Post on 23-Dec-2015
RET 1024RET 1024Introduction to Respiratory Introduction to Respiratory TherapyTherapy
Module 5.0Module 5.0
The Patient’s Medical RecordThe Patient’s Medical Record
The Patient’s Medical RecordThe Patient’s Medical Record
Medical Record – “Medical Record – “Chart”Chart”
A documented account of the occurrences A documented account of the occurrences pertaining to the patient throughout his or her stay in pertaining to the patient throughout his or her stay in a healthcare institutiona healthcare institution
The Patient’s Medical RecordThe Patient’s Medical Record
Medical Record – “Medical Record – “Chart”Chart”
It is the property of the institution and its It is the property of the institution and its contents are contents are confidentialconfidential and may not be read or and may not be read or discussed by anyone except those directly caring for discussed by anyone except those directly caring for the patient in a hospital or medical care facility.the patient in a hospital or medical care facility.
The Patient’s Medical RecordThe Patient’s Medical Record
Medical Record – “Medical Record – “Chart”Chart”
It is a legal document and must be maintained It is a legal document and must be maintained by the healthcare institution for days, months, or by the healthcare institution for days, months, or years, in case it is needed in a court of lawyears, in case it is needed in a court of law
The Patient’s Medical RecordThe Patient’s Medical Record
Components of the Medical RecordComponents of the Medical Record Admission SheetAdmission Sheet
Records pertinent patient information (e.g., name, Records pertinent patient information (e.g., name, address, religion, nearest of kin), admitting physician, address, religion, nearest of kin), admitting physician, and admission diagnosisand admission diagnosis
History and PhysicalHistory and Physical Records the patient’s admitting history and physical Records the patient’s admitting history and physical
examination as performed by the attending physician or examination as performed by the attending physician or residentresident
The Patient’s Medical RecordThe Patient’s Medical Record
Components of the Medical RecordComponents of the Medical Record Physician’s OrdersPhysician’s Orders
Records the physician’s orders and prescriptionsRecords the physician’s orders and prescriptions
Progress Sheet Progress Sheet Commonly referred to asCommonly referred to as “progress notes” “progress notes” Keep a continuing account of the patient’s progress for Keep a continuing account of the patient’s progress for
the physicianthe physician
The Patient’s Medical RecordThe Patient’s Medical Record
Components of the Medical RecordComponents of the Medical Record Nurses’ NotesNurses’ Notes
Describes the nursing care given to the patient, including Describes the nursing care given to the patient, including the patient’s complaints (subjective symptoms), the the patient’s complaints (subjective symptoms), the nurses’ observations (objective signs), and the patient’s nurses’ observations (objective signs), and the patient’s response to therapyresponse to therapy
Medication Admission Record “MAR”Medication Admission Record “MAR” Notes drugs and IV fluids that are given to the patientNotes drugs and IV fluids that are given to the patient
The Patient’s Medical RecordThe Patient’s Medical Record
Components of the Medical RecordComponents of the Medical Record Vital Signs Graphic SheetVital Signs Graphic Sheet
Records the patient’s temperature, pulse, respiration, Records the patient’s temperature, pulse, respiration, and blood pressure over timeand blood pressure over time
I/O SheetI/O Sheet Records the patient’s fluid intake (I) and output (O) over Records the patient’s fluid intake (I) and output (O) over
timetime
The Patient’s Medical RecordThe Patient’s Medical Record
Components of the Medical RecordComponents of the Medical Record Laboratory SheetLaboratory Sheet
Summarizes the results of laboratory testsSummarizes the results of laboratory tests
Consultation SheetConsultation Sheet Records notes by specialty physicians who are called in Records notes by specialty physicians who are called in
to examine a patient to make a diagnosisto examine a patient to make a diagnosis
The Patient’s Medical RecordThe Patient’s Medical Record
Components of the Medical RecordComponents of the Medical Record Surgical or Treatment ConsentSurgical or Treatment Consent
Records the patient’s authorization for surgery or Records the patient’s authorization for surgery or treatmenttreatment
Anesthesia and Surgical RecordAnesthesia and Surgical Record Notes key events before, during, and immediately after Notes key events before, during, and immediately after
surgerysurgery
The Patient’s Medical RecordThe Patient’s Medical Record
Components of the Medical RecordComponents of the Medical Record Specialized Therapy RecordsSpecialized Therapy Records
Records specialized treatments or treatment plans and Records specialized treatments or treatment plans and patient progress for various specialized therapeutic patient progress for various specialized therapeutic services (e.g., respiratory care, physical therapy)services (e.g., respiratory care, physical therapy)
Specialized Flow SheetsSpecialized Flow Sheets Records measurements made over time during Records measurements made over time during
specialized procedures (e.g., mechanical ventilation, specialized procedures (e.g., mechanical ventilation, kidney dialysis)kidney dialysis)
The Patient’s Medical RecordThe Patient’s Medical Record
Legal Aspects of RecordkeepingLegal Aspects of Recordkeeping
Legally, documentation of care given to a patient Legally, documentation of care given to a patient means that care was given means that care was given
Legally, no documentation means that care was Legally, no documentation means that care was not givennot given Lack of documentation can be interpreted as patient Lack of documentation can be interpreted as patient
neglectneglect
The Patient’s Medical RecordThe Patient’s Medical Record
General Rules for Medical RecordkeepingGeneral Rules for Medical Recordkeeping Entries should be printed or handwritten. After Entries should be printed or handwritten. After
completing the account, sign the chart with the completing the account, sign the chart with the initial of first name, complete last name, and your initial of first name, complete last name, and your title (CRT, RRT, Resp Care Student, etc.)title (CRT, RRT, Resp Care Student, etc.)
Example:Example: B. Kind, RRT B. Kind, RRT
Do Not Use ditto marks – “ “Do Not Use ditto marks – “ “
General Rules for Medical RecordkeepingGeneral Rules for Medical Recordkeeping Do not erase!Do not erase!
Erasures provide reason for questions if the chart Erasures provide reason for questions if the chart is used in a court of law.is used in a court of law.
If a mistake is made, a single line should be drawn If a mistake is made, a single line should be drawn through the mistake and the word “error” printed through the mistake and the word “error” printed above it; the correction should be initialedabove it; the correction should be initialed
Example:Example: Respiratory Tx given at 10:00 Respiratory Tx given at 10:00 10:3010:30
The Patient’s Medical RecordThe Patient’s Medical Record
error
General Rules for Medical RecordkeepingGeneral Rules for Medical Recordkeeping Record after completing each task for the patient Record after completing each task for the patient
(never beforehand)(never beforehand) and sign your name correctly and sign your name correctly after each entryafter each entry
Be exact in noting the time, effect, and results of Be exact in noting the time, effect, and results of all treatments and proceduresall treatments and procedures
Describe clearly and concisely observations and Describe clearly and concisely observations and assessments, e.g., the character of breath assessments, e.g., the character of breath sounds, percussion notes, secretions, etc. sounds, percussion notes, secretions, etc.
The Patient’s Medical RecordThe Patient’s Medical Record
General Rules for Medical RecordkeepingGeneral Rules for Medical Recordkeeping Leave no blank lines in the chartingLeave no blank lines in the charting
Draw a line through the center of an empty line or Draw a line through the center of an empty line or part of a line. This prevents charting by someone part of a line. This prevents charting by someone else in an area signed by youelse in an area signed by you
Use the present tense. Never use the future Use the present tense. Never use the future tense, as in “Patient to receive treatment after tense, as in “Patient to receive treatment after lunch.”lunch.”
The Patient’s Medical RecordThe Patient’s Medical Record
General Rules for Medical RecordkeepingGeneral Rules for Medical Recordkeeping Spell correctlySpell correctly
If you are not sure about the spelling of a word, If you are not sure about the spelling of a word, use a dictionary and look it upuse a dictionary and look it up
Use standard, hospital-approved abbreviationsUse standard, hospital-approved abbreviations Do not make up your ownDo not make up your own
The Patient’s Medical RecordThe Patient’s Medical Record
The Problem-Oriented Medical RecordThe Problem-Oriented Medical Record A documentation format used by some A documentation format used by some
healthcare institutionshealthcare institutions
POMR contains the following:POMR contains the following:1.1. The DatabaseThe Database
2.2. The Problem ListThe Problem List
3.3. The PlanThe Plan
4.4. The Progress NoteThe Progress Note
The Patient’s Medical RecordThe Patient’s Medical Record
The Problem-Oriented Medical RecordThe Problem-Oriented Medical Record The DatabaseThe Database
Routine information about the patientRoutine information about the patient
General health historyGeneral health history
Physical examination resultsPhysical examination results
Results of diagnostic testsResults of diagnostic tests
The Patient’s Medical RecordThe Patient’s Medical Record
The Problem-Oriented Medical RecordThe Problem-Oriented Medical Record The Problem ListThe Problem List
A problem is something that interferes with a patient’s A problem is something that interferes with a patient’s physical or psychological health or ability to functionphysical or psychological health or ability to function
Problems are identified and listed, based on the Problems are identified and listed, based on the information provided by the databaseinformation provided by the database
The problem list is dynamic; new problems are added The problem list is dynamic; new problems are added as they develop and others problems are removed as as they develop and others problems are removed as they are resolvedthey are resolved
The Patient’s Medical RecordThe Patient’s Medical Record
The Problem-Oriented Medical RecordThe Problem-Oriented Medical Record The Progress NoteThe Progress Note
Contain the findings (subjective and objective), Contain the findings (subjective and objective), assessment, plans, and orders of the doctors, nurses, assessment, plans, and orders of the doctors, nurses, and other practitioners involved in the care of the and other practitioners involved in the care of the patientpatient
The format used in often referred to as SOAPThe format used in often referred to as SOAP S – subjectiveS – subjective O – objectiveO – objective A – assessmentA – assessment P - planP - plan
The Patient’s Medical RecordThe Patient’s Medical Record
Charting Using the SOAP FormatCharting Using the SOAP Format SubjectiveSubjective
Information obtained from the patient, his or her relatives, or a Information obtained from the patient, his or her relatives, or a similar sourcesimilar source
ObjectiveObjective Information based on caregivers’ observations of the patient, Information based on caregivers’ observations of the patient, the physical examination, or diagnostic or laboratory tests the physical examination, or diagnostic or laboratory tests such as ABG or PFT such as ABG or PFT
AssessmentAssessmentThe analysis of the patient’s problemThe analysis of the patient’s problem
PlanPlanAction to be taken to resolve the problemAction to be taken to resolve the problem
The Patient’s Medical RecordThe Patient’s Medical Record
Example of SOAP EntryExample of SOAP EntryProblem 1Problem 1
PneumoniaPneumonia
SubjectiveSubjective““My chest hurts when I take a deep breath”My chest hurts when I take a deep breath”
ObjectiveObjectiveAwake; alert; oriented to time, place, and person; sitting upright in Awake; alert; oriented to time, place, and person; sitting upright in bed with arms leaning over bedside stand; pale, dry skin; bed with arms leaning over bedside stand; pale, dry skin; respiration 22/min and shallow; pulse 110 beats/min, regular but respiration 22/min and shallow; pulse 110 beats/min, regular but thready; blood pressure 130/89 (sitting); temperature 101thready; blood pressure 130/89 (sitting); temperature 101 F; F; bronchial breath sounds in left bases - posteriorly, occasionally bronchial breath sounds in left bases - posteriorly, occasionally expectorating small amounts of purulent sputumexpectorating small amounts of purulent sputum
The Patient’s Medical RecordThe Patient’s Medical Record
Example of SOAP EntryExample of SOAP Entry
AssessmentAssessment
Pneumonia continuesPneumonia continues
PlanPlanTherapeuticTherapeutic:: Assist with coughing and deep breathing at least Assist with coughing and deep breathing at least every 2 hours; postural drainage and percussion every 4 hours; every 2 hours; postural drainage and percussion every 4 hours; assist with ambulation as per physician orders and patient assist with ambulation as per physician orders and patient tolerance.tolerance.
Diagnostic:Diagnostic: Continue to monitor lung sounds before and after Continue to monitor lung sounds before and after each treatment.each treatment.
Education:Education: Teach to cough and deep breathe and evaluate return Teach to cough and deep breathe and evaluate return demonstrationdemonstration
The Patient’s Medical RecordThe Patient’s Medical Record