Acute care handbook for physical therapists (fourth edition) chapter 2 the medical record Acute care handbook for physical therapists (fourth edition) chapter 2 the medical record Acute care handbook for physical therapists (fourth edition) chapter 2 the medical record Acute care handbook for physical therapists (fourth edition) chapter 2 the medical record Acute care handbook for physical therapists (fourth edition) chapter 2 the medical record Acute care handbook for physical therapists (fourth edition) chapter 2 the medical record
CHAPTER The Medical Record Michele P West CHAPTER OUTLINE CHAPTER OBJECTIVES Confidentiality Physical Therapist Documentation Physical Therapy Considerations Components of the Medical Record Orders Admission Note Format Progress Notes Reports The objectives for this chapter are the following: Briefly describe the medical record in paper and electronic forms, including medical record confidentiality and security Review documentation standards for the physical therapist and physical therapist assistant Describe the different components of the medical record, including a detailed outline of the admission history and physical PREFERRED PRACTICE PATTERNS The medical record is multifactorial and applies to many body systems For this reason, specific practice patterns are not delineated in this chapter Please refer to Appendix A for a complete list of the preferred practice patterns to identify the most applicable practice pattern for a given diagnosis The medical record, whether paper or electronic, is a legal document that chronicles a patient’s clinical course during hospitalization and is the primary means of communication between the various clinicians caring for a single patient More specifically, the medical record contains information about past or present symptoms and disease(s), test and examination results, interventions, and the medical-surgical outcome.1 Additionally, the medical record may be used for educational purposes and for performing quality improvement studies, conducting research, and resolving legal issues such as competency or disability.2 The widespread use of electronic health records (EHR) has been promoted by the Health Information Technology for Economic and Clinical Health (HITECH) Act, which consists of three-stage criteria, including financial incentives for hospitals to comply with an EHR Stage calls for EHR compliance by the end of 2014, with penalties for those institutions or providers not in compliance.3 Stages and are yet to be specifically defined In conjunction with the transition to EHR, an initiative known as “meaningful use” has been developed to ensure providers are able to enhance the quality of patient care with the implementation of EHR.4 Specific advantages of an EHR compared with a paper record include complete and accurate patient health data that is readily available and shared with multiple providers to improve care coordination, the convenience of electronic prescriptions, the ability to track quality data, patient empowerment (by giving them access to their own records), and the potential for improved automatic patient follow-up.5 Confidentiality According to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, any information in the medical record that contains “protected health information (PHI)” should be kept confidential, and all health care providers should safeguard the availability and integrity of health care information in oral, written, or electronic forms.6 PHI includes any information that pertains to the past, present, or future physical or mental health conditions of an individual, including provision of care, payment of care, and demographics.7 A subset of the Privacy Rule is the Security Rule, which specifically addresses the confidentiality of electronic PHI (e-PHI) The Security Rule states that a covered entity must ensure the integrity 11 12 CHAPTER 2 The Medical Record and availability of e-PHI that it creates, maintains, or transmits.8 The goal of the Security Rule is to protect e-PHI as institutions such as hospitals adopt new and efficient technologies.8 Specific topics, such as human immunodeficiency virus status, substance abuse, domestic abuse, or psychiatric history, are privileged information, and discussion of them is subject to additional ethical and regulatory guidelines.9 The physical therapist must be compliant with HIPAA,10 the American Physical Therapy Association’s Guide for Professional Conduct and Code of Ethics for Physical Therapists,11,11a and any policies and procedures of the facility or state in regard to sharing medical record information with the patient, family, caretakers, visitors, or third parties CLINICAL TIP To ensure confidentiality of PHI in the acute care setting, the physical therapist should log off the computer when not in use, keep the written medical chart and flow books closed when not in use, cover any paperwork kept on clipboards when traveling in the facility, and use discretion when discussing patient information in shared rooms, hallways, and/or elevators Physical Therapist Documentation The physical therapist should comply with the documentation standards including, but not limited to, the policies/procedures of the organization, the state, and the American Physical Therapy Association’s Guidelines for Physical Therapy Documentation of Patient/Client Management.12 In general, documentation must be: • Dated and timed with an authenticated signature, including therapist credentials • Legible and in black ink (in a paper chart) • Clearly labeled with the appropriate patient identification • Complete, accurate, and objective • Cosigned for a physical therapist assistant or student therapist Documentation should be free of ambiguous acronyms or abbreviations to minimize misinterpretation and prevent errors that could result in patient safety issues (Table 2-1).13 These standards apply to the examination, evaluation, and plan of care portions of physical therapist documentation, including flow sheets A documentation entry is required for every physical therapist visit and should include the following, if applicable14: • Phone calls or conversations with other health care providers • Handouts provided to the patient, including exercise programs or educational materials • The use of interpreter services • Therapist response and assessment of an adverse event or situation Ideally, documentation of physical therapy intervention should occur at point of service or as close to the time of intervention as possible If a documentation error is noted, correct the error as soon as possible Be familiar with your institution’s policy for correcting chart errors in written or electronic formats Physical Therapy Considerations • Be sure to document when a patient/family member declines or refuses therapy intervention or requests a specific time of day for therapy, including a rationale for such • Documentation of deferring or “holding” therapy should include a rationale and the source of the deferral, whether it is from the physician, nursing, or other providers Deferring physical therapy when originated from the therapist’s perspective should be succinctly described • Documentation of patient unavailability (e.g., off the floor at a test) is also suggested Components of the Medical Record The organization of the medical record can vary from institution to institution; however, the medical record typically is composed of the following basic sections TABLE 2-1 Prohibitive Abbreviations* Do Not Use Potential Problem Use Instead U, u (unit) IU (International Unit) Q.D, QD, q.d., qd (daily) QOD., QOD, q.o.d., qod (every other day) Trailing zero (X.0 mg)† Lack of trailing zero (.X mg) MS MSO4 and MgSO4 Mistaken for “0” (zero), the number”4” (four) or “cc” Mistaken for IV (intravenous) or the number 10 (ten) Mistaken for each other Period after Q mistaken for “I” and the “O” mistaken for the “I” Write “unit” Write “International Unit” Write “daily” Write “every other day” Decimal point is missed Write X mg Write 0.X mg Write “morphine sulfate” Write “magnesium sulfate” Can mean morphine sulfate or magnesium sulfate Confused for one another *Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms †Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes It may not be used in medication orders or other medication-related documentation.Data from The Joint Commission Official “Do Not Use “ List www.jointcommission.org Last accessed June 9, 2012 CHAPTER 2 The Medical Record Orders The order section is a log of all instructions of the plan of care for the patient, including medications, diagnostic or therapeutic tests and procedures, vital sign parameters, activity level, diet, the need for consultation services, and resuscitation status Orders may be written by a physician, physician assistant, or nurse practitioner An order may be taken by a nurse or other health care provider, including a physical therapist, according to departmental, facility, and state policies In the interest of patient safety and error prevention, the process of taking a verbal order, especially for medications, has been minimized in many hospitals.15 All (telephone) orders must be dated, timed, and signed or cosigned by the appropriate personnel In addition, a telephone order should be read back to the person giving the order for the purpose of verification.16 Physical Therapy Considerations • The order section of the patient’s medical record should be reviewed before the initial and any subsequent physical therapy intervention(s) for the following: the order for physical therapy, patient activity level, weight-bearing status (if applicable), vital sign parameters, and positioning restrictions (if applicable) On subsequent physical therapy sessions, the review of the order section offers a “snapshot” of change(s) in a patient Look for new or discontinued medications, changes in PO status, and new laboratory or diagnostic testing orders • If an order appears incomplete or ambiguous to the physical therapist, clarify the order before beginning physical therapy Admission Note Format The following outline summarizes the basic format of the initial admission note (often referred to as the “H&P,” or History and Physical) written by a physician, physician’s assistant, or nurse practitioner in the medical record.17 The italicized items indicate the standard information the physical therapist should review before beginning an intervention I History (subjective information) A Data that identify the patient, including the source and degree of reliability of the information B History of present illness (HPI), including the chief complaint and a chronologic list of the problems associated with the chief complaint C Medical or surgical history, risk factors for disease, and allergies D Family health history, including age and health or age and cause of death for immediate family members as well as a relevant familial medical history 13 E Personal and social history, including occupation, lifestyle, functional mobility status, the need for home or outpatient services, and architectural barriers at home F Current medications, including level of compliance II Physical examination (objective information) Negative (normal) or positive (abnormal) findings are described in detail according to the following: A General information, including vital signs, laboratory findings, mental status, and appearance B Skin C Head, eyes, ears, nose, throat (HEENT), and neck D Chest and back E Heart (cor) F Abdomen G Genitalia/rectal exam H Extremities I Neurologic system III Assessment The assessment is a statement of the condition and prognosis of the patient in regard to the chief complaint and medical-surgical status If the etiology of the problem(s) is unclear, then differential diagnoses are listed IV Plan The plan of care includes further observation, tests, laboratory analysis, consultation with additional specialty services or providers, pharmacologic therapies, other interventions, and discharge planning Progress Notes A progress note is a shortened version of the initial note with an emphasis on any new physical findings, an updated assessment, and plan The progress note section in a written record is typically multidisciplinary, with documentation from all caregivers in chronologic order The nursing staff documents its own admission assessment, problem list, and care plan(s) Medication reconciliation sheets, flow sheets, clinical pathways, consult service notes from other physicians and allied health professionals, and operative and procedural notes are also included in this section Reports A variety of reports are filed chronologically in individual sections in the medical record (e.g., radiologic or laboratory reports) Each report includes an interpretation or normal reference ranges, or both, for various diagnostic or laboratory test results Other types of reports include pulmonary function tests, electroencephalograms (EEGs), and stress testing References Roach WH et al: Medical record entries In Medical records and the law, ed 4, Boston, 2006, Jones and Bartlett, pp 51-61 Monarch K: Documentation, part 1: principles for selfprotection, AJN 107(7):58, 2007 Centers for Medicare and Medicaid Services: CMS HER meaningful use overview (website): http://www.cms.gov/ EHRIncentivePrograms/30_Meaningful_ Use.asp#BOOKMARK1 Accessed March 20, 2012 Blumenthal D, Tavenner M: The “meaningful use” regulation for electronic health records, N Engl J Med 363(6):501-504, 2010 14 CHAPTER 2 The Medical Record U.S Department of Health and Human Services, The Office of the National Coordinator for Health Information Technology: Electronic health records and meaningful use (website): http:// healthit.hhs.gov/portal/ server.pt?open512&objID=2996&mode=2 Accessed March 20, 2012 U.S Department of Health and Human Services: Health information privacy (website): http://www.hhs.gov//ocr/privacy/ hippa/understanding/coveredentities/index/html Accessed March 20, 2012 U.S Department of Health and Human Services: Summary of the privacy rule (website): http//:www.hhs.gov/ocr/privacy/hippa/ understanding/summary/privacysummary.pdf Accessed March 20, 2012 U.S Department of Health and Human Services: Summary of the security rule (website): http:www.hhs.gov/ocr/privacy/ hippa/understanding/srsummary.html Accessed March 20, 2012 Rutberg MP: Medical records confidentiality In Weintraub MI, editor: Neurologic clinics: medical-legal issues facing neurologists, Neurol Clin 17:307-313, 1999 10 Office for Civil Rights—HIPAA: Medical privacy—national standard to protect the privacy of personal health information (website): http//:www.hhs.gov/ocr/privacy/hipaa/administrative/ privacyrule/index.html Accessed March 20, 2012 11 American Physical Therapy Association: Code of ethics for the physical therapist (website): http://www.apta.org Accessed March 20, 2012 11a. American Physical Therapy Association: Guide for professional conduct (website): http://www.apta.org Accessed March 20, 2012 12 American Physical Therapy Association Guidelines: Physical therapy documentation of patient/client management BOD G03-05-16-41 (website): http://www.apta.org Accessed March 20, 2012 13 The Joint Commission: Official “do not use” list (website): http://www.jointcommission.org/topics/patient_safety.aspx Accessed March 20, 2012 14 American Physical Therapy Association: Improving your clinical documentation: reflecting best practice (website): http:// www.apta.org/Documentaion/DefensibleDocumentaion Accessed March 20, 2012 15 The Joint Commision: Comprehensive Accreditation Manual for Hospitals (CAMH), Update September 2011.MM.04.01.01 16 The Joint Commision: Comprehensive Accreditation Manual for Hospitals (CAMH), Update September 2011 PC.02.01.03.10 17 Surviving the wards: evaluating the patient (H&P) In Ferri FF, editor: Practical guide to the care of the medical patient, Philadelphia, 2010, Mosby, pp 1-3 ... Accessed March 20 , 20 12 11 American Physical Therapy Association: Code of ethics for the physical therapist (website): http://www.apta.org Accessed March 20 , 20 12 11a. American Physical Therapy Association:... of the Medical Record The organization of the medical record can vary from institution to institution; however, the medical record typically is composed of the following basic sections TABLE 2- 1 ... incomplete or ambiguous to the physical therapist, clarify the order before beginning physical therapy Admission Note Format The following outline summarizes the basic format of the initial admission