Transcript Medical Records are Our Road Maps

Medical Records
Turan SET, Assist. Prof.
Atatürk University Medical Faculty, Erzurum
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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
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It is always easier to find your way if you have a road map!
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Which data are we recording in
practice?
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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
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• Has economic benefits
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Useful to produce health statistics
Provides epidemiological data
Assists practice management
Useful in QI activities
Is a communication tool
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Types
According to the method;
– Source oriented
– Problem oriented
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
Source oriented medical record
Data taken from the source are recorded as they are
(Source: patient, relative, laboratory etc.)

Easy and fast to record

Flexible
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Omitting information is highly possible
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Difficult to access the information
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
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

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Which data to record?
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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
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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...
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Source Oriented Medical Record
Patient -Source-Oriented Medical Record
Visits
21 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.
Lab
21 February 1996: ESR 25 mm, Hb 7.8, Fecal occult blood +.
4 March 1996: Hb 8.2, Fecal occult blood :-.
X-ray
21 February 1996: Chest x-ray: no atelectasis, light cardiac decompensation
findings
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Problem Oriented Medical Record
Problem 1: Coughing
21 February 1996
S: 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 1996
S: no coughing, slight dyspnea.
O: pulse 82/min. Slight rhonchi.
A: minimal bronchitis findings.
Problem 2: Dyspnea
21 February 1996
S: Dyspnea.
O: Rhonchi+, BP 150/90 mmHg.
Chest x-ray: no atelectasis, slight
cardiac decompensation findings.
A: Slight decompensation findings.
4 March 1996
S: slight dyspnea.
O: BP: 160/95, pulse 82/min.
A: No decompensation.
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Problem 3: Dark colored defecation
21 February 1996
S: 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 1996
S: Defecation normal.
O: Fecal occult blood A: No intestinal bleeding symptoms.
P: Continue Aspirin dosage 32 mg/day
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Rules in keeping medical records (NCQA)
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7.
Each page in the record contains the patient’s name or ID number.
Personal biographical data include the address, employer, home and
work telephone numbers and marital status.
All entries in the medical record contain the author’s identification.
Author identification may be a handwritten signature, unique
electronic identifier or initials.
All entries are dated.
The record is legible to someone other than the writer.
*Significant illnesses and medical conditions are indicated on the
problem list.
*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.
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http://www.ncqa.org/LinkClick.aspx?fileticket=dmQOrIgyvMQ%3D&tabid=125&mid=766&forcedownload=true
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 16noted
in
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weeks, months or as needed.
NCQA
15.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
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accordance with the organization’s practice guidelines.
Legal Problems
• Not recorded = Not done !
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In order to prevent legal
problems:
• Record everything you do (including phone
consultations)
• Apply guidelines (e.g.: NCQA)
• Don't use erasable pencils
• Don’t use humiliating expressions
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
Do not use vague expressions such as “the patient
feels well”
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If you need to make changes just strike through and
record also the date of change
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If you stated that the patient is not cooperative give
the reason
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If patient rejects a procedure or test, mention it and
give the reason why you requested it
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Follow-up Charts
• It is practical to use follow-up charts for
chronic diseases
– DM,
– Hypertension
– Obesity
–…
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Charts - Obesity
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Medical Records are Our Road Maps
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Summary
• What are the benefits of keeping records?
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•
Source oriented medical record is easy.
Data entry is flexible.
A. Correct
B. Wrong
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•
Problem oriented medical record is
systematic. Access to information is easy.
A. Correct
B. Wrong
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•
Source oriented medical record contains a
personal problem list.
A. Correct
B. Wrong
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•
Can you explain the meanings of PSOAP
in the medical record?
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• What are the core elements requested by
NCQA in the medical record?
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