Medical Documentation | Copyright © 2010 CEUFast.com

Course Contents

	Purpose    Objectives    Introduction    The Health Record    Communication of Information    Communicating Clearly in Chart Notes        Narrative-Chronological        Problem Oriented Medical Records        Charting by Exception        Clinical Pathways        Computerized Records    Legally Defensible Charting    Summary    New References      Click any section in the index above to browse to the corresponding course section

Purpose

The purpose of this course is to refresh nurses on medical record documentation requirements and professional, responsible documentation strategies.

Objectives

After completing the course, the learner will be able to:

Introduction

We live in a measurement culture. Actions, observations, and intent are all subject to review and comparison to desired standards. In order to meet pressures internal to our profession as well as external, records must be generated, stored, and maintained. Medical documentation has become a component of health care as significant as the rendering of hands on, direct person intervention. Refreshing our knowledge of documentation premise and process is essential to hone our professional technical skills.

The Health Record

Medical documentation refers to any written or electronically generated information about a client describing services or care provided to that client. Documentation may be in the form of paper records or electronic documents. Electronic documents include computer created medical record files, faxes, e-mails, pictures, video or audio recordings. Through documentation, key observations, decisions, actions, and outcomes can be communicated, as well as preserved in a lasting fashion. The intent of documentation is the creation of a lasting accurate account of what occurred and when it occurred.

The challenge today is to provide succinct but comprehensive records that accurately portray the client's experience while meeting the standards of professional and organizational care, regulatory requirements, fiscal responsibility, and criteria for reimbursement. This record of care, a legal document, includes information from nurses and various other health professionals who have contributed to client outcome.

With the abundance of information sources present in health care's data rich environment, a definition of exactly what elements comprise the legal health record is important. Guidelines from AHIMA, the American Health Information Management Association, suggest that each organization be responsible to define the content of the legal health record in accordance with its system capabilities and the legal environment (Dennis, 2010).

Each health care facility must have a compliance system able to guide and ensure accurate and complete record generation (e.g. documentation), record maintenance, and records destruction (when appropriate). The American Health Care Association (AHCA) offers guidance to facilities to help them comply.. In their recommendations concerning the creation and retention of records, AHCA lists the need for each facility rendering nursing care to address the following items (Burgess, K., 2009).

	Maintenance of records and information in a safe, secure place
	Routinely creating and maintaining hard copies of electronic documentation
	Limiting access to records in order to prevent fabrication or destruction
	Development of document retention and destruction policies that are consistent with applicable laws

Legal health records must meet accepted standards present within each organization as well as those applied by review or oversight authorities such as the Centers for Medicare and Medicaid Services, state and federal regulations, or the Joint Commission on Accreditation of Healthcare Organizations.

While organizations such as the Joint Commission recognize that both physical (e.g., paper charts) and electronic health records must be individualized to the unique needs and settings of each care facility, some basic components should uniformly be present:

	Client identifying data

	Known medical history

	Medical encounters

	Orders and Prescriptions

	Progress notes

	Test results

	Other information

Communication of Information

Documentation in the client chart provides a means by which health professionals can communicate information to each other. Notes on what each of us observe as well as how we respond with interventions, or the formations of plans of care, are entered into the chart..

Health care facilities are tasked by organizations such as The Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS) to effectively manage the collection of health information using uniform data sets and policies that guide record creation and handling. While the components of the health record may differ somewhat in each facility, certain standards are expected for both paper and electronic documentation systems (The Joint Commission 2009 Requirements, TJC, 2009).

Suggestions from external sources can be very specific, such as the 2010 abbreviation use standard (IM.02.02.01.EP.2) from the Joint Commission. In this standard, (formerly known as NPSG.02.02.01), each hospital is required to have a written policy that addresses the use of abbreviations and symbols. This policy is to address all orders and medication related documentation that are handwritten (including free-text computer entry) or on pre-printed forms.

The Joint Commission Information Management Chapter, 2010 Accreditation Standards: Hospital, Standard IM.02.02.01.EP.2 "Do Not Use” List

Each hospital is to have a written policy that includes the following:     Terminology and definitions approved for use in the hospital       Abbreviations, acronyms, symbols and dose designations approved for use in the hospital       Abbreviations, acronyms, symbols, and dose designations prohibited in the hospital, which include the following:             U, u             IU             Q.D., QD, q.d., qd             Q.O.D., QOD, q.o.d, qod             MS, MSO4, MgSO4             Lack of leading zero (.X mg)             Trailing zero (X.0 mg)     Note: A trailing zero may be used only when required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

(2010 Portable Comprehensive Accreditation Manual for Hospitals. TJC, 2009)

Communicating Clearly in Chart Notes

The knowledge base offered within the profession of nursing is full of practical information. Common practice experience leads to acceptable ways of handling information clearly and consistently..

Documentation Do's	Documentation Don'ts
Be timely with chart notes       Be accurate with information       Be complete in what you write       Be legible       Be objective and provide facts       Be clear about pertinent negative findings       Be observant to report unusual interactions between clients and others       Be correct in spelling, grammar, and use of approved abbreviations       Be sure client identifying information is on each page of the written chart	Avoid criticism       Avoid erasing or obliterating unwanted chart entries       Avoid gaps in your written notes       Avoid sarcasm, slurs, use of humor, and profanity       Avoid drawing conclusions – give the facts instead       Avoid removing parts of the chart to work on elsewhere       Avoid asking others to document for you       Avoid documenting for others       Avoid mentioning incident reports within the client chart
(Smalls, H., 2009)

Progress notes are essential medical records based on the nursing process: assessment, nursing diagnosis, planning with goal setting, implementation/ interventions, and evaluation. Progress notes serve to;

	Establish a communicated baseline
	Record relevant data at regular intervals
	Provide snap-shot summaries of a client's condition
	Document changes in condition
	Document response, or lack of response, to treatment

Each care setting tends to specify the patient data format or chart note style that they prefer for progress notes. Follow your facility's documentation policies. There are many charting styles currently available. Each notation format has advantages as well as disadvantages. Some have been around for a long time while others are rather new. Many institutions blend format systems together to get the record-keeping style that works for their unique needs. Whichever style is used, communicate clearly to avoid potential legal problems. Careful forethought and practice using a charting strategy will lead to consistently clear and legally defensible documentation.

Narrative-Chronological

The narrative note is the most traditional medical record progress note style. It involves the documentation of assessment data, interventions made and patient responses in chronological order with free flowing structure, content and form. Many facilities rely solely on this format, while in other settings narrative notes serve to supplement check-off forms and flow sheets..

Narrative charting tends to be thorough and detailed. It is also time consuming. The narrative chronological format is popular with nurses who document complex descriptions with comprehensive assessments.

One key legal issue with this style is that shift to shift, person to person, inconsistency makes it difficult to follow the patient"s progress and plan appropriate care. Each nurse may write her notes with a unique style, thus making continuity of care more difficult. Since this form allows for "free-flowing" paragraphs there is more room for sloppy writing, spelling errors, rambling repetitive narration, inappropriate personal opinions, and inaccurate language. Although these problems are not necessarily indicative of negligence, a negative inference may be made regarding the "professionalism" of the nurse and the facility.

To avoid problems, make certain that each nurse tries to achieve a measure of consistency with record keeping. Perhaps decisions can be made regarding the placement of vital signs, patient outcomes, and care rendered within each narrative paragraph. Have a dictionary available to help with spelling problems. Handwriting must be legible and descriptions of patient observations must be precise. When flow charts are used to document vital signs, avoid repeating that information in the narrative unless there is a specific change that you are addressing in the note.

Problem Oriented Medical Records

Problem area charting focuses on specific needs rather than general assessment information. POMR or problem oriented medical record systems frequently use acronyms to provide memory aides as to the structure of the progress note being written. As POMR documentation focuses on specific problems; it is sometimes generically referred to as "focus charting”.

Some problem oriented charting acronyms:

	SOAP – Subjective, Objective, Assessment, Plan
	SOAPIER – Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision
	APIE – Assessment, Plan, Intervention, Evaluation
	DAPE - Data, Assessment, Plan, Evaluation
	DARE – Data, Assessment, Response, Education
	DARP – Data, Assessment or Action, Response, Plan

We will now look at examples of POMR format charting as they move along a continuum away from straight narrative documentation.

SOAP - SOAP charting follows a distinct format that defines the various sources of information followed by a plan of intervention. SOAP stands for subjective, objective, assessment, and plan.

	Subjective provides the client's condition in a narrative form using that person's own words to describe their condition and concerns
	Objective relates findings such as vital signs, observations from physical examination, laboratory results, measurements (i.e., weight, age, etc.)
	Assessment summarizes findings into a professional observation of the patient's condition such as is found within the nursing diagnosis system
	Plan details what the nurse will do to address the client's needs

SOAPIER - The basic SOAP format for progress notes are sometimes expanded to fit unique organizational needs, such as;

	Intervention that details specifics of the Plan formulated in the earlier SOAP system
	Evaluation of outcomes from the nursing care plan
	Revision of planned care needed, based on the evaluation that occurred following the intervention

DARP - DARP moves further along the continuum away from straight narrative-chronological charting into a combination of check-off forms and flow sheets supplemented with narrative progress notes. The POMR style progress note usually follows the DARP format;

	Data gathered is related to a focus issue (e.g., a summary referring to information found on a checklist or flow sheet)
	Assessment of the data with additional information not related by the flow sheet (NOTE: Action is sometimes substituted for, or integrated into the Assessment phase)
	Response to the need brought into focus during the assessment of available data
	Plan for continuing care following the intervention phase of the response (i.e., continuation of observation, education of client, notification of another professional, etc.)

Risk management strategies with this charting style need to make certain that nurses from the unit where the forms will be utilized have input into design of the check-off forms and flow sheets. Ample room must be present to record pertinent information. Each institution should provide the staff with sufficient training to utilize the strengths of this system to its best advantage.

Charting by Exception

Many consider charting by exception ((CBE) the antithesis to narrative progress notes. CBE is a format developed to overcome the recurring frustration of lengthy, repetitive narratives. It consists of a heavy component of flow sheet documentation with a blending of POMR narrative added. Quickly marked checklists and flow sheets document normal assessment findings and routine care. The narrative documentation is limited to findings outside the expected norm.

One strong advantage is that flow sheet design can incorporate clearly defined expectations for the type of patients cared for on each unit and in each care setting. A standardization of forms process within each facility allows caregivers to provide consistency in patient assessment and documentation. The CBE system still requires POMR documentation of significant or abnormal findings yet does not require narrative noting when expected outcomes are achieved by nursing interventions. Charting by exception can reduce the amount of time spent on documentation.

Charting by exception has the potential to be a great asset to electronic medical records documentation. The use of quickly scored checklists that document routine matters complement at-the-bedside computerized data entry. By shifting the emphasis from descriptive, discursive narrative paragraphs for every routine and expected event, CBE uses minimal narrative notes for only unexpected or highly significant events. CBE may be the cutting edge of medical documentation (Stansfield, K., Yetman, L., & Renwick, C., 2009).

Since charting by exception is a departure from more traditional medical documentation models, it can lead to legal challenge. The biggest problem noted seems to be the appearance of large gaps of time without patient contact. Although this is not true, if no significant observations are made, no notes will appear in the record to prove the nurse"s attentiveness. Likewise, wellness promotion and preventive care may not be a component on a patient problem checklist, preventing full credit for the work done.

Clinical Pathways

Clinical pathways (aka care pathways, critical pathways, care maps, or integrated care pathways) are multidisciplinary descriptions of the expected care for a specific illness or condition with a specified timeline of the anticipated length of stay. Pathway focus is on outcomes and efficient use of resources while still providing quality care. Pathways have proven to be a good way to identify variances from expected outcomes and promote efficiently organized care that is centered on evidence-based practice..

Typically, pathways are written to address a specific condition. It usually includes the expected length of stay, care setting, timeline, assessment, multidisciplinary interventions, patient activity, medications, lab testing, patient and family education, and outcomes. Some facilities are using clinical pathways in conjunction with charting by exception. Use of pathways is changing documentation in many healthcare settings. Managed care, for example, is heavily invested in clinical pathways, recognizing them as an important tool for rendering and documenting quality care.

The major focus for avoiding the legal complications in clinical pathways is the understanding of how your facility is using them and what supportive documentation is required. At some facilities, the pathway has replaced the traditional care plan and progress notes with documentation made directly onto the pathway document unless the patient does not meet the outcome. At this point, a narrative note is made.

Computerized Records

Software programs are available to capture patient data in a computerized format. Depending upon the system selected by the facility, information may be entered by keyboard, voice activation, mouse, touch-sensitive screen, or a combination of these methods. Some systems allow the nurse to select pre-written phrases to describe the patient"s condition with very little sentence formation performed by the nurse..

Fear Factor in Computerized Health Record Technology

Concerns about electronic medical health records in discussions among nurses often focus more on the mechanics of the system and its availability and security rather than on documentation format styles. At heart, fears tend to revolve around three main points commonly cited as confidentiality, integrity, and availability. Often referred to as the "CIA” properties of computer documentation;     Confidentiality demands that no unauthorized party may access sensitive information       Integrity requires that information cannot be altered by unauthorized parties or by technical errors       Availability demands that sensitive services remain available at all times Distrust regarding computerized health records is a factor that limits acceptance with the staff asked to utilize them. The use of consistent measureable security processes and education concerning the systems employed can help overcome the fear of computerized charting and documentation.

(Weber-Jahnke, J., 2009)

Ample education must be provided before implementing a computerized system. A "hard copy" of essential information should be printed at designated times to ensure an accurate record in case of computer problems. Error correction must be completed before the information is permanently stored, and all information should be double-checked before you enter it. Any corrections made after storage will have to be specially noted.

Remember the basics of HIPAA training related to the use of electronic medical documentation.

	Never leave a computer terminal unattended after you have logged in
	Do not leave information about a patient on the screen when others can view the monitor
	Never give your personal password or computer signature to anyone
	Tell a supervisor if you suspect someone may have used your code.

Legally Defensible Charting

Certain guidelines apply regardless of the documentation format you use. The following tips will help ensure that your record keeping can be defended in the courtroom.

Legibility is essential. Never second-guess someone else's writing. Call the colleague for clarification, if necessary. Correct spelling and proper grammar are crucial, not only for safe patient care, but also because they enhance your professionalism. Make sure a dictionary is kept at the nurses' station and post a list of commonly misspelled words. Avoid abbreviations completely when possible. If you must use them, use only abbreviations approved by your facility.

Make sure you have the CORRECT CHART before you begin writing.

The medical record is a permanent legal "business record" and as such, entries must not be made in pencil or erasable ink. Write in permanent ink. Stick to blue and black ink. As a rule, courtroom proceedings will use copies of the record. Copying and electronic scanning machines duplicate blue and black ink with the highest clarity. If you use a highlighter in your record, perhaps as a way of noting discontinued medication, make certain that your medical records department can effectively copy highlighted information. Some copy machines "gray out" any writing covered by highlighter.

If anything is secured into the medical record with tape (monitor strips, blood product labels, etc.) use double-sided tape or tape only onto blank paper. Even though the tape itself is clear and can be read through by the naked eye, a copy machine may "black out" the taped area. Faxes must be copied prior to inclusion in the chart. Unless you have a plain paper copying fax, the ink on the fax may be water-soluble and fade in a matter of days.

EVERY PAGE of the record must have the date and patient name. This is required for a record to be admitted in a courtroom setting.

Your complete signature is required once per page. Your complete signature is your name followed by your professional designation.

When adding a progress note, follow institutional policy to determine if you are to note the time that the entry is being added, or the time that the observation took place.

Avoid block charting, such as "11:00 p.m. to 7:00 a.m.” This type of documentation gives the impression of vagueness. Note exact times of all critical treatments, physician contact, or notices to supervisors. Any time you leave a message with someone in a physician's office, note the time and the name or title of the person taking the message.

Make certain the "proper” person does the documentation. For example, The Joint Commission requires that the initial assessment and care plan to be performed and documented by a registered nurse. Documentation by the proper person is especially important in educational, nutritional. and rehabilitation assessments.

Avoid documentation practices that either allow or allude to alteration or falsification of a medical record. Eliminate excess white space in your record. When making a progress note, write flush to the margin. Likewise when you have completed your thought, draw a line through any remaining blank space on the line before signing your name. Do not leave blank lines between entries.

Do not make entries in advance. Wait until things happen before marking them down. Even the most predictable events can get off schedule in patient care.

To correct entries, put a single line through the error then add your initials and the date of correction. You may note "error” or "mistaken entry.” Do not use white out or tape designed to obliterate typographical errors. Do not correct another's error. Likewise, if you do not agree with an entry, do not record your opinion next to the disputed entry. Discuss your conclusions with a supervisor to ensure that the patient receives the best possible care and the chart reflects respect for all health care team members.

When possible, chart as soon as you can after you make an observation or provide care. This helps eliminate the chance of forgetting important data. Late entries, out-of-sequence entries, or addendum entries may sometimes be necessary. If the entry is made on a following day, always cross-reference the entry so that the reader will read the additional note in the proper sequence. The following steps will eliminate misunderstanding (Small, D., & Rutherford, L., 2009):

	Add the entry to the first available line,
	Indicate clearly "Late entry,”
	Record the day and time you are writing the entry, and
	In the body of the paragraph, indicate the day and time of the previous event now being described.

Never chart for someone else. If you did not participate in an activity or observe someone else's care do not write anything. If you are on duty when a nurse calls to report that she forgot to record a patient interaction, chart it in the following way:

"At 8:35 a.m., Nurse Joann Green called and reported that at 5:30 a.m. this morning she observed…”

Understand countersigning. Only countersign notes when required by the institution.

	If you merely review someone's note, co-sign in the following manner:

"Student Nurse name/Entry Reviewed by Jane Doe R.N.”

	If you actually participate in the activity, co-sign in the following manner:

"Student Nurse name/Jane Doe R.N.”

Keep documentation objective. Do not chart opinions or assumptions. Rather than writing "the patient was unresponsive”, your notes should report what you saw through objective assessment. Document what you see, hear, or smell. Avoid entries like perhaps, maybe, or I think.

Be careful to avoid labeling the patient. For example, avoid descriptions like demanding, drug seeking, abusive, lazy, drunk, mean, litigious, or out-of-control. Instead, note observations as a description of the behaviors.

Unusual occurrences and patient injuries need documented. Objectively record what you witness without making any conclusions or unsubstantiated assumptions. Use quotation marks when documenting comments from the patient, roommate, or visitors,. Record the patient's vital signs, physical condition, mental condition, subjective complaints, physician's notification and arrival, and details of treatment. However, do not mention that an incident report or occurrence report was filled out.

Always document a client's uncooperative behavior. For example;

	Leaving against medical advice,
	Refusing or abusing medications,
	Failing to follow diet or exercise plan,
	Refusing to follow instructions to stay in bed or ask for assistance,
	Failing to give information that effects care such as complete history, current medication, treatments,
	Patient or family tampering with traction, IV's, monitors,
	Failing to follow-up with visits to clinic or physician,
	Bringing unauthorized items into the facility

Document any safeguards or other preventive measures you are taking to protect your patient (e.g., night light left on, call light available, floor clear of trip hazards, etc.).

Chart that the facility's safekeeping for valuable possessions system was explained and made available to the patient. Encourage patient/family to have possessions sent home. If they agree, have them sign their names next to a documented statement to that effect. Discuss the availability of a safe and make sure that all items put in the safe are recorded on a receipt complete with the client's name and ID number. Describe each item in detail using objective language. For example, yellow ring with clear stone instead of charting a gold diamond ring. Update valuables list frequently for long-term patients. Before a patient is transferred, take an inventory of the valuables list to verify location of items.

Document medication administration as thoroughly as possible. Note the date, time, your initials, the method of administration, and the site where the medication was given if it is an injection. Document the site of the infusion, the type and amount of fluid, any medications added, and the administration rate of IV infusions. At least once a shift, note the condition of the IV site along with the type and size of catheter. If a medication is given for pain, note the site of the pain and its severity. Then follow up, noting the effectiveness of the medication. When omitting a medication, document the rationale. For example, "pain medication held pending stabilization of vital signs.” If a medication order is being questioned, tactfully document your conversation with the doctor. If someone is giving your patient medication while you are off the unit, make sure that person charts that they administered the medication.

Avoid verbal and telephone orders when possible because of the high risk of errors. However, it is not always possible. The proper method for documentation of verbal or telephone orders includes:

	Time and date of phone call,
	Write the order verbatim, and then read the order back to the physician,
	Document T.O./R.B. (telephone order/read back) or V.O./R.B. (verbal order/read back) followed by the physician's name and your name

Documentation of discharge instructions should include information related to: diet, activity, medications (name, reason for taking, dosage, and frequency), skin care hygiene, specific treatments, follow-up appointments, and any agency referrals. Along with the note relating that instructions were given, document the patient and family's comprehension of the discharge instructions. If any skills were demonstrated record the patient's ability to return demonstrate what was taught.

Summary

The primary purpose of medical documentation is to establish that individual's health status and need for care, record the care given, and demonstrate the results of the care. Medical documentation allows for the exchange of information between all members of the healthcare team. The health record provides legal proof of the type of care the patient received and that person's response to that care. Medical documentation that is poorly maintained, incomplete, inaccurate, illegible, or altered, generates doubt regarding the treatment given to the patient. Be factual when documenting. Do not guess, generalize, or give personal opinions. Rely on your professionally guided physical observations. What did you see, feel, hear or smell? Documentation of patient care holds the healthcare team members to professional accountability and demonstrates the quality care you have given.

New References

Burgess, K. (2009). Creation and Retention of Records. American Health Care Association. Retrieved June 18, 2010 from http://www.ahcancal.org/facility_operations/ComplianceProgram/Pages/CreationRetentionRecords.aspx

Dennis, JC. (June 2010). Is Your Facility Up-to-date On the Standards for a Legal Health Record? South Florida Hospital News and Healthcare Report. Accessed June 26, 2010 from
http://southfloridahospitalnews.com/page/Is_Your_Facility_Up-to-ate_On_the_Standards_for_a_Legal_Health_Record/912/3/index.php

Documenting Telephone Orders. (2008). LPN2009. Accessed July 2, 2010 from : http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=800621

Small, D., & Rutherford, L., (2009). Documentation Myths in Litigation. Provider (Washington, D.C.), 35(7), 37. Accessed July 2, 2010 from MEDLINE with Full Text database.

Smalls, H. (2009). Documentation Do's and Don'ts. Neonatal Network: NN, 28(2), 133-135. Accessed June 21, 2010 from MEDLINE with Full Text database.

Stansfield, K., Yetman, L., & Renwick, C. (2009). eDoc Evaluation - At Eighteen Months into the Challenge. Studies in Health Technology and Informatics. Accessed July 1, 2010 from MEDLINE with Full Text database.

TJC (2009). 2010 Portable Comprehensive Accreditation Manual for Hospitals (CAMH). The Joint Commission. Accessed July 1, 2010 from website: http://www.jcrinc.com

TJC (2009). The Joint Commission 2009 Requirements that Support Effective Communication, Cultural Competence and Patient-Centered Care Hospital Accreditation Program. Accessed June 28,, 2010 from:
http://www.jointcommission.org/NR/rdonlyres/B48B39E3-107D-495A-9032-24C3EBD96176/0/PDF32009HAPSupportingStds.pdf

Weber-Jahnke, J. (2009). Security Evaluation and Assurance of Electronic Health Record. Studies in Health Technology and Informatics. Accessed July 2, 2010 from MEDLINE with Full Text database.