other)
- Back door - Morgue
What is included in the History and Physical (H&P)?
It’s an expanded soap note:
Subjective - CC, HPI, ROS, PMH, FH, SH
Objective - Physical exam (PE), Diagnostic studies (x-ray, CT, bloodwork, etc.), laboratory, radiologic studies, etc.
Assessment - Problem or dx, differential diagnosis
Plan - What is it?, Why? (why do you think the problem is what you say it is), When? (need an appendectomy now), Who? (who will perform procedure or carry out orders)
The act of altering the medical record in a way that seems intentional (aka hiding something)
spoliation
Abbreviation are ___, not ___
regional; universal
What is included in a progress note?
Miniature soap SOAP note - documenting what has changed (if pt is progressing or not and when pt can go home)
- Subjective findings
- Objective - exam, lab, radiology, procedures (frequently documented with subjective portion)
- Assessment - anything different?
- Plan - changes to treatment (if any), anticipated disposition
How often is a progress note required?
at least daily (and every time there is a significant change to a patient’s status)
What 5 things are mandated to be in the Discharge Summary according to the Joint Commission for Accreditation of Hospitals?
- Reason for hospitalization
- Significant findings
- Procedures and treatments provided
- Patient’s discharge condition
- Patient instructions
What is included in the Discharge Instructions?
- Presenting problem
- Final diagnoses
- Medications
- Diet
- Therapies
- Follow up appointments
- Anticipated problems
- 24/7 call back number
In patients > 65 years, ___% recall their diagnosis and ___% recall follow up appointments. What does these stats infer?
60%; 46%
- Infers that patients are not getting the care they need and/or instructions were not given adequately
The National Patient Safety Foundation (2009) developed “Ask Me 3”, what is this and its purpose?
“Ask Me 3” are 3 questions to help the patient recall important info from their appointment:
1. Why was I in the hospital?
2. What do I need to do now?
3. Why is it important for me to do this?
What is a consult note and how is it different from H&P or a progress note?
A SOAP note from a specialist’s point of view:
- has much of the same info as a regular SOAP note (Subjective, Objective data) but interpreted from a different perspective.
- Ex: GI consult - expanded GI history and ROS; Cardiology - expanded cardiac history, ROS, exam
Make diagnoses and recommendations in their field - stay in your lane OR NOT
Consultants may write daily progress notes AS NEEDED
Consultants may sign off a case before discharge (they has nothing to do with discharge summary)
______ - this process occurs when communication between a patient and physician results in the patient’s authorization and agreement to undergo a specific medical intervention
Informed consent
What must be included during the informed consent process according to the AMA?
- Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision.
- Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information. The physician should include info about:
- The diagnosis (when known)
- The nature and purpose of recommended interventions
- The burdens, risks, and expected benefits of all options, including forgoing treatment - Document the informed consent conversation and the patient’s (or surrogate’s) decision in the medical record in some manner. When the patient/surrogate has provided specific written consent, the consent form should be included in the record.
What is included in a procedure note?
- Date and Time
- Name of procedure
- Who did the procedure and who else was involved
- Statement that informed consent was obtained prior to procedure
- Type of anesthesia used and who administered it
- Procedure details:
- What was done
- Describe complications
- Document blood loss
What is the difference between a procedure note and an operative note?
Operative note is for procedures/surgeries occurring in the OR
What are the operative note requirements per CMS (10)?
1.Name and hospital identification number of patient
2. Date and time of surgery
3. Name(s) of the surgeon(s) and all assistants who performed surgical tasks, even if under supervision
4. Pre-operative and post-operative diagnosis
5. Name of the specific surgical procedure(s) performed
6. Type of anesthesia administered, if any
7. Complications, if any
8. Narrative of procedure - a description of techniques, findings, and tissues removed or altered
9. Name(s) of surgeon(s) and assistant(s) and description of significant surgical task(s) performed by above named practitioners if different than primary surgeon
10. Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any
What is included in the transfer note?
- Reason for transfer to another hospital service or physical area (note would also be needed if patient was changing floors in the same hospital)
- Summary of care to date
- Current physical exam
- If transferring care to a new provider or care team, a statement documenting acceptance of transfer is required before the transfer is initiated.
What would a physician be charged of if acceptance of transfer was not provided prior to transfer of patient?
Abandoment
