MEDICAL DOCUMENTATION
Dr.T.V.Rao MD
1
What is Documentation
• Anything written
or printed
• Relied on as a
record of proof
for authorized
persons
• Vital part of
professional
practice 2
Purposes of Documentation
• Quality of care
• provides evidence that care was necessary
• describes responses to care
• describes any changes made in plan of care
• Coordination of care
• plan interventions
• decision making about ongoing interventions
• evaluation of patient's progress 3
• used by all team members
Purposes of Documentation
in Medicine
• Clinical records are
reviewed to
ensure the facility
meets the
required standards
assessed for
ongoing
compliance
4
Importance of Medical Documentation
• Proper and adequate
medical documentation
is essential for
quality of medical
care and health care
services throughout
the industry, from
receiving proper and
correct treatment
5
Who Writes Medical Documents
• Medical documentation
or documentation of a
medical condition means
a statement from a
licensed physician or
other appropriate
practitioner providing
information the agency
considers necessary
6
Function of Medical Documentation is
Important When Referring Patients
• Why is important medical documentation vital? Without it,
your health care would be compromised. One doctor
wouldn't know what another doctor was doing.
Without adequate documentation of visits, lab
tests, treatments or surgeries, quality of care would
certainly be erratic and potentially deadly. Medical
documentation generally provides all the
information about a specific patient that any doctor
looking at a medical record would need to know to
treat that patient 7
Documentation increases
Patient Care
• Medical record documentation is required to
record pertinent facts, findings, and
observations about an individual's health
history including past and present illnesses,
examinations, tests, treatments, and
outcomes. The medical record chronologically
documents the care of the patient and is an
important element contributing to high quality
care. 8
General Principles
• A. The medical record should be complete and
legible.
• B. The documentation of each patient encounter should
include:
• reason for the encounter and relevant history, physical
examination findings and prior diagnostic test results;
• assessment, clinical impression or diagnosis;
• plan for care; and
• Date and legible identity of the observer.
9
Ethics and Documentation
• Adequate medical
documentation assures
patient confidentiality and
ensures that standards of
care are being met. Doctors
and other medical
personnel have an
obligation to treat illnesses
to the best of their ability
in regard to information
documented in a patient's
medical record.
10
Patients Health Care
Information a Vital Document
• The patient's history is a
vital piece of information
that enables physicians
to determine the best
diagnosis and treatment
plan for that individual,
based on information
found in the medical
record.
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Must contain Subjective/History
• Past Medical History (PMH)
• Medications Allergies
• Allergies Medications
• Illnesses Pertinent past history
• Doctor Last oral intake
• Surgery Events leading to illness
or injury
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Common standards for
documentation
• assessment
• plan of care
medical
orders
• progress
notes
• discharge 13
summary
Skills Used in Documentation
•Cognitive
•Technical
Interpersonal
Ethical/Legal
14
A Documents of all Critically ill
patients be given due care in filing
• Clinical findings from the most recent medical
evaluation, including any of the following which have
been obtained: Findings of physical examination;
results of laboratory tests; X-rays; EKG's ECG MRI CT
Scans and other special evaluations or diagnostic
procedures; and, in the case of psychiatric evaluation
of psychological assessment, the findings of a mental
status examination and the results of psychological
tests, if appropriate must be filed with due care
15
Good Documentation Increases
Legal Protection
• Peer review
• Requirements for
reimbursement
• Legal protection
• Research &
continuing
education
16
Patient Records Helps in
Planning Your Future Actions
• Communication
• Care Planning
• Quality Review
• Research
• Decision Analysis
• Education
• Legal
Documentation
• Reimbursement
17
Residents should Document
• Computer-based
Records
• Standardization
• Legible
• Follow policies and
procedures to
ensure
confidentiality
18
Fill all Laboratory Requests with
Sense of Responsibility
Name xxxx Age Sex
IP/ OP No xyz Time Date
Ward xx123 Urgent / Routine
Nature of specimen
Investigation needed
Doctor/Staff
Contact No 1234567
Patients Records are confidential
do not discuss without purpose
20
Correct your Mistakes with
Sense and Legality
• Never use whitener
• Never scratch out
• Draw a line through
the mistake
• Initial above the
mistake
21
Document the Patient Record
with Institutional Protocols
• Initial evaluation
• Age and gender (Pt. is 20 y.o. white
• male)
• Prior level of function (including
• occupation/ functional status
• Social history (Lifestyle, home
• situation, home accessibility)
• Emotions/attitudes
• Direct quotes (to illustrate
• confusion, denial, attitudes, etc.)
• Chief complaints or complains of
• MOI 22
• Onset (insidious or traumatic)
• DOI
Documentation Standards Vary
from Situation and Specialties
• Pain scale (1-10)
• Location and type of pain (burning,
• stinging, sharp, dull, radiating, etc.)
• Aggravates and alleviates pain
• Details since onset (history of
• injury)
• PMHx
• PRx (Past treatment)
• Date of surgery (DOS)
• Special tests (x-rays, MRI, CT scan)
• Rule out
• Meds and allergies 23
• Patient and/or family goals
Every Case sheet should contain a
Minimal Data
• Personal info: age, sex, occupation, training, family...
• Risk factors: tobacco, alcohol, life styles...
• Allergies and drug reactions
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• Problem list
• Disease history: diseases, operations. . .
• The disease process: main problem, history, exam, lab.
• Management plan: advice, education, medication. . .
• Progress notes: in the P S O A P format
Rules in keeping medical records as it requires
Confidentiality
1. Personal biographical data include the address, employer, home and work
telephone numbers and marital status.
2. All entries in the medical record contain the author’s identification.
Author identification may be a handwritten signature, unique electronic
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identifier or initials.
3. All entries are dated.
4. The record is legible to someone other than the writer.
5. *Significant illnesses and medical conditions are indicated on the
problem list.
6. *Medication allergies and adverse reactions are prominently noted in the
record. If the patient has no known allergies or history of adverse
reactions, this is appropriately noted in the record.
Record all the Progress of the
Patient – As Things can go Wrong
• Future notes
• Response to treatment
and rehab.
• Reassessing subjective
information from
previous notes
• Change in function
• Change in pain (location,
type)
• Patient compliance issues
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Legal Aspects of Charting
• Do not erase, use white-out, or scribble out
errors
• Do not write retaliatory or critical
comments; do not place blame on your
colleagues
• Correct all errors promptly
• Spell correctly 27
• Record all facts in objective terms
Court Believes your
Documents only
•Document
completely [in
court - if it's
not
documented,
it wasn't done
28
Legal Aspects of Charting
• Be accurate about time &
chart as soon as possible
after an event
• Document omissions (med
not given or treatment not
completed) & reason &
actions taken
• Do not leave blank
spaces
• Record legibly & in
black ballpoint pen 29
Legal Aspects of Charting
• Use only approved
abbreviations
• Record clarification
requests &/or
corrections
• Chart only for yourself
• Avoid vague statement
• Begin with time and end
with appropriate
signature 30
In order to prevent legal problems:
• Record everything you do (including
phone consultations)
31
• Apply guidelines LEARN FROM
YOUR SENIORS OR
CONSULTANTS
• Don't use erasable pencils
• Don’t use humiliating expressions
Why to keep records?
• Helps in medical decisions
(is the size of a lymph node or nodule increasing
with time?)
32
• Helps to share responsibility with the
patient
• Legal obligation.
• Protects the patient as well as doctor in
front of the court
Still you want to Correct the
Errors
• When a correction becomes necessary, merely
draw a single line through the entry so that
the original entry is still readable. Make a
notation explaining the correction, or directing
the reader to the appropriate addendum. Date
and sign the correction. If using an addendum,
place it in sequence or chronological order
33
Hand over the Matters when
changing the Shifts
• Change-of-shift report
• Accurate information
• Factual information
• Organized
• What & how you say it can
make a big difference in
quality of care
• Avoid negativism &
subjectivity
• Use written or printed
guide to prompt
thoroughness &
organization
34
Medical Billing and Coding Needs
Documentation
• Without adequate medical
documentation, your health
care providers might not be
reimbursed for providing you
with care, leaving you stuck
with the bill. There's an old
saying in the health care
industry: "If it's not
documented, it didn't 35
happen.
Why to keep records?
• Helps in medical decisions
Helps to share responsibility with the patient
• All reputed Hospitals Keep Your Documents for
36
several decades.
• Legal obligation.
• Protects the patient as well as doctor in front of the
court
When documenting Spell the
Words Correctly
medication names
37
Last But Not the Least Do
not miss spell the words
It is Your Identity
clavicle
clavical X
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Excellence in Medical Documentation Reduces
Malpractice Allegations
• Excellence in medical
documentation reflects and
creates excellence in
medical care. At its best,
the medical record forms a
clear and complete plan
that legibly communicates
pertinent information,
credits competent care and
forms a tight defense
against allegations of
malpractice by aligning
patient and provider
expectations.
39
Be Familiar with Computer Documentation as
Technology is taking over every Profession even our’s
40
Your Scientific Documentation saves you
from Many Litigations
41
•Created by Dr.T.V.Rao MD for ‘ e
‘ Learning for Medical
Professionals in the Developing
world
•Email
•[email protected] 42
