Patient records, Documentation Flashcards
What are features of ideal medical records (EMR) (6)
- Timely
- Factual
- Complete
- Systematic
- Attributable
- Chronological
What is included in the facesheet or banner of EMR (7)
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)
What is included in the History and Physical exam of EMR (7)
Who completes this?
MRP completes this
- story of patient before presentation
- initial findings
- MRP’s initial impression and plan
Usefulness decreases with time
What is included in the Consult letters/notes of EMR (3)
Who completes this?
- Story of patient before CONSULTATION
- Consultant’s initial findings
- Consultant’s initial impression and plan
More focused than H&P
- MRP still in charge and required to action based on consultant’s recommendations
What does the progress/treatment notes include?
Who contributes?
How to read it?
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
What is the assessment part in the EMR used for?
Separate section in hospital charts
- used by nurses to document day to day care
What are types of nursing assessments?
- Vitals (temp, HR, BP, RR, O2)
- Fluid balance
- Focused assessments (pain, neuro, CV, MSK, psychosocial, skin, GI etc..)
Which section is the most up to date and has wealth of information and often pulled into others’ notes?
Assessments (done by nurses)
In practice what do you do when you see an order
cross-check with progress notes
T/F the patient’s record is a legal document
True
What are the 7 C’s for professional communication?
Clear
Coherent
Concise
Concrete
Correct
Complete
Courteous
What does SNOMED CT stand for?
What is it developed for?
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”
Define interoperability
the ability for 2 systems to communicate, and is necessary for e-Health
- Uses standard abbreviations and generic names
- Uses standardized clinical terminology
T/F you can delete or alter a prior progress note
False
Structured notes vs unstructured notes
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
What is included in each section of a SOAP note?
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)
When is DAP beneficial over SOAP notes
For mental health or patient counselling documentation where where it is mainly subjective data
What does DARP stand for?
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
What does F-DAR stand for
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.
What are barriers to documentation? (6)
- Lack of time
- Lack of reimbursement
- Fears of litigation
- Lack of training
- Fear of criticism
- Lack of comfort with written communication
What are solutions to lack of time? (5)
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
What are solutions to lack of reimbursement
Consistency
- Becoming familiar with the reimbursement requirements will help you streamline your documentation.
- also generates evidence of the extent and impact of your service
Fears of litigation solution
Documentation
- it will protect you in instances where record keeping is necessary to demonstrate that appropriate patient care was delivered.
Solutions for lack of training
Competence
- ask to arrange a documentation session for your workplace
- complete an online program
- consult with colleagues who have experience documenting
