Patient records, Documentation

Question 1

What are features of ideal medical records (EMR) (6)

Answer 1

1. Timely
2. Factual
3. Complete
4. Systematic
5. Attributable
6. Chronological

Question 2

What is included in the facesheet or banner of EMR (7)

Answer 2

Name
Demographics (age, DOB, gender, weight)
Allergies (code status, isolation)
MRP (most responsible physician)
ID numbers
Institutional settings (admitting diagnoses could be changed, don’t assume it is correct)

Question 3

What is included in the History and Physical exam of EMR (7)
Who completes this?

Answer 3

MRP completes this
- story of patient before presentation
- initial findings
- MRP’s initial impression and plan

Usefulness decreases with time

Question 4

What is included in the Consult letters/notes of EMR (3)
Who completes this?

Answer 4

1. Story of patient before CONSULTATION
2. Consultant’s initial findings
3. Consultant’s initial impression and plan

More focused than H&P
- MRP still in charge and required to action based on consultant’s recommendations

Question 5

What does the progress/treatment notes include?
Who contributes?
How to read it?

Answer 5

Summary of:
- clinical findings/data collected
- Assessment
- Plan

Can be contributed by doctors, physiothereapists, dieticians
- nurse interactions are documented somewhere else

Less detailed than H&P and consult notes
- can be copy and pasted
- read in reverse chronological order

Question 6

What is the assessment part in the EMR used for?

Answer 6

Separate section in hospital charts
- used by nurses to document day to day care

Question 7

What are types of nursing assessments?

Answer 7

• Vitals (temp, HR, BP, RR, O2)
• Fluid balance
• Focused assessments (pain, neuro, CV, MSK, psychosocial, skin, GI etc..)

Question 8

Which section is the most up to date and has wealth of information and often pulled into others’ notes?

Answer 8

Assessments (done by nurses)

Question 9

In practice what do you do when you see an order

Answer 9

cross-check with progress notes

Question 10

T/F the patient’s record is a legal document

Answer 10

True

Question 11

What are the 7 C’s for professional communication?

Answer 11

Clear
Coherent
Concise
Concrete
Correct
Complete
Courteous

Question 12

What does SNOMED CT stand for?
What is it developed for?

Answer 12

SNOMED CT
- Systematized Nomenclature of Medicine Clinical Terms

Developed for:
a consistent approach to “capture, retrieve, aggregate and share relevant clinical information across health care settings and providers in a consistent, safe and reliable manner”

Question 13

Define interoperability

Answer 13

the ability for 2 systems to communicate, and is necessary for e-Health
- Uses standard abbreviations and generic names
- Uses standardized clinical terminology

Question 14

T/F you can delete or alter a prior progress note

Answer 14

False

Question 15

Structured notes vs unstructured notes

Answer 15

Structured
- SOAP
- DAR
- Focus charting

Unstructured
- free form notes
- used for patient contact descriptions
- Patient counselling, patient care, communication with HCP
- should be signed and dated

Question 16

What is included in each section of a SOAP note?

Answer 16

Subjective:
- includes chief complaint
- history of present illness
- Allergies
- medications if reported by the patient or family member

Objective:
- Physical exam findings (inspection)
- Vital signs
- Lab values
- Imaging results

Assessment
- supported by subjective and objective findings
- each problem should be numbered and begin with 1 sentence description of the problem

Plan
- Should be numbered to match assessment
- include therapy needed, specialist referral or consult
- include any monitoring (what, who, when)

Question 17

When is DAP beneficial over SOAP notes

Answer 17

For mental health or patient counselling documentation where where it is mainly subjective data

Question 18

What does DARP stand for?

Answer 18

Data
- subjective and objective

Assessment
- what you did about the findings stated in the data, and any recommendations.

Response:
- how the patient responded to your actions

Plan
- includes future plans or follow-up

Question 19

What does F-DAR stand for

Answer 19

A Focus Statement begins the note, which is typically the diagnosis, event, or patient concern.

• Data includes subjective and objective data.
• Action includes your assessment, what you did about the findings stated in the data, and any recommendations.
• Response includes how the patient responded to your actions. The response may be written later once you determine the patient’s response.

Question 20

What are barriers to documentation? (6)

Answer 20

• Lack of time
• Lack of reimbursement
• Fears of litigation
• Lack of training
• Fear of criticism
• Lack of comfort with written communication

Question 21

What are solutions to lack of time? (5)

Answer 21

Time
- making a note of all encounters at the time of the encounter
- Having greater access to a computer
- Making use of electronic tools such as EMRs
- Documenting concisely including only relevant information
- Scheduling time in your day to document

Question 22

What are solutions to lack of reimbursement

Answer 22

Consistency
- Becoming familiar with the reimbursement requirements will help you streamline your documentation.
- also generates evidence of the extent and impact of your service

Question 23

Fears of litigation solution

Answer 23

Documentation
- it will protect you in instances where record keeping is necessary to demonstrate that appropriate patient care was delivered.

Question 24

Solutions for lack of training

Answer 24

Competence
- ask to arrange a documentation session for your workplace
- complete an online program
- consult with colleagues who have experience documenting

Question 25

Solution for fear of criticism

Answer 25

Constructive criticism