/ 291

Medical Records Medical Records

Turan SET, Assist. Prof.

Atatürk University Medical Faculty, Erzurum

/ 292

Objectives

• At the end of this presentation, the participants should be able to;

–Define source oriented medical record–Define problem oriented medical record–List items to be included in the medical record–Discuss reasons for keeping medical records–Explain the PSOAP acronym for keeping

records

/ 293

It is always easier to find your way if you have a road map!It is always easier to find your way if you have a road map!

/ 294

Which data are we recording in practice?

/ 295

Why to keep records?

• Helps in medical decisions(is the size of a lymph node or nodule increasing with time?)

• Helps to share responsibility with the patient

• Legal obligation.• Protects the patient as well as doctor in

front of the court

/ 296

• Has economic benefits• Useful to produce health statistics• Provides epidemiological data• Assists practice management• Useful in QI activities• Is a communication tool

/ 297

Types According to the method;

– Source oriented

– Problem oriented

/ 298

Source oriented medical recordData taken from the source are recorded as they are (Source: patient, relative, laboratory etc.)

Easy and fast to record

Flexible

Omitting information is highly possible

Difficult to access the information

/ 299

Problem oriented medical record Structure is defined in advance. The patient with problem is in the focus It is systematic Data is easily accessible Not flexible. Recording information is difficult

and time consuming

/ 2910

Which data to record?

• Personal info: age, sex, occupation, training, family...• Risk factors: tobacco, alcohol, life styles...• Allergies and drug reactions• 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

/ 2911

PSOAP• Problem

– Everything the patient reports and doctor’s findings which are regarded as problems

• Subjective– History of the problem; what the patient feels

or thinks about the problem• Objective

– Doctors findings related with the problem• Assessment

– Evaluation of the problem; the diff. diagnosis• Plan

– Prescription, consultation, advice, control visit...

/ 2912

Visits21 February 1996: dyspnea, coughing and fever. Dark defecation. PE: BP 150/90, pulse 95/min, Fever: 39.3 oC.Ronchi +, no abdominal tenderness.Medications: 64 mg Aspirin/day. Possible acute bronchitis and cardiac decompensation.Possible bleeding due to Aspirin.Rx: Amoxicilline 500 mg 2x1, Aspirin 32 mg/day.

4 March 1996: no cough, slight dyspnea, defecation normal.PE: light rhonchi, BP 160/95, pulse 82/min.Rx: Aspirin 32 mg/day.

Lab21 February 1996: ESR 25 mm, Hb 7.8, Fecal occult blood +.

4 March 1996: Hb 8.2, Fecal occult blood :-.X-ray21 February 1996: Chest x-ray: no atelectasis, light cardiac decompensation findings

Patient -Source-Oriented Medical Record

Source Oriented Medical Record

/ 2913

Problem 1: CoughingProblem 1: Coughing21 February 1996S: dyspnea, coughing, fever.O: pulse 95/min, Fever: 39.3 oC.Rhonchi+. ESR 25 mm.Chest x-ray: no atelectasis, light cardiac decompensation findings.A: Acute bronchitis.P: Amoxicilline 500 mg 2x1.

4 March 1996S: no coughing, slight dyspnea.O: pulse 82/min. Slight rhonchi.A: minimal bronchitis findings.

Problem Oriented Medical Record

Problem 2: DyspneaProblem 2: Dyspnea21 February 1996S: Dyspnea.O: Rhonchi+, BP 150/90 mmHg.Chest x-ray: no atelectasis, slight cardiac decompensation findings.A: Slight decompensation findings.

4 March 1996S: slight dyspnea.O: BP: 160/95, pulse 82/min.A: No decompensation.

/ 2914

 Problem 3: Dark colored defecationProblem 3: Dark colored defecation

21 February 1996S: Dark feces. Using Aspirin 64 mg/day.O: No abdominal tenderness, rectal exam revealed no blood, Hb 7.8 mg/dl. Fecal occult blood +A: Possible intestinal bleeding due to Aspirin.P: Decrease Aspirin dose to 32 mg/day.

4 March 1996S: Defecation normal.O: Fecal occult blood -A: No intestinal bleeding symptoms.P: Continue Aspirin dosage 32 mg/day

/ 2915

Rules in keeping medical records (NCQA)1. Each page in the record contains the patient’s name or ID number.

2. Personal biographical data include the address, employer, home and work telephone numbers and marital status.

3. All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials.

4. All entries are dated.

5. The record is legible to someone other than the writer.

6. *Significant illnesses and medical conditions are indicated on the problem list.

7. *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.

http://www.ncqa.org/LinkClick.aspx?fileticket=dmQOrIgyvMQ%3D&tabid=125&mid=766&forcedownload=true

/ 2916

National Committee for Quality Assurance (NCQA)

8. * Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses.

9. For patients 12 years and older, there is appropriate notation concerning the use of cigarettes, alcohol and substances (for patients seen three or more times, query substance abuse history).

10. The history and physical examination identifies appropriate subjective and objective information pertinent to the patient’s presenting complaints.

11. Laboratory and other studies are ordered, as appropriate.12. * Working diagnoses are consistent with findings.13. * Treatment plans are consistent with diagnoses.14. Encounter forms or notes have a notation, regarding follow-up care,

calls or visits, when indicated. The specific time of return is noted in weeks, months or as needed.

/ 2917

NCQA15.Unresolved problems from previous office visits are addressed in

subsequent visits.16.There is review for under - or over utilization of consultants.17.If a consultation is requested, there a note from the consultant in the

record.18.Consultation, laboratory and imaging reports filed in the chart are

initialed by the practitioner who ordered them, to signify review. (Review and signature by professionals other than the ordering practitioner do not meet this requirement.) If the reports are presented electronically or by some other method, there is also representation of review by the ordering practitioner. Consultation and abnormal laboratory and imaging study results have an explicit notation in the record of follow-up plans.

19.* There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.

20.An immunization record (for children) is up to date or an appropriate history has been made in the medical record (for adults).

21.There is evidence that preventive screening and services are offered in accordance with the organization’s practice guidelines.

/ 2918

Legal Problems

• Not recorded = Not done !

/ 2919

• Record everything you do (including phone consultations)

• Apply guidelines (e.g.: NCQA)

• Don't use erasable pencils

• Don’t use humiliating expressions

In order to prevent legal problems:

/ 2920

Do not use vague expressions such as “the patient feels well”

If you need to make changes just strike through and record also the date of change

If you stated that the patient is not cooperative give the reason

If patient rejects a procedure or test, mention it and give the reason why you requested it

/ 2921

Follow-up Charts

• It is practical to use follow-up charts for chronic diseases – DM,

– Hypertension

– Obesity

– …

/ 2922

Charts - Obesity

/ 2923

Medical Records are Our Road Maps

/ 2924

Summary

• What are the benefits of keeping records?

/ 2925

• Source oriented medical record is easy. Data entry is flexible.

A. Correct

B. Wrong

/ 2926

• Problem oriented medical record is systematic. Access to information is easy.

A. Correct

B. Wrong

/ 2927

• Source oriented medical record contains a personal problem list.

A. Correct

B. Wrong

/ 2928

• Can you explain the meanings of PSOAP in the medical record?

/ 2929

• What are the core elements requested by NCQA in the medical record?