Patient Record, Outpatient, And Physician Office

CHAPTER

5

Content of the Patient Record: Inpatient, Outpatient, and Physician Office
Chapter Outline
Key Terms Objectives Introduction General Documentation Issues Hospital Inpatient Record—Administrative Data Hospital Inpatient Record—Clinical Data Hospital Outpatient Record Physician Office Record Forms Control and Design Internet Links Summary Study Checklist Chapter Review

Key Terms addressograph machine admission note admission/discharge record admitting diagnosis advance directive advance directive notification form against medical advice (AMA) alias ambulance report ambulatory record ancillary reports ancillary service visit anesthesia record antepartum record anti-dumping legislation APGAR score attestation statement automatic
stop order autopsy autopsy report bedside terminal system birth certificate birth history case management note 109 certificate of birth certificate of death chief complaint (CC) clinical data clinical résumé comorbidities complications conditions of admission consent to admission consultation consultation report death certificate

110 • Chapter 5

dietary progress note differential diagnosis discharge note discharge order discharge summary doctors orders DRG creep durable power of attorney emergency record encounter encounter form face sheet facility identification family history fee slip final diagnosis follow-up progress note forms committee graphic sheet health care proxy history history of present illness (HPI) informed consent integrated progress notes interval history labor and delivery record licensed practitioner macroscopic maximizing codes medication administration record (MAR)

necropsy necropsy report neonatal record newborn identification newborn physical examination newborn progress notes non-licensed practitioner nurses notes nursing care plan nursing discharge summary nursing documentation obstetrical record occasion of service operative record outpatient visit past history pathology report patient identification patient property form patient record committee physical examination physician office record physician orders postanesthesia note postmortem report postoperative note postpartum record preanesthesia evaluation note prenatal record preoperative note primary diagnosis

principal diagnosis principal procedure progress notes provisional autopsy report read and verified (RAV) recovery room record rehabilitation therapy progress note respiratory therapy progress note review of systems (ROS) routine order secondary diagnoses secondary procedures short stay short stay record social history standing order stop order superbill telephone order call back policy tissue report transfer order Uniform Ambulatory Care Data Set (UACDS) Uniform Hospital Discharge Data Set (UHDDS) upcoding verbal order written order

Objectives
At the end of this chapter, the student should be able to:

• •

• • •

Explain general documentation issues that impact all patient records Differentiate among administrative, financial, and clinical data collected on patients List the contents of inpatient, outpatient, and physician office records

Identify accreditation standards and federal and state laws and regulations that impact patient record content Detail forms design and control requirements, including the role of the forms committee

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 111

INTRODUCTION
Health care providers (e.g., hospitals, physician offices, and so on) are responsible for maintaining a record for each patient who receives health care services. If accredited, the provider must comply with standards that impact patient record keeping (e.g., Joint Commission on Accreditation of Healthcare Organizations). In addition, federal and state laws and regulations (e.g., Medicare Conditions of Participation) provide guidance as to patient record content requirements (e.g., inpatient, outpatient, and so on). To appropriately comply with accreditation standards and federal and state laws and regulations, most facilities establish a forms design and control procedure along with a forms committee to manage the process. NOTE: For content of alternate care patient records (e.g., home health care, hospice care, long-term care, and so on), refer to Thomson Delmar Learning’s Comparative Records for Health Information Management by Ann Peden.

entry. Medical records must be retained in their original or legally reproduced form for a period of at least 5 years, and the hospital must have a system of coding and indexing medical records to allow for timely retrieval by diagnosis and procedure to support medical care evaluation studies. The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with federal or state laws, court orders, or subpoenas.

GENERAL DOCUMENTATION ISSUES
Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards require that the patient record contain sufficient information to identify the patient. The American Osteopathic Association (AOA) Accreditation Requirement for Acute Care Hospitals outlines requirements for patient identification. Medicare Conditions of Participation (CoP) state that the hospital must have a medical record service that has administrative responsibility for medical records, and the hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed, properly retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. The author of each entry must be identified and must authenticate his or her entry—authentication may include signatures, written initials or computer

The patient record is a valuable tool that documents care and treatment of the patient.
It is essential that every report in the patient record contain patient identification, which consists of the patient’s name and some other piece of identifying information such as medical record number, date of birth, or social security number. Every report in the patient record and every screen in an automated record system must include the patient’s name and identification number. In addition, for reports that are printed on both sides of a piece of paper, patient identification must be included on both sides. Documents that contain multiple pages (e.g., computer-generated lab reports) must include patient identification information on all pages. NOTE: Some patients insist on the use of an alias, which is an assumed name, during their encounter. The patient might be a movie star or sports figure; receiving health care services under an alias affords privacy (e.g., protection from the press). The name that the patient provides is accepted as the official name, and the true name can be entered in the master patient index as an AKA (also known as). However, the true name is not entered in the patient record or in the billing files. Patients who choose to use an alias should be informed that their insurance company probably will not reimburse the facility for care provided, and the patient will be responsible for payment.
EXAMPLE
A pregnant patient was admitted to the hospital and signed in under an alias. Her baby was delivered, and the baby’s last name was entered on the record using the alias. The patient explained that an order of protection had been issued because her spouse was abusive and she

112 • Chapter 5

didn’t want him to know that she had been admitted to deliver the baby. Upon discharge, she and the baby traveled to a safe house.

It is common for health care facilities to print the attending/primary care physician’s name and the date of admission/visit on each form using an addressograph machine (Figure 5-1), which imprints patient identification information on each report. A plastic card that looks similar to a credit card is created for each patient and placed in the addressograph machine to make an impression on the report. Using an addressograph also allows forms to be imprinted prior to patient admission, creating the record ahead of time. (Some facilities print computer-generated labels, which are affixed to blank forms.) Facility identification, including the name of the facility, mailing address, and a telephone number, must also be included on each report in the record so that an individual or health care facility in receipt of copies of the record can contact the facility for clarification of record content.

entries must be dated (month, date, and year, such as mmddyyyy) and timed (e.g., military time, such as 0400). Providers are responsible for documenting entries as soon as possible after the care and treatment of a patient, and predated and postdated entries are not allowed. (Refer to the discussion of addendums in Chapter 4 for clarification on how providers should amend an entry.) NOTE: When nurses summarize patient care at the end of a shift, documentation should include the actual date and time the entry was made in the record.

Content of the Patient Record
Because patient record content serves as a medicolegal defense, providers should adhere to guidelines (Table 5-1) that ensure quality documentation. Exercise 5–1 General Documentation Issues

True/False: Indicate whether each statement is True (T) or False (F). 1. All medical record entries should be authenticated by the author at the time of the entry. 2. Documentation of the names of other patients in a record should not occur; the record should reference the other patients’ medical record numbers.

Dating and Timing Patient Record Entries
For a record to be admissible in a court of law according to Uniform Rules of Evidence, all patient record

Figure 5-1

Addressograph Machine and Plastic Card (Permission to reprint granted by Addressograph.com.)

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 113

Table 5-1 Patient Record Documentation Guidelines Guideline
Authentication Change in Patient’s Condition

Description
• Entries should be documented and signed (authenticated) by the author. • If the patient’s condition changes (e.g., worsens) or a significant patient care issue develops (e.g., patient falls out of bed and breaks hip), documentation must reflect this as well as indicate follow-through. • Any communication provided to the patient’s family (e.g., discharge requirements) or physician (e.g., change of condition on night shift) should be properly documented. • Significant information related to the patient’s care and treatment should be documented (e.g., patient condition, response to care, treatment course, and any deviation from standard treatment/reason). • All fields on preprinted forms should be completed (e.g., flow sheets). For information not entered, document N/A for not applicable. • If an original entry is incomplete, the provider should amend the entry (e.g., document in the next blank space in the record and refer to the date of the original entry). • If documentation is reported by exception (e.g., only when a specific behavior occurs), the form should indicate these charting instructions. • Document current observations, outcomes, and progress. • Entries should be consistent with documentation in the record (e.g., flow charts). • If documentation is contradictory, an explanation should be included. • Providers should not skip lines or leave blanks when documenting in the patient record. • Do not generate a new form (e.g., progress note sheet) until the previous form is filled. • If a new form is started, the provider should cross out any remaining space on the previous form. (An entry documented out of order should be added as a late entry.) • Blank space on a form raises the question that the record may have been falsified (e.g., blank page inserted or pages out of order because the provider backdated an entry). • State facts about patient care and treatment, and avoid documenting opinions. • INCORRECT: Patient is peculiar. • CORRECT: Patient exhibits odd behavior . . . • If other patient(s) are referenced in the record, do not document their name(s). Reference their patient number(s) instead. • Documentation entries in the patient record are considered permanent, and policies and procedures should be established to prevent falsification of and tampering with the record. • Select white paper with permanent black printing (e.g., laser, not inkjet printer) to ensure readability of paper-based records. • Require providers to enter documentation using permanent black ink. • Plain paper (not thermal paper) faxes are best if filed in the patient record. • File original documents in the patient record, not photocopies. • Avoid using labels on reports because they can become separated from the report. • Be sure to document specific information about patient care and treatment. Avoid vague entries. • INCORRECT: Eye exam is normal. • CORRECT: Eye exam reveals pupils equal, round, and reactive to light.

Communication with Others Completeness

Consistency

Continuous Documentation

Objective Documentation

Referencing Other Patients Permanency

Physical Characteristics

Specificity

114 • Chapter 5

3. Documentation in a progress note should be continuous; do not skip any lines or leave blanks when documenting in the patient record. 4. When documenting on preprinted forms it is acceptable to leave a blank field.

HOSPITAL INPATIENT RECORD— ADMINISTRATIVE DATA
As defined in Chapter 4, administrative data includes demographic, socioeconomic, and financial information, which is gathered upon admission of the patient to the facility and documented on the inpatient face sheet (or admission/discharge record). Some facilities gather this information prior to admission through a telephone interview. The following reports comprise administrative data: • • • • • • Face sheet (or admission/discharge record) Advance directives Informed consent Patient property form Birth certificate Death certificate

the condition or disease for which the patient is seeking treatment. The admitting diagnosis is often not the patient’s final diagnosis, which is the diagnosis determined after evaluation and documented by the attending physician upon discharge of the patient from the facility. NOTE: Financial data is collected from the patient upon admission and submitted to third-party payers for the reimbursement purposes. The Uniform Hospital Discharge Data Set (UHDDS) is the minimum core data set collected on individual hospital discharges for the Medicare and Medicaid programs, and much of this information is located on the face sheet. The official data set consists of the following items: • • • • • • • • • • • • • • • • • Personal Identification Date of Birth Sex Race and Ethnicity Residence Health Care Facility Identification Number Admission Date and Type of Admission Discharge Date Attending Physician Identification Surgeon Identification Principal Diagnosis Other Diagnoses Principal Procedure and Dates Other Procedures and Dates Disposition of Patient at Discharge Expected Payer for Most of This Bill Total Charges

Face Sheet
JCAHO standards do not specifically require a face sheet, but it does require that all medical records contain identification data. The JCAHO requires completion of the medical record within 30 days following patient discharge. AOA requirements include a statistical summary sheet, which documents the date, name, and address of the patient, the hospital admission number, and other data necessary to clearly identify the patient to the professional staff. The AOA requires completion of the medical record within 30 days following patient discharge. Medicare CoP requires a final diagnosis with completion of medical records within 30 days following patient discharge.

In early 2003, the National Committee on Vital Health and Statistics (NCVHS) recommended that the following be collected as the standard data set for persons seen in both ambulatory and inpatient settings, unless otherwise specified: • • • • • • • • • • Personal/Unique Identifier Date of Birth Gender Race and Ethnicity Residence Living/Residential Arrangement Marital Status Self-Reported Health Status Functional Status Years Schooling

Both the paper-based and computer-generated face sheet (or admission/discharge record) (Figures 5-2A and 5-2B) contain patient identification or demographic, financial data, and clinical information (Table 5-2). The face sheet is usually filed as the first page of the patient record because it is frequently referenced. Upon admission to the facility, the attending physician establishes an admitting diagnosis that is entered on the face sheet by the admitting department staff. The admitting diagnosis (or provisional diagnosis) is

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 115

Figure 5-2A

Sample Paper-Based Patient Record Face Sheet

116 • Chapter 5

ABC Hospital 1000 Inpatient Lane Hospital City, New York 12345 FACE SHEET
PATIENT RECORD NUMBER: 23345670 NAME/ADDRESS: Sam Jones 123 Wood Street Endwell, NY 13456 TYPE OF ADMISSION: Inpatient AGE: 085Y REL: SEX: M SRC: 7 6/08/YYYY 13:40

RACE: W ROOM/BED: MD 220 1

ATTENDING DOCTOR: Best, Sarah REFERRING DOCTOR: Great, Beth EMPLOYER NAME: Retired MARITAL STATUS Widowed SSN: 111-22-1111 EMERGENCY CONTACT: Sandy Jones (daughter) 45 Brook Street Liberty, PA 56789 [phone] GUARANTOR EMPLOYER: R

NEAREST RELATIVE: Sandy Jones (daughter) 45 Brook Street Liberty, PA 56789 [phone] GUARANTOR #: 1123

ADMITTING DIAGNOSIS: Dyspnea. Dehydration.

INS # 1: Medicare SUBSCRIBER: Sam Jones ID #: 098586389T INS # 2: Mutual of Omaha SUBSCRIBER: Sam Jones ID #: 67890TNH

PLAN: 10

PLAN: 20

COMMENTS:

POWER OF ATTORNEY: None

ADVANCE DIRECTIVE: On file

CONSULTANT: Fenton, Sean

DISCHARGE:

6/12/YYYY

10:30

CONDITION AT DISCHARGE: Improved ATTENDING PHYSICIAN Keen, Abby

Abby Keen
SIGNATURE

06/12/YYYY
DATE

Figure 5-2B

Sample Computer-Generated Face Sheet

• Patient’s Relationship to Subscriber/Person Eligible for Entitlement • Current or Most Recent Occupation/Industry • Type of Encounter • Admission Date (inpatient) • Discharge Date (inpatient) • Date of Encounter (ambulatory and physician services)

• • • • • • • •

Facility Identification Type of Facility/Place of Encounter Provider Identification (ambulatory) Provider Location or Address (ambulatory) Attending Physician Identification (inpatient) Operating Physician Identification (inpatient) Provider Specialty Principal Diagnosis (inpatient)

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 117

Table 5-2 Face Sheet—Sections and Content Section
Identification (or demographic) data • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Content
Complete name Mailing address Phone number Date and place of birth, and age Social security number Patient record number Patient account number Gender Race and ethnicity Marital status Admission and discharge date and time* Type of admission (e.g., elective, emergency) Next-of-kin name and address Next-of-kin contact information Employer name, address, and phone number Admitting and/or referring physician Hospital name, address, and phone number Third-party payer • Name • Address • Phone number • Policy number • Group name and/or number Insured (or guarantor)* • Name • Date of birth • Gender • Relationship to patient (e.g., self, spouse) • Name and address of employer Secondary and/or supplemental payer information. (All information collected for primary payer is also collected for secondary and/or supplemental payers.) Admitting (or provisional or working) diagnosis Principal diagnoses (1) Secondary diagnoses (e.g., comorbidities and/or complications, up to 8) Principal procedure (1) Secondary procedure(s), up to 5 Condition of patient at discharge Authentication by attending physician ICD-9-CM or CPT/HCPCS codes

*Military time is usually reported on the face sheet (e.g., 3:00 p.m. is 1500).

Financial data

*This is primary payer information.

Clinical information

• • • • • • • •

• • • •

Primary Diagnosis (inpatient) Other Diagnoses (inpatient) Qualifier for Other Diagnoses (inpatient) Patient’s Stated Reason for Visit or Chief Complaint (ambulatory)

• Physician’s Tentative Diagnosis (ambulatory) • Diagnosis Chiefly Responsible for Services Provided (ambulatory) • Other Diagnoses (ambulatory) • External Cause of Injury

118 • Chapter 5

• • • • • • • • • • • •

Birth Weight of Newborn (inpatient) Principal Procedure (inpatient) Other Procedures (inpatient) Dates of Procedures (inpatient) Services (ambulatory) Medications Prescribed Medications Dispensed (pharmacy) Disposition of Patient (inpatient) Disposition (ambulatory) Patient’s Expected Sources of Payment Injury Related to Employment Total Billed Charges

length of stay by at least one day in 75% of the cases) EXAMPLE
Patient is admitted for acute asthmatic bronchitis and also treated for uncontrolled hypertension during the admission. Comorbidity is hypertension.

NOTE: To code a comorbidity, the pre-existing condition must be treated during inpatient hospitalization or the provider must document how the pre-existing condition impacted inpatient care. • Complications (additional diagnoses that describe conditions arising after the beginning of hospital observation and treatment and that modify the course of the patient’s illness or the medical care required; they prolong the patient’s length of stay by at least one day in 75% of the cases) EXAMPLE
Patient is admitted for viral pneumonia and develops a staph infection during the stay. The infection is treated with antibiotics. Complication is “staph infection.”

NOTE: Terms in parentheses indicate items collected for those settings only. The NHVCS also provides specifications as to data to be collected for each item (e.g., patient/unique identifier involves collection of patient’s last name, first name, middle initial, suffix, and a numerical identifier). The identification and financial sections of the face sheet are completed by the admitting (or patient registration) clerk upon patient admission to the facility (or prior to admission as part of the preadmission registration process). Third-party payer information is classified as financial data and is obtained from the patient at the time of admission. If a patient has more than one insurance plan, the admitting clerk will determine which insurance plan is primary, secondary, and/or supplemental. This process is important for billing purposes so that information is appropriately entered on the face sheet. The admitting clerk enters the patient’s admitting diagnosis (obtained from the admitting physician), and the attending physician documents the following: • Principal diagnosis (condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care) EXAMPLE
Patient admitted with chest pain. EKG is negative. Chest X-ray reveals hiatal hernia. Principal diagnosis is hiatal hernia.

• Principal procedure (procedure performed for definitive or therapeutic reasons, rather than diagnostic purposes, or to treat a complication, or that procedure which is most closely related to the principal diagnosis) EXAMPLE
Patient is admitted with a fracture of the right tibia for which a reduction of the tibia was performed. While hospitalized, patient developed appendicitis and underwent an appendectomy. Principal diagnosis is fracture, right tibia. Secondary diagnosis is appendicitis. Principal procedure is open reduction, fracture, right tibia. Secondary procedure is appendectomy.

• Secondary procedures (additional procedures performed during inpatient admission) EXAMPLE
The patient is admitted for myocardial infarction and undergoes EKG and cardiac catheterization within 24 hours of admission. On day 2 of admission, the patient undergoes coronary artery bypass graft (CABG, pronounced “cabbage”) surgery. Principal procedure is CABG. Secondary procedure is cardiac catheterization. (Most hospitals do not code an inpatient EKG.)

• Secondary diagnoses (additional conditions for which the patient received treatment and/or impacted the inpatient care), including: • Comorbidities (pre-existing condition that will, because of its presence with a specific principal diagnosis, cause an increase in the patient’s

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 119

Health information personnel with the title of “coder” assign numerical and alphanumerical codes (ICD-9-CM and/or CPT/HCPCS codes) to all diagnoses and procedures.
These codes are recorded on the face sheet and in the facility’s abstracting system. (Some facilities allow coders to enter diagnoses/ procedures from the discharge summary onto the face sheet or to code directly from the discharge summary if the face sheet does not contain diagnoses/ procedures. If, upon review of the record, coders determine that additional diagnoses/procedures should be coded, they contact the responsible physician for clarification.) NOTE: Abstracting is discussed in Chapter 7. Prior to 1995, the Health Care Financing Administration, (HCFA, now called Centers for Medicare and Medicaid Services, CMS) required physicians to sign an attestation statement, which verified diagnoses and procedures documented and coded at discharge. Medicare originally required the statement because, when the diagnosis-related groups’ prospective payment system was implemented in 1983, there was concern that physicians would document diagnoses and procedures that resulted in higher payment for a facility (called upcoding or maximizing codes, and also known as DRG creep). In 1995, the attestation requirement was dropped. At the same time, some hospitals also eliminated the requirement that physicians document diagnoses/procedures on the face sheet since this information is routinely documented as part of the
dictated/transcribed discharge summary. Hospitals now establish facility policy regarding documentation of diagnoses and procedures upon discharge of patients.

directive (Table 5-3), which is a legal document in which patients provide instructions as to how they want to be treated in the event they become very ill and there is no reasonable hope for recovery. The written instructions direct a health care provider regarding a patient’s preferences for care before the need for medical treatment. NOTE: State laws regarding advance directives vary greatly. EXAMPLE
Anne lives in the state of Washington and writes a living will allowed by law, which documents her requests in the event that she is diagnosed with a terminal condition or is permanently unconscious. She relocates to New York State and gives a copy of her living will to her new health care provider. The provider informs her that living wills are not legal in New York State; however, she can designate a health care proxy.

Informed Consent
JCAHO standards require that a patient consent to treatment and that the record contain evidence of consent. JCAHO states “evidence of appropriate informed consent” is to be documented in the patient record. The facility’s medical staff and governing board are required to develop policies with regard to informed consent. In addition, the patient record must contain “evidence of informed consent for procedures and treatments for which it is required by the policy on informed consent.” AOA requirements indicate that “an informed consent for surgery shall be part of the patient’s chart before surgery is performed. It must be dated, timed, and signed by the patient and physician informant.” In addition, “an informant consent that is dated, timed, and signed by the patient, or if necessary, the patient’s next of kin or legal guardian, shall be obtained before administration of anesthesia and performance of any surgical procedure specified by the medical staff and/or by federal or state law. The consent form shall include the name, time, and date and shall be signed by the physician’s informant.” Medicare CoP state that all records must contain written patient consent for treatment and procedures specified by the medical staff, or by federal or state law. In addition, patient records must include documentation of “properly executed informed consent forms for procedures and treatments specified by the medical staff, or by federal or state law if applicable, to require written patient consent.”

Advance Directives
The Patient Self Determination Act (PSDA) of 1990 required that all health care facilities notify patients age 18 and over that they have the right to have an advance directive (e.g., health care proxy, living will, medical power of attorney) placed in their record. Facilities must inform patients, in writing, of state laws regarding advance directives and facility policies regarding implementation of advance directives. Upon admission, an advance directive notification form (Figure 5-3) is signed by the patient to document that the patient has been notified of their right to have an advance directive. The patient record must document whether the individual has executed an advance

120 • Chapter 5

Addressograph

ADVANCE DIRECTIVE ADMISSION FORM & CHECKLIST

Your answers to the following questions will assist your Physician and the Medical Center to respect your wishes regarding your medical care. This information will become a part of your patient record. YES 1. Have you been provided with a copy of the information called “Patient Rights Regarding Health Care Decisions”? Have you prepared a “Living Will”? If yes, please provide a copy for your patient record. Have you prepared a “Health Care Proxy”? If yes, please provide a copy for your patient record. Have you prepared a Durable Power of Attorney for Health Care? If yes, please provide a copy for your patient record. Have you provided this facility with an Advance Directive on a prior admission and is it still in effect? If yes, Admitting Office will contact Health Information Department to obtain a copy for your current patient record. Do you wish to execute a Living Will, Health Care Proxy, and/or Durable Power of Attorney? If yes, Admitting Office will notify: a. Physician b. Social Service c. Volunteer Service NO PATIENT’S INITIALS

2. 3. 4.

5.

6.

ADMITTING OFFICE STAFF: Enter a checkmark when each step has been completed.
1. 2. Verify the above questions where answered and actions taken where required. If the “Patient Rights” information was provided to someone other than the patient, state reason:

Name of Individual Receiving Information 3. 4. 5. 6.

Relationship to Patient

If information was provided in a language other than English, specify language and method below. Verify patient was advised on how to obtain additional information on Advance Directives. Verify the Patient/Family Member/Legal Representative was asked to provide the Medical Center with a copy of the Advance Directive, which will be retained in the patient record. File this form in the patient record, and give a copy to the patient.

Name of Patient or Name of Individual giving information, if different from Patient Signature of Patient Signature of Medical Center Representative Date Date

ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-3

Sample Advance Directive Admission Form and Checklist

Table 5-3 Advance Directives—Types and Descriptions Advance Directive
Do Not Resuscitate (DNR) Order (Figure 5-4)

Description
• Tells medical professionals not to perform cardiopulmonary resuscitation • (CPR), which means that doctors, nurses, and emergency medical personnel will not attempt emergency CPR if the patient’s breathing or heartbeat stops. • DNR orders are written for patients in a hospital or nursing home, or for patients at home. Hospital DNR orders tell the medical staff not to revive the patient if cardiac arrest occurs. If the patient is in a nursing home or at home, a DNR order tells the staff and emergency medical personnel not to perform emergency resuscitation and not to transfer the patient to a hospital for CPR. • An adult patient may consent to a DNR order through a health care proxy, which allows patients to appoint someone to make decisions about CPR and other treatments if they are unable to decide for themselves. • Legal document in which patients states the kind of health care they do or do not want under certain circumstances. • Written document that informs a health care provider of a patient’s desires regarding life-sustaining treatment. • Legal document in which patients name someone close to them to make • decisions about health care in the event they become incapacitated. • Individuals indicate their intent to donate organ(s) and/or tissue. • Persons under 18 years of age must have a parent’s or guardian’s consent. • Medical suitability for donation is determined at the time of death. • Indicate intent to be an organ and tissue donor on your driver’s license, and inform family members of your intention.

Living Will (Figure 5-5)

Health Care Proxy (or durable power of attorney) (Figure 5-6) Organ or Tissue Donation (Figure 5-7)

I, . I understand that this order remains in effect until revoked by me. I acknowledge that cardiopulmonary resuscitation (CPR) will not be performed if breathing or heartbeat stops. I understand this decision will prevent me from obtaining other emergency care by emergency medical services personnel and/or care directed by a physician prior to my death. I understand I may revoke this DNR consent at any time by destroying this consent form.

Patient or Legal Representative Signature

Date

Address of Patient

Attending Physician Signature

Date

Address of Attending Physician

Witness Signature

Date

Address of Witness

Figure 5-4

Sample Do Not Resuscitate (DNR) Advance Directive Consent Form

122 • Chapter 5

My name is and my address is . If I am determined by my attending physician to be in a terminal condition or a persistent vegetative state, and I am no longer able to make or communicate decisions regarding my medical treatment, then I direct my attending physician to withhold or withdraw all life-sustaining treatment that is not necessary for my comfort or to alleviate pain; and if there is any conflict at that time between this document and any other document I may have signed previously then this document shall control.

My Signature

Date

Social Security Number

Date of Birth

The above named , in my presence, voluntarily signed this writing or directed another to sign this writing on his/her behalf.

Witness Signature

Date

Witness Address

Witness Signature

Date

Witness Address

Figure 5-5

Sample Living Will (Reprinted according to CMS Web reuse policy.)

Informed consent is the process of advising a patient about treatment options and, depending on state laws, the provider may be obligated to disclose a patient’s diagnosis, proposed treatment/surgery, reason for the treatment/surgery, possible complications, likelihood of success, alternative treatment options, and risks if the patient does not undergo treatment/ surgery. Informed consent should be carefully documented whenever applicable. An informed consent entry should include an explanation of the risks and benefits of a treatment or procedure, alternatives to the treatment or procedure, and evidence that the patient or appropriate legal surrogate understands and consents to undergo the treatment or procedure.

documents a patient’s consent to receive medical treatment at the facility. NOTE: The Health Insurance Portability and Accountability Act (HIPAA) privacy rule specifies that facilities are no longer required to consent to admission, but most still obtain the patient’s signed consent. (HIPAA mandates administrative simplification regulations that govern privacy, security, and electronic transactions standards for health care information.)

Consent to Release Information
Patient authorization to release information for reimbursement (Figure 5-9) is routinely obtained as part of the consent to admission. Releases of information for other purposes require the patient’s authorized consent to release information. NOTE: The HIPAA privacy rule specifies that facilities are no longer required to consent to release

Consent to Admission
Upon admission the patient may be asked to sign a consent to admission (or conditions of admission) (Figure 5-8), which is a generalized consent that

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 123

I,

, hereby appoint
(name) (home address and telephone number)

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect only when and if I become unable to make my own health care decisions. Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall remain in effect indefinitely. This proxy shall expire
(specify date and/or conditions)

.

I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows or as stated below. I direct my health care agent to make health care decisions in accordance with the following limitations and/or instructions: (state wishes or limitations above) Name Signature Address (Witnesses must be 18 years of age or older and cannot be the health care agent.) I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence. Name of Witness #1 Signature of Witness #1 Address of Witness #1 Name of Witness #2 Signature of Witness #2 Address of Witness #2 Date Date Date

Figure 5-6

Health Care Proxy (or Durable Power of Attorney)

124 • Chapter 5

information for the purpose of reimbursement, research, and education, but most still obtain the patient’s signed consent.

Special Consents
Health care facilities require separate consents, such as a consent to surgery (Figure 5-10), and consents for diagnostic, therapeutic, and surgical procedures. Prior to the patient undergoing medical or surgical treatment, it is required that written consent be obtained from the patient or representative, which indicates that the patient acknowledges informed consent as to the nature of treatment, risks, complications, alternative forms of treatment available, and the consequences of the treatment or procedure. The surgeon (or other provider, such as radiologist) will discuss the procedure to be performed with the patient. Patients sign special consents, which include the following elements: • • • • Name of the patient Type and limitations of procedure Risks of procedure Alternatives to procedure

Figure 5-7 Sample Organ/Tissue Donation Card (Reprinted according to OrganDonor.gov Web reuse policy.)

Figure 5-8

Sample Consent to Admission

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 125

Figure 5-9

Sample Authorization to Release Information for Reimbursement Purposes

• Signature of person qualified to give consent and date • Name of surgeon performing procedure • Physician/Surgeon signature (per facility policy) • Witness signature and date

Patient Property Form
The patient property form (Figure 5-11) records items patients bring with them to the hospital. This form is completed and signed by a hospital staff member and also signed by the patient. It is important for the staff member to complete this form correctly as some patients may claim that they arrived at the hospital with items they do not actually possess.

(NCHS) developed a standard certificate of birth, which states can adopt for their use. Birth certificate information is submitted to state departments of health or offices of vital statistics (or records, depending on state title), usually within 10 days of birth. State policies and procedures for birth certificates vary, and some states require electronic submission of birth certificate information. Other states do not require electronic submission because they require that a physician sign the certificate. Birth certificate contents include: • • • • Infant’s and parents’ demographic information Parents’ occupation, education, ethnicity, race Pregnancy information Medical risk factors, complications, and/or abnormal conditions of newborn

Certificate of Birth
The certificate of birth (or birth certificate) (Figure 5-12) is a record of birth information about the newborn patient and the parents, and it identifies medical information regarding the pregnancy and birth of the newborn. The National Center for Heath Statistics

NOTE: Some states do not allow a copy of the birth certificate to be filed in the patient record. However, they usually allow the worksheet used to collect birth certificate data to be filed in the record.

126 • Chapter 5

Figure 5-10 Sample Special Consent to Surgery

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 127

Figure 5-11 Sample Patient Property Record

128 • Chapter 5

Figure 5-12 Standard Birth Certificate (Reprinted according to HHS Content Reuse Policy.)

Certificate of Death
The certificate of death (or death certificate) (Figure 5-13) contains a record of information regarding the decedent, his or her family, cause of death, and the disposition of the body. The National Center for Heath Statistics (NCHS) also developed a standard certificate of death, which states can adopt for their use. The death certificate, signed by a physician, is filed with the state department of health’s office of vital statistics (or records, depending on the title of the state agency), usually with five days. While each state develops its own death certificate, in general it contains the following information: • • • • Name of deceased Deceased’s date and place of birth Usual residence of deceased at time of death Cause of death

• • • • • • •

Deceased’s place of burial Names and birth places of both parents Name of informant (usually a relative) Name of doctor Method and place of disposition of body Signature of funeral director Signature of certifying physician

Exercise 5–2 Hospital Inpatient Record— Administrative Data Matching: For each data element, state whether it represents clinical (C), financial (F), or patient identification (I). ________ 1. Primary diagnosis ________ 2. Patient name ________ 3. Insurance policy number

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 129

Figure 5-13 Standard Death Certificate (Reprinted according to HHS Content Reuse Policy.)

130 • Chapter 5

________ 4. Patient medical record number ________ 5. Admitting diagnosis ________ 6. Patient address True/False: Indicate whether each statement is True (T) or False (F). 7. A health care proxy is a legal document a patient uses to name someone to make health care decisions in the event the patient becomes incapacitated. 8. A death certificate, signed by a physician, is filed with the National Center for Health Statistics, usually within five days. 9. The identification and financial sections of the face sheet are completed by the admitting nurse when the patient arrives on the nursing unit. 10. The National Center for Heath Statistics (NCHS) has developed a standard certificate of birth that states must adopt for their use. 11. Upon admission, all patient records must contain documentation as to whether an individual has executed an advance directive.

To ensure continuity of care, JCAHO standards also state that a copy of the emergency room report should be sent to the provider who administers follow-up care (if authorized by the patient or legal representative). AOA requirements state that a patient record is to be maintained on each patient provided treatment in the emergency department. The record is to be dated and timed, and should contain full patient identification, history of disease or injury, physical findings, laboratory/X-ray reports, treatment provided, disposition of case, and physician’s signature. An operating surgeon responding to an emergency situation is to (time permitting) document the nature of the emergency, assume responsibility for chart completion at the end of the emergency procedure, and date, time, and sign the record.

HOSPITAL INPATIENT RECORD— CLINICAL DATA
Clinical data includes all health care information obtained about a patient’s care and treatment, which is documented on numerous forms in the patient record. For inpatients, the first clinical data item is the admitting diagnosis that is entered on the face sheet. Sometimes, a patient is admitted through the emergency department (ED), and the first clinical data item is the chief complaint recorded as part of the ED record.

Emergency Record
JCAHO standards outline the following documentation requirements in the emergency room record: time and means of arrival, conclusion at termination of treatment, final disposition, condition at discharge, and instructions for follow-up. JCAHO standards require that pertinent inpatient and ambulatory care patient records (including emergency records) be made available upon request by the attending physician or other authorized individuals. The emergency record is to be authenticated by the practitioner responsible for its clinical accuracy.

The emergency record (Figure 5-14A) documents the evaluation and treatment of patients seen in the facility’s emergency department (ED) for immediate attention of urgent medical conditions or traumatic injuries. The record includes documentation of the immediate assessment and treatment of patients, reason for the patient’s disposition (whether admitted, discharged, or transferred), and a copy of the discharge instructions provided to the patient (Figure 5-14B). Some patients are transported to the ED via ambulance, and an ambulance report (Figure 5-15) is generated by emergency medical technicians (EMTs) to document clinical information such as vital signs, level of consciousness, appearance of the patient, and so on. A copy of the ambulance report is placed on the ED record. (The original ambulance report is the property of the ambulance company.) Anti-dumping legislation (Emergency Medical Treatment and Labor Act, EMTALA) prevents facilities licensed to provide emergency services from transferring patients who are unable to pay to other institutions, and it requires that a patient’s condition must be stabilized prior to transfer (unless the patient requests transfer). EXAMPLE 1:
A woman in active labor cannot be transferred to another facility due to inability to pay for care.

EXAMPLE 2:
If permanent disability or death would result from delayed treatment, a patient cannot be transferred to another facility due to inability to pay.

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 131

Figure 5-14A

Sample Emergency Department Record

132 • Chapter 5

Figure 5-14B

Discharge Instructions for ED Patient (Permission to reprint granted by MedQuest, LLC.)

Contents of an emergency record include: • Patient identification • Time and means of arrival at the emergency department EXAMPLE
Patient transported via ambulance.

EXAMPLE
Skin warm and moist. Fever of 104.9 degrees at present. Color pale. Pulse 112. Respirations 32. BP 110/50.

• Emergency care provided prior to arrival EXAMPLE
Patient received IV D5NSS 200 cc/hr. Kefzol 1 gram IV stat.

• Pertinent history of illness or injury EXAMPLE
Patient pulled foley catheter out at nursing home. He was unable to void the next morning and started running a very high fever (105 degrees). He was brought to the ED for evaluation.

• Diagnostic and therapeutic orders EXAMPLE
Chest X-rays. CBC. Foley catheter insertion. Urinalysis. Electrolytes. BUN.

• Physical findings, including vital signs

• Clinical observations, including results of treatment

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 133

Figure 5-15 Sample Ambulance Report (Reproduced with permission from the State of Wisconsin.) EXAMPLE
Foley catheter insertion attempted, which failed. Consult with Dr. Bellinger who was able to insert Foley without significant difficulty. Dr. Bellinger evaluated the patient and did not feel further treatment was necessary.

instructions given to the patient, and physician’s signature EXAMPLE
Patient admitted to hospital for treatment (Kefzol 1 gram every 6 hours).

• Reports of procedures, tests, and results EXAMPLE
Chest X-ray negative. CBC revealed WBC 10.6, Hgb 12.3, Hct 36.3. UA revealed 3 WBC and 3 gram negative rods. Blood chemistry test revealed bilirubin (direct) 1.1, bilirubin (total) 1.8, and albumin 5.6. BUN negative.

• Evidence of a patient leaving against medical advice (e.g., signed AMA form and physician documentation in progress notes) NOTE: An appropriate filing system must be established for storage of emergency records and, when appropriate, emergency records are to be combined with inpatient and outpatient records.

• Diagnostic impression EXAMPLE
Diagnosis: Urinary tract infection

Discharge Summary
JCAHO standards require that the discharge summary be completed by the attending physician within 30 days of discharge or the record is considered delinquent. A discharge progress note can be

• Conclusion at termination of evaluation/treatment, including final disposition, patient’s condition,

134 • Chapter 5

documented instead of a discharge summary if a patient has had an uncomplicated hospital stay of less than 48 hours (short stay). The note must contain documentation of the patient’s hospital outcome, condition on discharge (disposition), provisions for follow-up care including instructions, and final diagnoses. The JCAHO also requires that “the use of approved discharge criteria to determine the patient’s readiness for discharge” (e.g., decreased dependency on oxygen, discharge planning, transition of patient from intravenous to oral medications, and so on) be documented in the record. (Many facilities use utilization management criteria, such as McKesson Interqual products, for this purpose. Facilities also develop criteria, which is used to discharge patients from specialty units [e.g., intensive care unit] and departments [e.g., anesthesia department].) AOA requirements state that the record must contain a final progress note or discharge summary signed or countersigned by the attending physician and that it include a summary of the patient’s hospital stay, condition on discharge, patient’s disposition, termination of physician’s responsibility for the patient, resolution of admission diagnosis and chief complaint, discussion of complications that developed during hospital stay, and determination as to whether diagnosis and treatment were justified or whether a diagnosis could not be established. Medicare CoP state that all records must document a discharge summary which includes the outcome of hospitalization, disposition of the case, and followup provisions.

EXAMPLE
Patient was admitted with long-term ulcer on dorsum of left foot that has not improved, and in fact is getting worse. He was given intensive medication as an outpatient but the foot became more swollen and red, and he is admitted at this time for more intensive therapy.

• Principal/secondary diagnoses and principal/ secondary procedures, including results and dates (all relevant diagnoses and operative procedures should be recorded using acceptable disease and operative terminology that includes topography and etiology as appropriate) EXAMPLE
Principal diagnosis: Cellulitis and gangrene, left foot and lower leg. Comorbidities: Diabetes mellitus, insulin dependent, controlled. Staphylococcus aureus coagulase positive septicemia. Urinary retention. Principal procedure: Amputation, left leg, above knee. Secondary procedures: Suprapubic cystostomy with permanent suprapubic drainage.

• Significant findings, including pertinent laboratory, X-ray, and pathological findings—negative results may be as pertinent as positive EXAMPLE
Blood culture revealed staph aureus coagulase positive septicemia. EKG revealed left bundle branch block and myocardial changes similar to previous tracings. Chest X-ray showed no active pulmonary disease, and heart was normal size. Lower leg specimen showed severe atherosclerosis with focal thrombosis, gangrene of the foot with extensive dissection of acute inflammatory exudates into the lower leg between the fascial planes. Sugars came under good control. Urinalysis showed evidence of the bleeding and minimal infection.

The discharge summary (or clinical résumé) (Figure 5-16) provides information for continuity of care and facilitates medical staff committee review; it can also be used to respond to requests from authorized individuals or agencies (e.g., a copy of the discharge summary will suffice instead of the entire patient record). The discharge summary documents the patient’s hospitalization, including reason(s) for hospitalization, course of treatment, and condition at discharge. The discharge summary must fully and accurately describe the patient’s condition at the time of discharge, patient education when applicable, including instructions for self-care, and that the patient/ responsible party demonstrated an understanding of the self-care regimen. Contents of a discharge summary include: • Patient and facility identification • Admission and discharge dates • Reason for hospitalization (brief clinical statement of chief complaint and history of present illness, HPI)

• Treatment provided (medical and surgical), and patient’s response to treatment, including any complications and consultations EXAMPLE
Patient was placed on insulin to control new onset of diabetes. His diabetes is well controlled with insulin, but his bladder condition did not improve. He underwent suprapubic cystostomy, and following this began to improve. His temperature finally dropped to a reasonable level, and he is eating well. He remains uncommunicative, as he had been for several years. He was treated

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 135

Figure 5-16 Sample Discharge Summary (Permission to reprint in accordance with va.gov Web reuse policy.)

136 • Chapter 5

with IV Vancomycin and following surgery placed on Gentamicin and IV Vibramycin.

• Condition on discharge, as stated in specific measurable terms relative to condition on admission, avoiding use of vague terms such as improved (in addition, presence and status of drains, wounds, and sutures should be noted) EXAMPLE
Patient’s medications were effective in controlling his infection. He is transferred to the nursing facility for continued care. His leg stump sutures will be removed as able, probably in about two weeks.

information to manage and guide patient care). AOA requirements state that a complete history be documented 24 hours after admission or no more than 7 days before admission and filed in the patient’s record with 48 hours after admission. AOA requirements also state that the physical examination must be performed within 24 hours after admission and filed on the record within 48 hours after admission. Medicare CoP state that evidence of a physical examination, including a health history, must be performed no more than 7 days prior to admission or within 48 hours after admission. (If a patient is scheduled for surgery prior to these deadlines, a complete history and physical must be documented.)

• Instructions to patient and/or family (relative to physical activity, medication, diet, and follow-up care) EXAMPLE
Patient will continue his insulin dosage and be followed at the nursing facility as necessary. Discharge instructions, including medications, diet, physical activities, and plans for follow-up care were discussed with the primary care nurse at nursing facility.

• Authentication by attending physician NOTE: A delinquent record can result in the suspension of a physician’s privileges, which means that the physician may not admit patients or perform surgery.

History and Physical Examination
JCAHO standards state the history and physical examination must be performed and documented in the patient record within 24 hours after admission (including weekends and holidays) as an acute care hospital inpatient (48 hours for subacute inpatients and 72 hours for long-term care inpatients), or if a history and physical examination (H&PE) was completed within 30 days prior to admission and reviewed and updated, it can be placed on the record within 24 hours after admission. This means the patient must either have undergone no changes subsequent to the original examination or the changes must be documented upon admission. When the history and physical cannot be placed on the record within the required time frame due to a transcription delay, the physician can document a handwritten note containing pertinent findings, (e.g., enough

Usually the history and physical examination is prepared as one handwritten or transcribed report, which assists the physician in establishing a diagnosis on which to base treatment and serves as a reference for future illnesses. The history (Figure 5-17) documents the patient’s chief complaint, history of present illness (HPI), past/family/social history (PFSH), and review of systems (ROS) (Table 5-4). The individual responsible for documenting the history should obtain the information directly from the patient and should document only the facts regarding the patient’s case. The source of the history should also be documented, especially when the individual providing the information is someone other than the patient. NOTE: Although the history might be documented by someone other than the attending physician (e.g., intern or resident), the attending physician is responsible for authenticating the report generated. An interval history documents a patient’s history of present illness and any pertinent changes and physical findings that occurred since a previous inpatient admission if the patient is readmitted within 30 days after discharge for the same condition. The original history and physical examination must also be made available to the attending physician (e.g., a copy filed on the current inpatient chart or the previous discharged patient record available on the unit). EXAMPLE
Patient is discharged from the hospital with the diagnosis of acute asthmatic bronchitis. Within 30 days, the patient is readmitted for the same condition. In this situation, it would be appropriate for the attending physician to document an interval note that specifies the patient’s present complaint, pertinent changes, and physical findings since the last admission.

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 137

Addressograph

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST FAMILY, MEDICAL, SOCIAL, AND SURGICAL HISTORY:

MEDICATIONS AND DOSAGES:

ALLERGIES:

CONSITUTIONAL: HEENT: ENDOCRINE RESPIRATORY: CARDIOVASCULAR: GASTROINTESTINAL: LYMPHATIC: HEMATOLOGIC: GENITOURINARY: REPRODUCTIVE: MUSCULOSKELETAL: INTEGUMENTARY: NEUROLOGIC: PSYCHIATRIC: ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-17 Sample History

After the history is completed, the physician performs a physical examination (Figure 5-18), which is an assessment of the patient’s body systems (Table 5-5), to assist in determining a diagnosis, documenting a provisional diagnosis, and which may include differential

diagnoses. A differential diagnosis indicates that several diagnoses are being considered as possible. The physician also summarizes results of pre-admission testing (PAT) (e.g., blood tests, urinalysis, ECG, X-rays, and so on). (PAT results are filed in the patient’s record.)

138 • Chapter 5

Table 5-4 Description and Documentation Examples for Elements of Patient History Element
Chief Complaint (CC)

Description
Patient’s description of medical condition, stated in the patient’s own words. EXAMPLE: Chief Complaint: “My knee gives out” and “my knee hurts when I walk.” (Patient is scheduled for arthroscopy, knee.) Chronological description of patient’s present condition from time of onset to present. HPI should include location, quality, severity, duration of the condition, and associated signs and symptoms. EXAMPLE: HPI: Patient presents for arthroscopy, left knee. Probable torn cartilage. Knee is very bruised. Patient complains of pain, which started one week ago. Patient denies injury. Summary of past illnesses, operations, injuries, treatments, and known allergies EXAMPLE: Past History: Reveals a healthy individual who has been hospitalized in the past x3 for childbirth; the patient has NKA, no history of diseases, and is not currently on any medications. NOTE: NKA means “no known allergies.” A review of the medical events in the patient’s family, including diseases that may be hereditary or present a risk to the patient EXAMPLE: Family History: Patient states that father died at age 51 of heart disease, and mother is living and well. An age-appropriate review of past and current activities such as daily routine, dietary habits, exercise routine, marital status, occupation, sleeping patterns, smoking, use of alcohol and other drugs, sexual activities, and so on EXAMPLE: Social History: Patient has history of marijuana use as a teenager and currently drinks alcohol socially; previous history of smoking cigarettes (quit three years ago). A listing of current medications and dosages EXAMPLE: Medications: Zocor, 40 mg qd. Inventory by systems to document subjective symptoms stated by the patient. Provides an opportunity to gather information that the patient may have forgotten to mention or that may have seemed unimportant. NOTE: Providers should not document negative or normal in response to ROS items. Instead, document a statement relative to the item. EXAMPLE: Respiratory: The patient denies shortness of breath. The ROS includes: • General • Cardiovascular • Skin • Gastrointestinal • Head • Genitourinary • Eyes • Musculoskeletal • Ears • Neurological • Nose • Endocrine • Mouth • Psychological • Throat • Hematologic/Lymphatic • Breasts • Allergic/Immunologic • Respiratory

History of Present Illness (HPI)

Past History

Family History

Social History

Medications Review of Systems (ROS)

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 139

Figure 5-18 Sample Physical Examination Report (Copyright © Bibbero Systems, Inc., Petaluma, CA. (800) 2422376. www.bibbero.com.)
(Continues)

140 • Chapter 5

Figure 5-18 (Continued)

Table 5-5 Documentation Examples for Elements of Physical Examination Element
General Survey

Example
Reveals well-developed, somewhat obese, elderly, white male in severe distress with severe substernal discomfort and pain in upper arms. Conscious. Alert. Appears to be stated age. No deformity. Patient cannot sit or stand still because he is in such agony. Gait affected only by pain; otherwise it is normal. Carriage normal. Age 67. Sex male. Height 5 11 . Weight 188 lbs. Temperature 98.0°F orally. Pulse 56 and regular. Blood pressure 150/104. Reveals pale, cool, moist surface with no cyanosis or jaundice. No eruption. No tumors. Hair, scalp, skull within normal limits. Facies anxious. Pupils round, regular, equal. Pupils react normally to light and accommodation. Extraocular muscles intact. Corneae, sclerae, conjunctivae clear. Fields intact. Ophthalmoscopic examination reveals fundi discs to be well outlined. Examination reveals grossly intact hearing. No lateralization. External canals and ears, and left membrana tympanica clear. No tumor. Inspection reveals grossly intact sense of smell. No deformity. No tenderness. Septum benign. Only residual mucous in both nostrils. No tumor. Sinuses within normal limits. Mouth edentulous. Lips, gums, buccal mucosa, and tongue within normal limits. Examination reveals posterior oropharynx and tonsils to be very red and inflamed. Palate and uvula benign. Larynx not visualized. Reveals cervical structures to be supple with no masses, scars, or abnormal glands or pulsations. Chest inspection reveals it to have normal expansion. Thorax observation reveals it to be somewhat obese but with normal shape and symmetry without swellings or tumors or significant lymphadenopathy. Respiratory motions normal. Palpable tactile fremitus physiologically normal. Felt to be symmetrical and without masses or tenderness. Nipples normal. No axillary lymphadenopathy. Investigation reveals lungs clear on inspection, palpation, percussion, and auscultation. Examination reveals heart to be indicated as normal since the area of cardiac dullness is normal is size, shape, and location. Heart rate slow. Rhythm regular. No accentuation of A2 and P2. Appearance is slightly obese with no striae. Has a well-healed herniorrhaphy scar on the right inguinal area. No tenderness, guarding, rigidity, or rebound phenomena. No abnormal abdominal masses palpable. No organomegaly. No distention. No herniae. Bowel sounds are normal. Reveals male type and circumcised penis. Scrotum, testes, and epididymes appear to be normal in size, shape, and color without skin lesions or tumors. Inspection proves sphincter tone good. Lumen clear. Hemorrhoids, internal and external, found on examination. Examination reveals no loss of motor function of the extremities or back. Patient can sit, stand, squat, and walk although it causes excruciating pain and this is in the substernal chest area. Patient advised to avoid doing these things. No evidence of injury. No paralysis. Patient squirms and moves constantly in his agony. He cannot sit long nor can he stand in one position. Extremities exam reveals them to be intact. Shoulder girdle inspection reveals no tenderness, muscle spasms, or abnormality or motion. No crepitation. Examination of the back reveals a slight infected and tender pilonidal cyst over the sacrum. No deformity or limitation of motion of the back noted. No other tenderness. Arms, hands, legs, and feet investigation reveals no deformity, fracture, dislocations, injury, tremors, atrophic muscles, swelling, tenderness, muscle spasms, or abnormality of motion. System check reveals lymph glands to be normal throughout. Investigation reveals veins to be normal. Arteries are arteriosclerotic and all peripheral pulses are palpable and undiminished. System review reveals the patient generally conscious, cooperative, mentally alert, and reasonably intelligent, although he seems to be somewhat confused. Cranial nerves intact. Superficial and deep tendon reflexes intact and equal bilaterally. No pathological reflexes. No abnormality of the sensory perception or of the associated movements, or of the autonomic or endocrine systems felt to be due to neurological disorder. Acute myocardial infarction. Essentials hypertension. Arteriosclerosis. Pilonidal cyst with mild infection. Internal and external hemorrhoids.

Skin Head Eyes

Ears Nose and Sinuses Mouth Throat Neck Chest

Breasts Lungs Heart Abdomen

Genitalia Rectal Extremities

Lymphatics Blood Vessels Neurological

Impression

141

142 • Chapter 5

EXAMPLE
Patient is admitted to the hospital with complaints of severe pain in the pelvis region. The physician documents the following differential diagnoses: Possible endometriosis. Possible adhesions.

NOTE: While the history and physical examination is the responsibility of the attending physician, it is appropriate for house staff to perform the history and physical examination and dictate the report. The house staff member signs the report, and the attending physician reviews the report to be sure it is completed. The attending physician is responsible for documenting additional pertinent findings and authenticating the report.

• Documents a physician order requesting consultation with a particular doctor • Documents a progress note that outlines the reason for consultation • Contacts the consulting physician to discuss the patient’s case and to agree to the consultant’s role in patient care, if any NOTE: The consulting physician may participate in patient care with the attending physician or even take over patient care and become the patient’s attending physician. As part of the consultation process, the consulting physician: • • • • Reviews the patient’s record Examines the patient Documents pertinent findings Provides recommendations and/or opinions

Consultation Report
JCAHO and AOA standards state that medical records shall contain documentation of consultation reports. AOA requirements state that, except in emergencies, consultations are required on critically ill patients, patients who are poor surgical risks, and those whose diagnoses are difficult or obscure. The AOA clarifies that just one physician is to be designated as the attending physician, responsible for patient care until the patient is discharged or transferred and that if the attending physician and consultant disagree as to management of patient care, a second consultation is to be ordered. The AOA also delineates attending physician responsibilities for requesting a consultation along with documentation for indications (e.g., consultation only, consultation and management, participation in management, consultant assuming responsibility for patient management, and patient care management transfer to another physician).

Physician Orders
JCAHO standards require medical records to contain diagnostic and therapeutic orders and verbal orders (e.g., telephone orders) to be authenticated by the responsible physician within a time frame specified by the facility (based state laws, if applicable). In 2004, the JCAHO added a standard that each medication ordered be supported by a documented diagnosis, condition, or indication-for-use. (Facilities may require physicians to document either the indication for usage, such as a diagnosis, for each medication ordered. This standard also serves to facilitate patient safety because it is less likely that a medication will misinterpreted as written [e.g., physician mistakenly documents “Paclitaxel for anxiety,” nurse questions the order, and physician amends it documenting “Paxil for anxiety.”) AOA requirements state that physician orders must be documented, dated, time, and authenticated by the practitioner responsible for patient care. The AOA also requires that “routine orders shall not be used unless a printed or typed copy of such orders is affixed to the patient’s hospital record and signed by the attending physician specifying how routine orders apply to each patient.” Medicare CoP state that all physician order entries must be legible, complete, authenticated (name and discipline), and dated promptly by the responsible practitioner.

A consultation (Figure 5-19) is the provision of health care services by a consulting physician whose opinion or advice is requested by another physician. (Once a patient is admitted to the hospital, the attending physician is responsible for requesting consultations.) A consultation report is documented by the consultant and includes the consultant’s opinion and findings based on a physical examination and review of patient records. The attending physician generally requests a consulting physician (e.g., specialist) to provide evaluation and, possibly, treatment of a patient. Occasionally, a general surgeon will request a general practitioner to evaluate a patient prior to surgery to determine medical risks, if any. To initiate a consultation, the attending physician:

Physician orders (or doctors orders) (Table 5-6) (Figure 5-20) direct the diagnostic and therapeutic patient care activities (e.g., medications and dosages,

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 143

Figure 5-19 Sample Consultation Report (Copyright © Bibbero Systems, Inc., Petaluma, CA. [phone]. www.bibbero.com.)

144 • Chapter 5

Table 5-6 Physician Orders Type of Order
Discharge Order

Description
The final physician order documented to release a patient from a facility. NOTE: Patients who sign themselves out of a facility do so against medical advice (AMA), and they sign a release from responsibility for discharge that includes the following language:
I hereby request my discharge from this hospital against the advice of its medical staff. It has been explained to me that my present condition is such as to require further hospitalization and that I leave the hospital at my own risk. I hereby release the hospital and its staff from all responsibility for any consequences of this act.

Routine Order

Standing Order

Stop Order (or Automatic Stop Order)

Telephone Order (T.O.)

Transfer Order Verbal Order

Voice Order (V.O.)

Written Order

Physician orders preapproved by the medical staff, which are preprinted and placed on a patient’s record (e.g., standard admitting orders for a surgical patient, discharge orders following surgery, and so on). Physician orders preapproved by the medical staff that direct the continual administration of specific activities (e.g., mediations) for a specific period of time as a part of diagnostic or therapeutic care. As a patient safety mechanism, state law mandates and in the absence of state law facilities decide, for which circumstances preapproved standing physician orders are automatically discontinued (stopped), requiring the physician to document a new order (e.g., 72 hours after narcotics are ordered, they are automatically stopped). A verbal order dictated via telephone to an authorized facility staff member. Facilities should establish a telephone order call back policy, which requires the authorized staff member to read back and verify what the physician dictated to ensure that the order is entered accurately. To document that the policy was followed, the staff member enters the abbreviation RAV (read and verified) below the telephone order (and then signs the order). NOTE: Avoid using the abbreviation P.O. (phone order) because it also an abbreviation for the Latin phrase per os, which means “by mouth.” A physician order documented to transfer a patient from one facility to another. Orders dictated to an authorized facility staff member (e.g., registered nurse, pharmacist, physical therapist, and so on) because the responsible physician is unable to personally document the order. NOTE: Medical staff rules and regulations contain the qualifications of staff members authorized to record verbal orders. A verbal order dictated to an authorized facility staff member by the responsible physician who also happens to be present. NOTE: Medical staff rules and regulations must stipulate when voice orders are allowed (e.g., emergency situations only, such as when the emergency department physician has made a chest incision and inserted both hands to massage the patient’s heart to get it restarted). Orders that are handwritten in a paper-based record or entered into an electronic health record by the responsible physician.

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 145

Addressograph

Date

Time

Orders

Nurse’s Initials

HIM501/01-03

COPIES: White-Record Yellow-Pharmacy ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-20 Sample Physicians Orders

146 • Chapter 5

frequency of dressing changes, and so on). They should be: • • • • Clear and complete Legible, if handwritten Dated and timed Authenticated by the responsible physician

is responsible for authenticating it, and pre-doctoral medical students who document progress notes must have them countersigned by the attending physician. AOA requirements also provide for allied health personnel (e.g., physical therapists, respiratory therapists, dieticians, etc.) to document appropriately dated, timed, and authenticated progress notes.

NOTE: Think of physician orders as prescriptions for care while the patient is an inpatient. When a patient visits the physician in the office, the doctor often “prescribes” a medication or lab test. In the hospital, the physician documents numerous such “prescriptions” as physician orders. EXAMPLE
Adam is treated in the emergency room (ER) due to trauma sustained from an automobile accident. The ER physician evaluates Adam and starts immediate treatment due to severity of injuries. He dictates a series of orders to the registered nurse, who records them in the patient’s ER record. The ER physician authenticates the verbal order after Adam is transferred to the intensive care unit.

Progress Notes
JCAHO standards state that medical staff and other authorized individuals are to document progress notes in the patient record; when house staff (e.g., interns, residents, and so on) are involved in patient care, they must document progress notes—the attending physician must show evidence of active participation by substantiating participation in and supervision of patient care (e.g., co-authenticate house staff entries, document that the “attending physician has seen the patient and concurs with diagnosis and treatment plan,” and so on). Medical staff rules and regulations must define circumstances that require countersignature by supervisory or attending medical staff members (e.g., entries in the patient record by house staff or non-physicians). AOA requirements state that progress notes are to be dated, timed, and written by the attending physician or house staff during all phases of the patient’s hospitalization. An admitting progress note must be documented to briefly state the chief complaint, symptoms, and physical findings that led to the working diagnosis, expected therapy, and possible consultation. Progress notes are to contain documentation of significant physical changes, new signs and symptoms, complications, consultations, and treatment. The physician documenting the progress note

Progress notes (Figure 5-21) contain statements related to the course of the patient’s illness, response to treatment, and status at discharge. They also facilitate health care team members’ communication because progress notes provide a chronological picture and analysis of the patient’s clinical course—they document continuity of care, which is crucial to quality care. As a minimum, progress notes should include an admission note, follow-up notes, and a discharge note (Table 5-7); the frequency of documenting progress notes is based on the patient’s condition (e.g., once per day to three or more times per day). Progress notes are usually organized in the record according to discipline (e.g., each discipline, such as physical therapy, has their own section of progress notes). Some facilities adopt integrated progress notes, which means all progress notes documented by physicians, nurses, physical therapists, occupational therapists, and other professional staff members are organized in the same section of the record. Integrated progress notes allow the patient’s course of treatment to be easily followed because a chronological “picture” of patient information is presented. Facilities also allow physicians and other staff to dictate progress notes, which are later transcribed by medical transcriptionists and placed on the patient’s record. While convenient for physicians and others, a delay in transcribing dictated notes could delay patient care. Facilities that allow the dictation of progress notes should adopt electronic authentication procedures to avoid placing another document on the patient’s record that requires signatures. NOTE: Progress notes must be documented in a timely, accurate, and legible manner—there is no standard or regulation that specifies how often notes are to be documented except that they are to be documented as the patient’s condition warrants. This means that a patient admitted to an intensive care unit will have proportionately more progress notes documented on the chart than a patient admitted for an uncomplicated elective surgery. In addition, progress notes must document that adequate treatment was rendered to justify the patient’s length of

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 147

Figure 5-21 Sample Progress Notes (Reprinted with permission of Bibbero Systems, Inc., Petaluma, CA. [phone]. www.bibbero.com.)

148 • Chapter 5

Table 5-7 Progress Notes Type of Progress Note
Admission Note

Definition
Progress note documented by the attending physician at the time of patient admission, which includes: • Reason for admission, including description of patient’s condition • Brief HPI • Patient care plan • Method/mode of arrival (e.g., ambulance) • Patient’s response to admission • Physical assessment NOTE: The admission note is documented in addition to the dictated history and physical examination. Daily progress notes documented by the responsible physicians, which include: • Patient’s condition • Findings on examination • Significant changes in condition and/or diagnosis • Response to medications administered (e.g., effectiveness of pain medications) • Response to clinical treatment • Abnormal test findings • Treatment plan related to each of the above Final progress note documented by the attending physician, which includes: • Patient’s discharge destination (e.g., home) • Discharge medications • Activity level allowed • Follow-up plan (e.g., office appointment) NOTE: The discharge note is documented in addition to a dictated discharge summary. Progress note documented by a case manager, which outlines a discharge plan that includes case management/social services provided and patient education. Progress note documented by the dietitian (or authorized designee), which includes: • Patient’s dietary needs • Any dietary observations made by staff (e.g., amount of meal consumed, food likes/dislikes, and so on). NOTE: JCAHO standards require dietary orders to be documented in the patient record prior to serving the diet to the patient. After a physician order is written, dietetic services can be provided to patients. AOA requirements state that “food and nutritional needs of the patient should be met in accordance with physician orders and recognized dietary practices.” The nutritional care of the patient is to be documented in the patient record. Progress notes documented by various rehabilitation therapists (e.g., occupational therapy, physical therapy, psychology, speech/audiotherapy, and so on), which demonstrate the patient’s progress (or lack thereof) toward established therapy goals. JCAHO standards require the following to be documented in the patient record: • Reason for referral to rehabilitation care • Summary of patient’s clinical condition • Goals of treatment and treatment plan • Treatment and progress records (including ongoing assessments) • Assessment of physical rehabilitation achievement and estimates of further rehabilitation potential (documented at least monthly for outpatient care) (Continues)

Follow-up Progress Note

Discharge Note

Case Management Note Dietary Progress Note

Rehabilitation Therapy Progress Note

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 149

Table 5-7 Progress Notes (Continued) Type of Progress Note
Respiratory Therapy Progress Note

Definition
Respiratory therapy progress notes documented by respiratory therapists include therapy administered, machines used, medication(s) added to machines, type of therapy, dates/times of administration, specifications of the prescription, effects of therapy including any adverse reactions, and reassessment of duration/frequency of respiratory therapy. Patients discharged from the hospital on respiratory therapy should be provided with instructions as to pulmonary care (e.g., indications for therapy, dosage of medications, complications of misuse, safety, maintenance of equipment, frequency/use of machine settings, postural drainage, and therapeutic percussion). Examples of respiratory therapy include: • Aerosol, humidification, and therapeutic gas administration • Mechanical ventilatory and oxygenated support • Coughing and breathing exercises • Bronchopulmonary drainage • Therapeutic percussion and vibration • Pulmonary function testing • Blood gas analysis • Cardiopulmonary resuscitation NOTE: JCAHO and AOA standards and Medicare CoP state that the attending physician is responsible for documenting a physician’s order for respiratory care services, including type, frequency and duration of treatment, type and dose of medication, type of dilutant, and oxygen concentration. A progress note documented by the anesthesiologist prior to the induction of anesthesia, which includes evidence of: • Patient interview to verify past and present medical and drug history and previous anesthesia experience(s) • Evaluation of the patient’s physical status • Review of the results of relevant diagnostic studies (EKG, pulmonary function tests, cardiac stress tests, laboratory, imaging) • Discussion of preanesthesia medications and choice of anesthesia to be administered (e.g., general, spinal, or other regional anesthesia) • Surgical and/or obstetrical procedure to be performed • Potential anesthetic problems (e.g., smoking) and risks A progress note documented by the anesthesiologist, which includes: • Patient’s general condition following surgery • Description of presence/absence of anesthesia-related complications and/or postoperative abnormalities • Blood pressure, pulse, presence/absence of swallowing reflex and cyanosis NOTE: A written order releasing the patient from the recovery room must also be authenticated by the physician responsible for release (e.g., surgeon or anesthesiologist) A progress note documented by the surgeon prior to surgery, which summarizes the patient’s condition and documents a preoperative diagnosis A progress note documented by the surgeon after surgery, which documents the patient’s response to surgery and a postoperative diagnosis NOTE: The surgeon documents the postoperative note in addition to a dictated operative record.

Preanesthesia Evaluation Note

Postanesthesia Note

Preoperative Note Postoperative Note

150 • Chapter 5

stay; thus, progress notes indicate that a patient’s care required intervention by a physician and professional personnel. EXAMPLE 1:
Sarah has a postoperative temperature of 101 and is vomiting. The nursing staff monitors her condition continually and documents multiple progress notes (e.g., nurses note) for each shift, including date, time, and authentication for each note.

EXAMPLE 2:
2/3/YYYY 1300 Patient admitted with severe pain in upper arms and a constricting, squeezing feeling in the substernal area that feels like indigestion and gas and was not relieved by soda. Tony Tierney, M.D.

or blood products (if applicable), oxygen flow rate, and continuous recordings of patient status noting blood pressure, heart, and respiration rate. The AOA states that the postanesthetic evaluation is to be documented, dated, timed, and authenticated by the anesthesiologist or anesthetist who administered anesthesia not more than 24 hours after surgery, as follows: postoperative abnormalities, complications, blood pressure and pulse, presence or absence of swallowing reflex, any degree of cyanosis, and general condition of the patient. Medicare CoP require documentation of a preanesthesia evaluation note by an individual qualified to administer anesthesia within 48 hours prior to surgery is also required. Medicare CoP also require that an intra-operative anesthesia record be maintained. A postanesthesia follow-up report is also to be documented by the individual who administered the anesthesia within 48 hours after surgery.

EXAMPLE 3:
2/24/YYYY Less weak. Walking without instability or pain. Patricia Smart, M.D. 2/25/YYYY Patient very much improved. To start patient walking more. Patricia Smart, M.D. 2/25/YYYY Very upset and unable to rest all night due to his demented and very noisy roommate. Patricia Smart, M.D. 2/27/YYYY Patient states he feels good. Clear to decrease Valium to 5 mg. Slept last night without a sleeping capsule. Patricia Smart, M.D.

Anesthesia Record
JCAHO standards require documentation of appropriate monitoring of the patient during administration of anesthesia, to include patient monitoring, dosage of drugs/agents administered, type and amount of fluids administered (including blood and blood products), technique(s) used, unusual events during anesthesia period, and status of the patient at the conclusion of anesthesia. AOA requirements include documentation of a preoperative evaluation as performed by the anesthesiologist or representative within 48 hours prior to surgery. The AOA requires a separate anesthesia record that documents the type of anesthesia administered and the patient’s condition throughout all operative procedures. This record is to be authenticated by the anesthesiologist or anesthetist, and documentation is to include: patient’s name, dosage, route and time of administration of drugs and anesthesia agents, I.V. fluids, blood

In addition to preoperative and postoperative anesthesia progress notes (discussed above) documented by the anesthesiologist, an anesthesia record (Figure 5-22A) is required, when a patient receives an anesthetic other than a local anesthetic, to document patient monitoring during administration of anesthetic agents and other activities related to the surgical episode. The anesthesia record, pre- and postanesthesia progress notes (Figure 5-22B), and recovery room (discussed below) record provide complete documentation of the administration of preoperative medications, anesthetic agents administered during operative procedures, evaluation of the patient pre- and postoperatively, and recovery of the patient from anesthesia during the immediate postoperative period. NOTE: Preanesthesia and postanesthesia progress notes are sometimes documented on a special form located on the reverse side of the anesthesia record. This can prove helpful to anesthesiologists so that no documentation elements are forgotten. Contents of the anesthesia record include: • Preanesthesia medication administered, including time, dosage, and effect on patient • Appraisal of any changes in the patient’s condition (since preanesthesia evaluation) • Anesthesia agent administered, including amount, technique(s) used, effect on patient, and duration • Patient’s vital signs (e.g., temperature, pulse, blood pressure) • Any blood loss

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 151

Addressograph

ANESTHESIA RECORD

Stop

❑ Patient Identified ❑ ID band verified ❑ Patient questioned ❑ Chart reviewed ❑ Consent form signed ❑ Patient reassessed prior to anesthesia (ready to proceed) ❑ Peri-operative pain management discussed with patient/guardian (plan of care completed) Pre-Anesthetic State: ❑ Awake ❑ Anxious ❑ Calm ❑ Lethargic ❑ Uncooperative ❑ Unresponsive ❑ Other: ❑ Anesthesia machine #5626984 checked ❑ Secured with safety belt ❑ Arm secured on board ❑ Left ❑ Right

❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑

Stethoscope ❑ Precordial Suprasternal ❑ Esoph Non-invasive B/P ❑ V-lead ECG Continuous ECG ❑ ST Analysis Pulse oximeter ❑ End tidal CO 2 Nerve stimulator: ❑ Ulnar ❑ Tibial ❑ Facial Oxygen monitor ❑ Cell Saver ET agent analyzer ❑ B/S ❑ TEE Fluid/Blood warmer ❑ Temp: ______ BIS ❑ ICS NG/OG tube ❑ FHT monitor Foley catheter ❑ EEG Airway humidifier Evoked potential: ❑ SSEP ❑ BAEP ❑ MEP Arterial line ❑ CVP ________

GA Induction: ❑ IV ❑ Pre-O 2 ❑ RSI ❑ PR ❑ Cricoid pressure ❑ Inhalation ❑ IM GA Maintenance: ❑ TIVA ❑ Inhalation ❑ Inhalation/IV ❑ GA/Regional Comb. Regional: Epidural : ❑Thoracic ❑ Lumbar ❑ Caudal ❑ Femoral ❑ Auxiliary ❑ Interscalene ❑ CSE ❑ Bier ❑ SAB ❑ Ankle ❑ Continuous Spinal ❑ Cervical Plexus Regional Techniques: ❑ Position ______ ❑ Site ______ ❑ LA ______ ❑ Additive ______ 15 30 45 15 ❑ See Remarks ❑ Prep _____ ❑ Needle _____ ❑ Narcotic _____ ❑ Test dose Rx ___ 30 45 15

❑ Oral ETT ❑ LTA ❑ RAE ❑ Nasal ETT ❑ LMA # ___ ❑ Stylet ❑ LMA Fastrach # ___ ❑ DVL ❑ LMA ProSeal # ___ ❑ EMG ETT ❑ Bougie ❑ Armored ETT ❑ LIS ❑ Breath sounds = bilateral ❑ Cuffed – min occ pres with ❑ air ❑ NS ❑ Uncuffed – leaks at _______ cm H2O ❑ Oral airway ❑ Nasal airway ❑ Bite block Circuit: ❑ Circle system ❑ NRB ❑ Bain ❑ Via tracheotomy/stoma ❑ Mask case ❑ Nasal cannula ❑ Simple O2 mask Nebulizer: Nerve Block(s):

15 ❑ Des Air ✓ ❑ Oxygen ✓ ❑ N2O ✓ ❑ Forane ✓ ❑ Anectine ✓ ❑ Pentothal (L/min) (%) (mg) (mg) (L/min) (L/min) ❑ Iso ❑ Sevo ❑ Halo (%)

30

45

15

30

45

30

45

FLUIDS

Urine EBL Gastric ✓ ❑ ECG ✓ ❑ % Oxygen Inspired (FI02) ✓ ❑ End Tidal CO2 ✓ ❑ Temp: ❑ C ✓ ❑ BP Monitor ✓ ❑F

BP cuff pressure ⊥ Arterial line pressure ✕ Mean arterial pressure
200 180 160 140 120 100 80 60 40 20 10

● Pulse ● Spontaneous Respirations

ø
Assisted Respirations T Tourniquet
Time of Delivery: _______ _______ _______ Gender: ❑ M ❑ F Apgars: /____

Tidal Volume (ml) Respiratory Rate Peak Pressure H2O) ❑ PEEP ❑ CPAP

(cm (cm H2O) Position: Surgeon Assistant Scrub Nurse Circulating Nurse Signature of Anesthesiologist or C.R.N.A. MAIN ST, ALFRED NY 14802 ■ [phone]

ALFRED STATE MEDICAL CENTER ■ 100

Figure 5-22A

Sample Anesthesia Report (Permission to reprint granted by www.anesthesia-nursing.com.)

152 • Chapter 5

Addressograph

❑ Patient

❑ Parent/ Guardian

❑ Significant Other

❑ Chart

❑ Poor Historian

❑ Language Barrier

G ❑ Male

❑ Female ❑ None ❑ None ❑ None ❑ None ❑ None ❑ MP1 ❑ MP2 ❑ MP3 ❑ MP4 ❑ Unrestricted neck ROM ❑ History of difficult airway ❑ Edentulous ❑ T-M distance = ❑ Short muscular neck ❑ Facial hair

(Enter ✕ in appropriate boxes)

❑ Obesity ❑ Teeth poor repair

❑ ↓ neck ROM ❑ Teeth chipped/loose

❑ WNL Tobacco Use: ❑ Yes ❑ No ❑ Quit Packs/Day for Years

Pulmonary Studies
❑ WNL Pre-procedure Cardiac Assessment:

❑ WNL Ethanol Use: ❑ Yes ❑ No Frequency ❑ History of Ethanol abuse

❑ Quit

❑ WNL

❑ WNL ❑ WNL

❑ WNL ❑ AROM ❑ SROM Weeks Gestation: ❑ Pitocin Drip ❑ Induction ❑ MgDrip P: EDC: ________ G:

Location ❑ Awake ❑ Stable ❑ Mask O 2 ❑ NC 02

Time

B/P

O2 Sat

Pulse

Respirations

Temperature

Medication

Used

Destroyed

Returned

❑ Somnolent ❑ Unstable

❑ Unarousable ❑ T-Piece

❑ Oral/nasal airway ❑ Intubated ❑ Ventilator

❑ Regional – dermatome level: ❑ Direct admit to hospital room ❑ See notes for anesthesia related concerns

❑ Continuous epidural analgesia ❑ No anesthesia related complications noted ❑ Satisfactory postanesthesia/analgesia recovery A LFRED S TATE MEDICAL CENTER ■ 100 M AIN S T, A LFRED NY 14802 ■ [phone]

Figure 5-22B Sample Pre- and Postanesthesia Evaluation Record (Permission to reprint granted by www.anesthesia-nursing.com.)

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 153

• Transfusions administered, including dosage and duration • IV fluids administered, including dosage and duration • Patient’s condition throughout surgery, including pertinent or unusual events during induction of, maintenance of, and emergence from anesthesia. • Authentication by anesthesiologist

NOTE: The discharge summary must include documentation of any postoperative instructions. Documentation elements include: • Principal participants (e.g., surgeon, assistant surgeon, anesthesiologist, and so on) • Pre- and postoperative diagnoses • Surgical procedure performed • Anesthesia administered • Detailed evidence that surgically acceptable techniques were used • Indications for surgery • Condition of the patient (pre-, intra-, and postoperatively) • Detailed description of the operative procedure performed (e.g., surgical techniques), including organs explored • Description of operative findings, unique elements in the course of procedures performed, any unusual events that occurred during the procedure, and specimens removed • Description of other procedures performed during operative episode • Documentation of ligatures, sutures, number of packs, drains, and sponges used

Operative Record
JCAHO standards require the surgeon to document the following prior to performing surgery: history, physical examination, laboratory and X-ray examinations, and preoperative diagnosis—authentication is the responsibility of the individual caring for the patient. All diagnostic and therapeutic procedures are to be documented in the patient record, and the report is to be filed in the patient record immediately after surgery (to provide for continuity of care of the patient). If the report cannot be filed immediately after surgery (e.g., transcription delay), the surgeon is responsible for documenting a comprehensive operative progress note in the patient record. AOA requirements include a preoperative evaluation of the surgical patient, detailed report of the operation, and postoperative evaluation within 24 hours after surgery. Medicare CoP require a complete H&PE to be documented in the patient’s record prior to surgery—if the report is not available in the patient’s record, the responsible physician must document a statement to that effect along with a complete admission note.

Pathology Report
JCAHO standards require documentation of an authenticated, dated report or examination as performed by pathology and clinical laboratory services. The pathologist is responsible for documenting a descriptive diagnostic report of gross specimens received and of autopsies performed. AOA requirements state that the pathology report is to contain a detailed and authenticated notation of all tissues examined, including microscopic findings. If only a gross examination is warranted, the record is to include documentation that the tissue was received and a report of the gross description of that tissue. The pathology report is to be authenticated by the pathologist, the original is to be filed in the patient’s record, and a copy is to be maintained in the pathology department. The pathology report must be promptly filed in the patient’s record and the surgeon requesting examination of tissue is to be notified promptly.

NOTE: The patient record often contains a comprehensive operative progress note documented by the surgeon as well as a transcribed operative record— both are authenticated by the responsible surgeon. Also, do not confuse pre- and postoperative evaluations documented by the surgeon with pre- and postanesthesia evaluations documented by the anesthesiologist. These are often documented in the progress notes and are authenticated by the responsible physician (surgeon or anesthesiologist). Some hospitals create special forms to facilitate documentation of these evaluations. The operative record (Figure 5-23) describes gross findings, organs examined (visually or palpated), and techniques associated with the performance of surgery. It is to be dictated or handwritten immediately following the operation and authenticated by the responsible surgeon.

The pathology report (or tissue report) (Figure 5-24) assists in the diagnosis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically (e.g., biopsy), or that expelled

154 • Chapter 5

Addressograph

Patient Number

Room/Bed

Patient Name (Last, First, MI)

Date of Procedure

Patient SSN

Time Started

Time Ended

Patient DOB

Gender

Service

Surgeon: Anesthetist: Preoperative Diagnosis: Postoperative Diagnosis: Procedure(s) Performed: Complications: Operative Findings:

Assistant: Anesthetic:

Dictation Date__________ Transcription Date_______ Signed ____________________________________________

Form 4107, OCT 03
ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-23 Sample Operative Report

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 155

Addressograph

Clinical History/Preoperative Diagnosis:

Patient’s diagnosis prior to review of tissue by pathologist. EXAMPLE: Breast mass. Right breast lumpectomy performed.

Specimen(s) Obtained:

Specimen received by pathologist as a result of the procedure (e.g., breast tissue). EXAMPLE: Single piece of fibrofatty tissue received in formalin.

Gross Description:

Pathologist views specimen without a microscope and describes size (after measuring it) and appearance (after feeling it). EXAMPLE: Fibrofatty tissue is 2 x 3 x 3 cm. A central mass is palpable.

Microscopic Description: Pathologist views specimen using a microscope and describes tissue. EXAMPLE: Tissue reveals infiltrating ductal carcinoma. Tumor contains irregular nests of infiltrating cells with minimal gland formation. Surgical margins are clear.

Pathologic Diagnosis:

Pathologist documents grade, histology, and stage. Grade: nature of cells and their aggressiveness. Histology: type of cancer found and arrangement of cells. Stage: size of cancer and extent to which it has spread. EXAMPLE: Poorly differentiated infiltrating ductal carcinoma, Grade III, Stage II.

ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-24 Sample Pathology Report (Permission to reprint granted by TheDoctorsDoctor.com.)

156 • Chapter 5

by the patient (e.g., products of conception). A tissue examination request is submitted to the pathologist along with the specimen and a clinical diagnosis. The pathologist performs macroscopic (gross) and microscopic examination of tissue and documents a report. The pathology report is filed in the patient record as soon as completed, usually within 24 hours. Contents of the pathology report include: • • • • • • • Date of examination Clinical diagnosis Tissue examined Pathologic diagnosis Macroscopic (or gross) examination Microscopic examination Authentication by pathologist

• Documentation of infusions, surgical dressings, tubes, catheters, and drains • Written order releasing patient from recovery room (authenticated by physician responsible for release) documented in the physician orders NOTE: The recovery room record is dated, timed, and authenticated by the responsible physician (anesthesiologist) or certified registered nurse anesthetist (CRNA).

Ancillary Reports
JCAHO standards require patient records to include reports of pathology and clinical laboratory examinations, radiology and nuclear medicine examinations or treatment, anesthesia records, and any other diagnostic or therapeutic procedures. Requests for ancillary testing must include the study requested and appropriate clinical data to aid in the performance of the procedures requested. AOA requirements state that laboratory reports are to be signed or initialed by the person performing the test prior to placement in the record. If the laboratory report is computer generated “the person performing the test should to be identifiable from data storage if the report is not signed or initialed.” The original laboratory report is to be filed in the health record and a copy is to be on file in the laboratory department. If an outside laboratory performs the testing, the original report from that laboratory becomes part of the permanent record. The AOA also states that laboratory reports of testing performed outside the hospital pertinent to the care and treatment of the patient are to be made a part of the patient’s record.

Recovery Room Record
JCAHO standards also require the patient’s postoperative status to be evaluated upon admission to and discharge from the postanesthesia recovery area, as follows: record of vital signs and level of consciousness, I.V. fluids and drugs administered including blood and blood products, and any unusual events or postoperative complications and the management of those events. When patients are discharged from the postanesthesia recovery area (PAR) or from the facility after ambulatory surgery, the licensed independent practitioner is responsible for documenting and signing a discharge order (which could be a telephone order).

After the completion of surgery, patients are taken to the recovery room where the anesthesiologist and recovery room nurse are responsible for documenting a recovery room record (Figure 5-25), which delineates care administered to the patient from the time of arrival until the patient is moved to a nursing unit. Elements of the recovery room record include: • Patient’s general condition upon arrival to recovery room • Postoperative/postanesthesia care given • Patient’s level of consciousness upon entering and leaving the recovery room • Description of presence/absence of anesthesiarelated complications and/or postoperative abnormalities (may be documented in progress notes) • Monitoring of patient vital signs, including blood pressure, pulse, and presence/absence of swallowing reflex and cyanosis

Ancillary reports (Table 5-8) are documented by such departments as laboratory, radiology (or X-ray), nuclear medicine, and so on; they assist physicians in diagnosis and treatment of patients. The responsible physician must document requests for ancillary testing to be performed in the physician orders, and the patient record must include documentation of ancillary report results as well as a treatment plan. All ancillary reports should be filed in the patient’s records as soon as an interpretation has been made (usually within 24 hours).

Nursing Documentation
JCAHO standards state that nursing documentation must include the following: initial assessments and reassessments; nursing diagnoses and/or patient care needs; interventions identified to meet patient’s

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 157

Addressograph

0
230 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0

15

30

45

60

15

30

45

60

❑

❑

. Postanesthesia Recovery Score
Moves 4 extremities voluntarily or on command (2) Moves 2 extremities voluntarily or on command (1) Moves 0 extremities voluntarily or on command (0) Able to deep breathe and cough freely (2) Dyspnea or limited breathing (1) Apneic (0) BP 20% of preanesthetic level BP + 20% of preanesthetic level BP + 50% of preanesthetic level Fully awake (2) Arouseable on calling (1) Not responding (0) Pink (2) Pale, dusky, blotchy, jaundiced, other (1) Cyanotic (0) Adm 30 min 1 hr 2 hr Disch

Activity Respiration Circulation Consciousness

Color

ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-25 Sample Recovery Room Record

158 • Chapter 5

Table 5-8 Ancillary Reports Type of Ancillary Report
Laboratory (Figure 5-26A)

Description
Clinical laboratory reports document name, date and time of lab test, results, time specimen was logged into the lab, time the results were determined, and initials of the laboratory technician. Examples include: • Blood chemistry (e.g., blood glucose level, WBC, CBC, urinalysis, culture and sensitivity, and so on) • Therapeutic drug assay (e.g., drug level in blood) • Blood gases (e.g., oxygen saturation) • Cardiac enzymes • Blood types • Blood factor (Rh) • Genetic testing Radiology (or imaging) reports document a description of the image, techniques used, narrative report of findings, diagnosis or impression, and authentication by the radiologist. Examples include: • X-rays (radiology) • CAT scans • Nuclear medicine • Ultrasound • MRI • Xerography • PET scans • Thermography NOTE: Obtain signed patient consent prior to performing deep X-ray therapy, radioactive isotope treatment, or special diagnostic procedures. EKG report includes the following: • Printout of graphic tracing of electrical changes in heart muscle, commonly called the EKG strip • Physician’s interpretation of the tracing • Authentication by physician EEG report includes the following: • Graphic printout of measurement of electrical activity of the brain • Physician’s interpretation of graphics • Authentication by physician EMG report includes the following: • Graphic printout of measurement of skeletal muscle activity • Physician’s interpretation of graphics • Authentication by physician Blood transfusion reports contain documentation of the complete and accurate description of the requisition for blood, report of crossmatching (compatibility tests), blood type and Rh, report of administration of blood, donor’s identification number, and notation of any transfusion reactions.

Radiology (Figure 5-26B)

Electrocardiogram (EKG or ECG) (Figure 5-26C)

Electroencephalogram (EEG) (Figure 5-26D)

Electromyogram (EMG) (Figure 5-26E)

Transfusion Record (Figure 5-26F)

nursing care needs; nursing care provided; patient’s response to, and outcomes of, care provided; and abilities of the patient and/or, as appropriate, significant other(s) to manage continuing care needs after discharge. AOA requirements include the following: concise, accurate, descriptive documentation of observations based on the nursing process relative to the patient’s admission, hospital stay, and discharge from the hospital and physician’s written order; date, time, and authentication by nursing personnel

(including classification); correlation with nursing care plan; evidence of nursing participation with physicians to improve patient care.

Nursing documentation (Table 5-9) plays a crucial role in patient care because the majority of care delivered to inpatients is performed by nursing staff, which include registered nurses (RN), licensed practical nurses (LPN), and certified nurses’ aides (CNA).

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 159

Addressograph

SPECIMEN COLLECTED:

SPECIMEN RECEIVED:

TEST
Glucose BUN Creatinine Sodium Potassium Chloride CO2 Calcium WBC RBC HGB HCT Platelets PT

RESULT

FLAG

REFERENCE
82-115 mg/dl 8-25 mg/dl 0.9-1.4 mg/dl 135-145 mmol/L 3.6-5.0 mmol/L 99-110 mmol/L 21-31 mmol/L 8.6-10.2 mg/dl 4.5-11.0 thous/UL 5.2-5.4 mill/UL 11.7-16.1 g/dl 35.0-47.0 % 140-400 thous/UL 11.0-13.0 seconds

***End of Report***
ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-26A

Sample Laboratory Report

160 • Chapter 5

Addressograph

Signature of Radiologist
ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-26B

Sample Radiology Report

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 161

Figure 5-26C Sample Electrocardiogram (EKG) Report (Reprinted with permission of Bibbero Systems, Inc., Petaluma, CA. [phone]. www.bibbero.com.)

162 • Chapter 5

Addressograph

Signature of Physician
ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-26D Sample Electroencephalogram (EEG) Report

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 163

Addressograph

EMG REPORT

Neurological and Electrodiagnostic Consultation:

Past History:

Social History

Neurological Examination:

Electromyographic Study:

Nerve Conduction Velocity Test:

Sensory Results:

Late Responses:

Summary:

Impression:

Recommendations:

Signature of Physician
ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-26E Sample Electromyogram (EMG) Report

Addressograph

Date: Hb Platelets WBC Neutrophils

Date: Hb Platelets WBC Neutrophils

Date: Hb Platelets WBC Neutrophils

Date: Hb Platelets WBC Neutrophils

History of reaction to blood products: Special blood products required: Allergies:
Date Administered Blood Component Units

❑ No ❑ No

❑ Not known ❑ Yes; specify

❑ Yes; specify reaction: ❑ Hyperpyrexia ❑Other

Duration

Signature

Serial No.

T, P, BP at start of each unit

Start time

Volume

T, P, BP at 15 minutes

End time

Hydrocortisone Piriton Name of physician informed: Was the laboratory informed? Was a transfusion reaction form completed? ❑ Yes ❑ Yes ❑ No ❑ No

ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-26F Sample Blood Transfusion Report

Table 5-9 Nursing Documentation Nursing Documentation
Nursing Care Plan (Figure 5-27A)

Description
Documents nursing interventions to be used to care for the patient. NOTE: Nursing care plans are not usually filed in the permanent patient record. Documents daily observation about patients, including an initial history of the patient, patient’s reactions to treatments, and treatments rendered. Documents patient discharge plans and instructions. Documents patient’s vital signs (e.g., temperature, pulse, respiration, blood pressure, and so on) using a graph for easy interpretation of data. Documents medications administered, date and time of administration, name of drug, dosage, route of administration (e.g., orally, topically, by injection, or infusion), and initials of nurse administering medication. NOTE: Patient reactions to drugs are documented in nurses notes. Computer system located at the patient’s bedside, which is used to automate nursing documentation. Patient information can be entered, stored, retrieved, and displayed.

Nurses Notes (Figure 5-27B) Nursing Discharge Summary (Figure 5-27C) Graphic Sheet (Figure 5-27D) Medication Administration Record (MAR) (Figure 5-27E)

Bedside Terminal System

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 165

NURSING CARE PLAN
Date/ Initials Nursing Diagnosis Nursing Intervention Outcome Evaluation Projected Date/Initials

IHS-80-1 (Rev. 3/89) Part 2

EF

Figure 5-27A

Sample Nursing Care Plan (Permission to reprint in accordance with IHS.gov Web reuse policy.)

166 • Chapter 5

Addressograph

DATE

TIME

NOTES

SIGNATURE

ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-27B

Sample Nurses Notes

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 167

Addressograph

Date/Time

Discharge to: ❑ Home ❑ Other:

Mode: ❑ Ambulatory ❑ Other:

Accompanied by:

Activity Specify limitations Diet ❑ No dietary restrictions Medications Name of Medication ❑ Special diet ❑ No medications Dosage Frequency of Administration Special Instructions

Treatment/Care Instructions: Equipment/Supplies: Follow-up You are scheduled to see Dr. Patient’s Conditions: on Date at Time .

Signature of Registered Nurse ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-27C Sample Nursing Discharge Summary

168 • Chapter 5

IHS-350 (REV. 01/89) MONTH YEAR 19 HOSPITAL DAY DAY OF MONTH 19
PULSE
( )

VITAL SIGNS RECORD

HOUR
TEMP. F
( )

.

140

105

130

104

110

102

38.9

100

101

90

100

37.8

80

99 98.6

37

70

98

60

97

36.4

50

96

RESPIRATION RECORD AM BLOOD PRESSURE PM HEIGHT DIET BATH STOOLS WEIGHT

TIME OF DAY

SUGAR

ACETONE

SUGAR

ACETONE

ACESUGAR TONE

ACESUGAR TONE

SUGAR

ACETONE

ACESUGAR TONE

ACESUGAR TONE

U R I N E

AM AM PM PM

PATIENT'S IDENTIFICATION (For typed or written entries give: Name middle; hospital or medical facility)

last, first,

RECORD OF TEMPERATURE, PULSE & RESPIRATION AND ACTIVITIES OF DAILY LIVING (EXCEPTION TO SF-511)

Figure 5-27D Sample Vital Signs Record Graphic Sheet (Permission to reprint in accordance with IHS.gov Web reuse policy.)

(Centigrade Equivalents, for Reference only)

120

103

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TEMP. C

40

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 169

Figure 5-27E Sample Medication Administration Record (MAR) (Reprinted with permission of Bibbero Systems, Inc., Petaluma, CA. [phone]. www.bibbero.com.)

170 • Chapter 5

Upon admission to the hospital, a nursing assessment is documented to obtain the patient’s history and evaluate vital signs. This information is used to create a nursing care plan, which records nursing diagnoses and interventions. Nursing staff is also responsible for recording vital signs, administration of medication, observations and progress during the patient’s inpatient hospitalization, and a discharge plan. This information is documented on various forms, which include nurses notes, graphic sheets, medication sheets, and so on.

Special Reports
Records of obstetric and neonatal patients contain unique forms. The obstetrical record is the mother’s record and contains an antepartum record, labor and delivery record, and postpartum record. The neonatal record (Figure 5-28) is the newborn’s record and contains a birth history, newborn identification, physical examination, and progress notes. The obstetrical record consists of the following reports: • Antepartum record (or prenatal record) (Figure 5-29A): Started in the physician’s office and includes health history of the mother, family and social history, pregnancy risk factors, care during pregnancy including tests performed, medications administered, and so on. A summary of this information is also documented in the hospital patient record or a copy is filed at the birthing facility by the 36th week of pregnancy. • Labor and delivery record (Figure 5-29B): Records progress of the mother from time of admission through time of delivery. Information includes time of onset of contractions, severity of contractions, medications administered, patient and fetal vital signs, and progression of labor. • Postpartum record (Figure 5-29C): Documents information concerning the mother’s condition after delivery. Contents of neonatal record include: • Birth history: Documents summary of pregnancy, labor and delivery, and newborn’s condition at birth. • Newborn identification: Immediately following birth, footprints (Figure 5-29D) and fingerprints of

the newborn are created, and a wrist or ankle band is placed on the newborn (with an identical band placed on the mother); within 12 hours of birth, an identification form is also used to document information about the newborn and mother. • Newborn physical examination: An assessment of the newborn’s condition immediately after birth, including time and date of birth, vital signs, birth weight and length, head and chest measurements, general appearance, and physical findings is completed. • Newborn progress notes: Documents information gathered by nurses in the nursery and includes vital signs, skin color, intake and output, weight, medications and treatments, and observations. NOTE: An APGAR score is documented in the newborn record (and in some states as part of the birth certificate) as an indication of infant health; it also helps direct medical personnel in determining whether intervention is necessary (e.g., oxygen therapy). The APGAR score measures the baby’s appearance (A) (e.g., skin color), pulse (P), grimace (G) (e.g., irritability), activity (A) (e.g., muscle tone and motion), and respirations (R) on a scale of 1 to 10, with up to 2 points assigned for each measurement and 10 being the maximum score. (Although named for pediatrician Virginia Apgar, the letters also serve as a mnemonic device or memory aid.) The APGAR score is usually measured at 1 minute and 5 minutes after birth, but may be recorded for up to 10 or 15 minutes if the infant is being resuscitated.

Autopsy Report
JCAHO standards state that a provisional anatomic diagnosis is to be documented in the patient record within 72 hours after an autopsy is performed. The complete autopsy protocol is to be made part of the permanent record within 60 days after completion (unless exceptions for special studies are established by the medical staff). AOA requirements state that autopsies are to be performed in compliance with state and local laws and that consent must be obtained prior to the performance of the autopsy. The AOA also requires that the autopsy report include a report of gross and microscopic findings, gross findings completed and documented on the record within 15 days of autopsy, microscopic findings completed and documented on the record within 30 days of autopsy, and toxicology reports documented on the record within 6 months. If the final diagnosis is

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 171

Figure 5-28 Neonatal Record (Reprinted with permission of Bibbero Systems, Inc., Petaluma, CA. (800) 2422376. www.bibbero.com.)

not in agreement with autopsy findings, disagreement or correction of the final diagnosis is to be documented in the progress note section of the patient’s record. Medicare CoP state that the medical staff should attempt to obtain autopsies in all cases of unusual deaths and to pursue medical-legal and educational interest. In addition, the mechanism for documenting permission to perform an autopsy must be defined, and there must be a system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed.

which contains a cause of death, is to be documented within 72 hours, while the autopsy report (necropsy report or postmortem report) may take up to 60 days. Prior to performing an autopsy, consent must be obtained from the legal next-of-kin of the deceased, and the signed consent becomes part of the permanent patient record (unless it is a coroner’s case, based on state law). In addition, documentation that an autopsy was performed is to be documented in the patient record (e.g., progress notes), and the record is considered incomplete until the autopsy report is filed. Elements of an autopsy report include: • Summary of patient’s clinical history including diseases, surgical history, and treatment • Detailed results of the macroscopic and microscopic findings, including external appearance of the body and internal examination by body system

An autopsy (or necropsy) (Figure 5-30) is an examination of a body after death that includes the macroscopic and microscopic examination of vital organs and tissue specimens to assist in determining a cause of death and the character or extent of changes produced by disease. The provisional autopsy report,

172 • Chapter 5

Figure 5-29A Sample Antepartum (or Prenatal) Record (Permission to reprint in accordance with IHS.gov Web reuse policy.)

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 173

Figure 5-29B

Sample Labor Record (Permission to reprint in accordance with IHS.gov Web reuse policy.)

174 • Chapter 5

Figure 5-29C Sample Postpartum Record (Permission to reprint in accordance with IHS.gov Web reuse policy.)

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 175

Exercise 5–3 Data

Hospital Inpatient Record—Clinical

Fill-In-The-Blank: Enter the appropriate term(s) to complete each statement below. 1. A discharge summary, also known as a ________, documents the patient’s hospitalization, including reason(s) for hospitalization, ________, and condition at discharge. 2. The ________ documents the patient’s chief complaint, ________, past/family/social history, and review of systems. 3. If a patient is readmitted within ________ days after discharge for the same condition, a(n) ________ can be completed to document the patient’s history of the present illness and any pertinent changes and physical findings that occurred since the previous admission. 4. Diagnostic and therapeutic patient care activities, such as medications and dosages, and completion of a chest X-ray, are initiated by ________, also known as ________. 5. Preprinted physician orders, known as ________ or ________ orders, are preapproved by the medical staff and placed on a patient’s record, usually at the time of admission. • Contributing factors that led to death • Clinical-pathologic correlation (e.g., medical conclusion of patient’s disease process) • Authentication by pathologist NOTE: An autopsy is completed for suspicious deaths and in the event of an untimely death. (State laws govern when autopsies are mandated.) Typically, an autopsy is required for the following circumstances: • Any case where there is medical/legal necessity • Cause of death is not related to treatment • Dead on arrival to emergency room or dying in emergency room (without previous diagnosis or before definitive diagnosis) • Occult hemorrhage • Pneumonia (no microbiologic diagnosis) • Sudden infant death • Trauma (internal) • Pediatric and perinatal deaths 6. A(n) ________ is generated by emergency medical technicians to document clinical information such as vital signs, level of consciousness, appearance of the patient, and so on when a patient is transported via ambulance to the emergency department. 7. A consulting physician, as part of the consultation process, is responsible for reviewing the patient’s record, ________, documenting pertinent findings, and providing ________ and/or opinions to the referring physician. 8. Some facilities adopt ________, which means all progress notes documented by physicians, nurses, physical therapists, occupational therapists, and other professional staff members are organized in the ________ of the record. 9. The anesthesia record, pre- and postanesthesia ________, and ________ record provide complete documentation of the administration of medications and anesthetic agents administered during

Figure 5-29D Sample Newborn Footprints (Permission to reprint granted by Precision Dynamics Corporation. Web site: PDCorp.com.)

176 • Chapter 5

Addressograph

CASE #: DATE OF DEATH: MANNER OF DEATH:

AGE:

RACE: DATE OF AUTOPSY:

GENDER:

IMMEDIATE CAUSE OF DEATH: FINAL ANATOMIC DIAGNOSES:

EXTERNAL EXAMINATION EVIDENT OF TREATMENT EVIDENCE OF INJURY INTERNAL EXAMINATION CAVITIES CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM CENTRAL NERVOUS SYSTEM URINARY SYSTEM GENITAL SYSTEM HEPATOBILIARY SYSTEM GASTROINTESTINAL TRACT LYMPHOPROLIFERATIVE SYSTEM MUSCULOSKELETAL SYSTEM MISCELLANEOUS

SIGNATURE OF PATHOLOGIST
ALFRED STATE MEDICAL CENTER ■ 100 MAIN ST, ALFRED NY 14802 ■ [phone]

Figure 5-30 Sample Autopsy Report

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 177

the pre- and postoperative time and during surgery. 10. The gross findings, organs examined (visually or palpated), and techniques associated with the performance of surgery are documented in the ________. 11. The ________ assists in the diagnosis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically, or that expelled by the patient. 12. Reports produced by the laboratory, radiology, and nuclear medicine departments are known as ________. 13. Nursing diagnoses and interventions are documented on a ________. 14. The ________ documents information concerning the mother’s condition after delivery. 15. An examination of a body after death, which includes the ________ and microscopic examination of vital organs and tissue specimens to assist in determining a cause of death and the character or extent of changes produced by disease, is an ________.

as hospital outpatient care.) The provision of medical supplies (e.g., splints) and ancillary tests (e.g., lab) billed by the hospital are also included as outpatient care. Hospital outpatient records (or ambulatory records) include a patient registration form similar to the inpatient face sheet, and depending on the complexity of outpatient services provided, additional reports can include ancillary reports, progress notes, physician orders, operative reports, pathology reports, nursing documentation, and so on. In addition, some hospital outpatient departments use a short stay record (Figure 5-31), which allows providers to record the history, physical examination, progress notes, physician orders, and nursing documentation on one double-sided form. EXAMPLE 1:
Sam undergoes a laparoscopic cholecystectomy on an outpatient basis. Sam’s patient record will consist of a patient registration form, history and physical examination report, operative report, anesthesia record, recovery room record, pathology report, and so on.

EXAMPLE 2:
Omar undergoes an outpatient X-ray of his left wrist. His outpatient record consists of only a patient registration form, a physician order form, and the X-ray report.

HOSPITAL OUTPATIENT RECORD
JCAHO standards state that by the third visit, the patient record of a patient who receives continuing ambulatory services (e.g., physical therapy services) must contain a summary list that documents the significant diagnosis and conditions, procedures, drug allergies, and medications. (This summary list must be updated on subsequent visits.) Medicare CoP categorize outpatient care as optional hospital services, and conditions state that the hospital must maintain a medical record for each outpatient with records documented accurately and promptly, properly filed and retained, and accessible. The hospital must further use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

The Uniform Ambulatory Care Data Set (UACDS) is the minimum core data set collected on Medicare and Medicaid outpatients. The goal of collecting standardized UACDS data is to improve data comparison in ambulatory and outpatient settings. Current UACDS data elements include the following (and it is anticipated that the standard data set, discussed on pages 114, 116, and 117–118, will be adopted): • Patient (person receiving health care services) EXAMPLE
VA medical centers collect patient’s name, date of birth, social security number (SSN), eligibility, and so on.

Outpatient care is defined as medical or surgical care that does not include an overnight hospital stay (and not longer than 23 hours, 59 minutes, 59 seconds). Hospital outpatient services usually include diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services. (For reimbursement purposes, Medicare categorizes emergency room services

• Date and time of encounter or ancillary service (actual date and time encounter or service occurred, usually collected from appointment scheduling software) NOTE: An outpatient visit is the visit of a patient on one calendar day to one or more hospital departments

178 • Chapter 5

Figure 5-31 Sample Short Stay Record (Reprinted according to Web reuse policy at www.vha.gov.)

for the purpose of receiving outpatient health care services (e.g., encounter or ancillary service visit). An encounter is a professional contact between a patient and a provider who delivers services or is professionally responsible for services delivered to a patient. An encounter is not the same as an ancillary service visit (or occasion of service), which is the appearance of an outpatient to a hospital department to receive an ordered service, test, or procedure. Ancillary services do not include exercise of independent medical judgment in diagnosing, evaluating and/or treating conditions; an ancillary service is usually the result of an encounter. EXAMPLE 1:
Laboratory tests or X-ray procedures are ordered as part of an encounter. A patient may undergo multiple ancillary services during one outpatient visit.

EXAMPLE 2:
A telephone contact between a physician and a patient is considered an encounter if the telephone contact includes the appropriate elements of a face-to-face encounter (e.g., history and medical decision making).

• Practitioner (e.g., physician, nurse practitioner, physician’s assistant) NOTE: Practitioners are categorized as licensed and non-licensed. A licensed practitioner is required to have a public license/certification to deliver care to patients (e.g., MD, RN), and a practitioner can also be a provider. A provider is a business entity that furnishes health care to consumers or a professionally licensed practitioner authorized to operate a health care delivery facility (e.g., VA medical centers). A non-licensed practitioner does not have a public

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 179

license/certification and is supervised by a licensed/ certified professional in the delivery of care to patients (e.g., physical therapy assistant). • Place of service (location where service was provided to outpatient) • Active problem(s) (purpose of outpatient visit, which is the diagnosis treated and coded according to ICD-9-CM) NOTE: When more than one active problem or diagnosis is identified for an encounter, the practitioner must determine the primary diagnosis (reason the patient sought treatment during that encounter). The primary diagnosis reflects the current, most significant reason for services provided or procedures performed. When coding pre-existing conditions, make certain the diagnosis code reflects the current reason for medical management. Chronic diseases may be coded as long as treated, but if the patient presents and a condition other than the chronic problem is treated, code only the new condition. Also, never code a diagnosis that is no longer applicable; if the disease or condition has been successfully treated and no longer exists, it is not billable and should not be coded or reported. • Service or procedure provided (services provided or procedures performed by the practitioner, which are coded according to CPT and HCPCS Level II) Exercise 5–4 Hospital Outpatient Records

5. Medicare categorizes emergency room services as hospital outpatient care for reimbursement purposes. Fill-In-The-Blank: Enter the term that completes each statement. 6. The minimum core data set collected on Medicare and Medicaid outpatients is the ________. 7. A professional contact between a patient and a provider who delivers services or is professionally responsible for services delivered to a patient is known as a(n) ________. 8. A practitioner must determine the ________, or the reason the patient sought treatment, when more than one active problem or diagnosis is identified for an encounter. 9. Ancillary service visits and encounters are considered types of ________, in which a patient receives outpatient health care services on one calendar day in one or more hospital departments. 10. The appearance of an outpatient to a hospital department to receive an ordered service, test, or procedure is known as an ancillary service visit or a(n) ________.

PHYSICIAN OFFICE RECORD
The content and organization of physician office records varies greatly depending on the size of the office, ownership, and whether the practice is accredited. As a minimum, physician office records (Table 5-10) should contain patient registration information, a problem list, a medication record, progress notes (including patient’s history and physical examination), and results of ancillary reports. An encounter form (superbill or fee slip) (Figure 5-33) is commonly used in physician offices to capture charges generated during an office visit and consists of a single page that contains a list of common services provided in the office. This form is initiated when the patient registers at the front desk and is completed by providers as the patient receives care. EXAMPLE
Polly presents to the office registration desk and the medical assistant generates an encounter form, which is attached to the cover of her patient record. Polly is

True or False: Indicate whether each statement is True (T) or False (F). 1. JCAHO standards require that by the fourth ambulatory visit the patient record of a patient who receives continuing ambulatory services must contain a summary list that documents the significant diagnosis and conditions, procedures, drug allergies, and medications. 2. Inpatient care is defined as medical or surgical care that does not include an overnight hospital stay. 3. The summary list for outpatient records needs to be updated on all subsequent visits. 4. Medicare CoP categorize outpatient care as optional hospital services, and state that the hospital must maintain a medical record for each outpatient.

180 • Chapter 5

Table 5-10 Physician Office Record Physician Office Report
Patient Registration Form (Figure 5-32A) Problem List (Figure 5-32B) Medication List Progress Notes (Figure 5-32C) Ancillary Reports (Figure 5-32D)

Description
Documents demographic, administrative, and financial data. Documents diseases, conditions, allergies, and procedures. Documents medications, dosage, associated diagnosis, and ordering physician. Documents the initial history and physical examination and all subsequent visits. Documents reports of ancillary testing completed in the office or by outside labs, including hospital labs.

an established patient who is being monitored for anemia, and Dr. Healthy orders blood tests and performs an examination. Using the encounter form, the doctor selects the proper code for the level of exam completed. After the medical assistant completes the venipuncture (drawing of blood) procedure, she selects the code on the encounter form. The completed encounter form is returned to the registration desk where the patient is scheduled for a follow-up visit. The medical assistant will use the completed encounter form to generate the patient’s bill and insurance claim, which is submitted to the third-party payer. (The blood specimen will be delivered to the hospital lab later that afternoon, where the blood test will be performed. The hospital billing department will generate a bill and claim for charges.)

completed in the office or by outside labs, including hospital labs. E. Documents demographic, administrative, and financial data.

FORMS CONTROL AND DESIGN
In a paper-based record system, it is imperative that each facility designate a person who is responsible for the control and design of all forms adopted for use in the patient record. This is usually the responsibility of the health information department, and in some facilities a forms committee (or patient record committee) is established to oversee this process and to approve forms used in the record. The role of a forms committee is to scrutinize each proposed form to: • Facilitate efficient use of the patient record (e.g., consolidation of forms, elimination of duplication of information throughout the record, and so on) • Ensure that documentation collected on forms complies with accrediting, regulatory, and reimbursement organizations • Enhance quality of documentation in the patient medical record • Streamline the forms approval process

Exercise 5–5

Physician Office Record

Matching: Match the term with its description. _______ 1. Ancillary reports _______ 2. Medication list _______ 3. Progress notes _______ 4. Patient registration form _______ 5. Problem list A. Documents initial history, physical examination, and all subsequent visits. B. Documents diseases, conditions, allergies, and procedures C. Documents medications, dosage, associated diagnosis, and ordering physician. D. Documents reports of ancillary testing

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 181

Figure 5-32A Patient Registration Form (Reprinted with permission of Bibbero Systems, Inc., Petaluma, CA. [phone]. www.bibbero.com.)

182 • Chapter 5

Figure 5-32B Problem List (Reprinted with permission of Bibbero Systems, Inc., Petaluma, CA. [phone]. www.bibbero.com.)

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 183

Figure 5-32C Sample Physician Office Progress Notes (Reprinted with permission of Bibbero Systems, Inc., Petaluma, CA. [phone]. www.bibbero.com.)

184 • Chapter 5

Figure 5-32D Sample Ancillary Report Forms (Reprinted with permission of Bibbero Systems, Inc., Petaluma, CA. [phone]. www.bibbero.com.)

When designing a form, the following functional characteristics must be considered: • Determine the purpose of the form. • Prior to designing the form, outline the purpose, use, and users of the form. • Make sure that the new form will not duplicate information that is already contained on another form. • Keep the form simple. • The simpler the form design, the easier it will be to design and use. • Include basic information. • All forms should contain the title of the form, form number, original date of form, revision date, and patient identification section. • Include preprinted instructions. • Instructions for completion of the form should be printed on the form (e.g., reverse of the form).

• Plan spacing on the form. • Consider the type size and margins of the form. • If handwritten information is going to be entered on the form, make sure that there is sufficient space. • Use color-coding for various sections of the record. • Consider using a different color border on forms for each discipline. • Select a color of ink, usually black, that will photocopy easily. • Allow for uniformity in size, content, and appearance. • All headings on the various forms used should have a standard format. • Be sure to standardize the size and appearance of individual forms. • Consider paper requirements. • Consider the weight and quality of paper used.

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 185

Figure 5-33 Encounter Form (Reprinted with permission of Bibbero Systems, Inc., Petaluma, CA. (800) 2422376. www.bibbero.com.)

186 • Chapter 5

• Reports that are accessed frequently (e.g., face sheet) should be a heavier weight of paper so they can withstand frequent use. • Prepare a draft of the form for review by the forms committee. • Pilot the form for trial use (e.g., 30 days) on one nursing unit. • Revisions can be made if necessary. • Consider adopting ready-to-use forms, which can be cheaper to purchase. Some facilities require that proposed forms be accompanied by a completed application form (e.g., Application for New or Revised Patient Record Form) (Figure 5-34). Exercise 5–6 Forms Control and Design

Core Health Data Elements Report at http://www.ncvhs .hhs.gov/ncvhsr1.htm. Go to http://www.uslivingwillregistry.com and click on ADVANCE DIRECTIVE FORMS to locate your state and link to free advance directive forms. Go to http://www.hospitalsoup.com and scroll down to select from the Documentation & Accreditation links. Go to http://www.vh.org and click on RADIOLOGY RESOURCES to view sample images. Go to http://www.embbs.com to click on and view sample emergency medicine scans, EKGs, and clinical reviews. Go to http://www.medicalstudent.com to view a myriad of health resources. Go to http://www.advanceforal.com and http://www .advanceformlp.com. Click on ARTICLES OF INTEREST to read about laboratory medicine (including record-keeping topics).

True/False: Indicate whether each statement is True (T) or False (F). 1. One of the roles of a forms committee is to review each proposed form to streamline the forms approval process. 2. In a paper-based record system, each department should designate a person who is responsible for the control and design of all forms adopted by the department for use in the patient record. 3. Prior to designing forms, the person designing the form should make sure that the new form will not duplicate information that is already contained on another form. 4. It is usually the responsibility of administration to oversee the forms process and to approve forms used in the record. 5. Documents that are used frequently should be printed on a heavier weight paper so they can withstand frequent use. INTERNET LINKS
Go to http://www.bibberosystems.com to view ready-touse forms. Go to http://www.ahima.org and click on HIM RESOURCES, PRACTICE TOOLS, and PRACTICE BRIEFS to view Recommended Regulations and Standards for Specific Healthcare Settings (Updated). Go to http://www.cdc.gov/nchs for more information about the National Center for Statistics and view the National Committee on Vital and Health Statistics (NCVHS)

SUMMARY
• The patient record is a valuable tool that documents care and treatment of the patient. • Every report in the patient record and every screen in an automated record system must contain patient identification, which consists of the patient’s name and some other piece of identifying information such as medical record number, date of birth, or social security number. • It is common for health care facilities to print the attending/primary care physician’s name and date of admission/visit on each form using an addressograph machine, which imprints patient identification information on each report. • Facility identification, including the name of the facility, mailing address, and a telephone number, must also be included on each report in the record so that an individual or health care facility in receipt of copies of the record can contact the facility for clarification of record contents. • For a record to be admissible in a court of law according to Uniform Rules of Evidence, all patient record entries must be dated (month, date, and year, such as mmddyyyy) and timed (e.g., military time, such as 0400). • Providers are responsible for documenting entries as soon as possible after care and treatment of a patient; predated and postdated entries are not allowed. • Because patient record content serves as a medicolegal defense, providers should adhere to documentation guidelines to ensure quality documentation.

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 187

APPLICATION FOR A NEW OR REVISED PATIENT RECORD FORM
TO: FROM: DATE: SUBJECT Application for approval of a new or revised patient record form ❒ New Form ❒ Revised Form (Form # ) (Attach copy of current and revised forms) Forms Committee Office Number:

Contact person for revisions/questions? Title of Form: Brief description of purpose of form: Department that will use the form: Estimated duration of use: ❒ Less than 1 year ❒ 1-5 years ❒ Indefinite

Number of NCR (no carbon required) copies to be attached to the form: List of departments to which NCR copies will be distributed: Storage location for form: Is form designed for multidisciplinary use? ❒ Yes Explain: What other forms currently in use document the same content?
Reserved for Forms Committee Use:

❒ No

Forms Subcommittee Action:

❒ Form approved

❒ Form denied

❒ Deferred:

(date)

Figure 5-34 Sample Application for a New or Revised Patient Record Form

• Administrative data includes demographic, socioeconomic, and financial information, which is gathered upon admission of the patient to the facility and documented on the inpatient face sheet (or admission/discharge record). • The face sheet is usually filed as the first page of the patient record because it is frequently referenced. Upon admission to the facility, the attending physician establishes an admitting diagnosis that is

entered on the face sheet by the admitting department staff. • The Uniform Hospital Discharge Data Set (UHDDS) is the minimum core data set collected on individual hospital discharges for the Medicare and Medicaid programs, and much of this information is located on the face sheet. • The identification and financial sections of the face sheet are completed by the admitting (or patient

188 • Chapter 5

•

•

•

•

•

•

•

• •

registration) clerk upon patient admission to the facility (or prior to admission as part of the preadmission registration process). Third-party payer information is classified as financial data and is obtained from the patient at the time of admission. If a patient has more than one insurance plan, the admitting clerk will determine which insurance plan is primary, secondary, and/or supplemental. The attending physician documents the following on the face sheet: principal diagnosis, secondary diagnoses (comorbidities and complications), principal procedure, and secondary procedures. (Some facilities allow this information to be documented in the discharge summary instead of on the face sheet.) Health information “coders” assign numerical and alphanumerical codes (ICD-9-CM and/or CPT/HCPCS codes) to all diagnoses and procedures, which are recorded on the face sheet and in the facility’s abstracting system. The Patient Self Determination Act (PSDA) of 1990 requires all health care facilities to notify patients age 18 and over that they have the right to have an advance directive (e.g., health care proxy, living will, medical power of attorney) placed in their record. Informed consent is the process of advising a patient about treatment options and, depending on state laws, the provider may be obligated to disclose a patient’s diagnosis, proposed treatment/surgery, reason for the treatment/surgery, possible complications, likelihood of success, alternative treatment options, and risks if the patient does not undergo treatment/surgery. Informed consent should be carefully documented whenever applicable. Upon admission the patient may be asked to sign the following: consent to admission (or conditions of admission) and consent to release information. (HIPAA states that facilities are no longer required to obtain such consents; however, most facilities continue to obtain them.) Health care facilities require separate consents, such as a consent to surgery, and consents for diagnostic, therapeutic, and surgical procedures. The patient property form records items patients bring with them to the hospital. The certificate of birth (or birth certificate) is a record of birth information about the newborn patient and the parents, and identifies medical

•

•

•

•

•

•

•

•

•

information regarding the pregnancy and the birth of the newborn. The certificate of death (or death certificate) contains a record of information regarding the decedent, his or her family, cause of death, and the disposition of the body. Clinical data includes all health care information obtained about a patient’s care and treatment, which is documented on numerous forms in the patient record. For inpatients, the first clinical data item is the admitting diagnosis that is entered on the face sheet. The emergency record documents the evaluation and treatment of patients seen in the facility’s emergency department (ED) for immediate attention of urgent medical conditions or traumatic injuries. Some patients are transported to the ED via ambulance, and an ambulance report is generated by emergency medical technicians (EMTs) to document clinical information such as vital signs, level of consciousness, appearance of the patient, and so on. Anti-dumping legislation (Consolidated Omnibus Budget Reconciliation Act of 1986) prevents facilities from unloading indigent patients onto other institutions and requires that a patient’s condition must be stable prior to transfer to another facility (unless the patient requests transfer). The discharge summary (or clinical résumé) documents the patient’s hospitalization, including reason(s) for hospitalization, course of treatment, and condition at discharge. The history documents the patient’s chief complaint, history of present illness (HPI), past/ family/social history (PFSH), and review of systems (ROS). An interval history documents a patient’s history of present illness and any pertinent changes and physical findings that occurred since a previous inpatient admission if the patient is readmitted within 30 days after discharge for the same condition. The original history and physical examination must also be made available to the attending physician (e.g., a copy filed on the current inpatient chart or the previous discharged patient record available on the unit). A physical examination of the patient’s body systems is necessary to assist in determining a diagnosis, documenting a provisional diagnosis, which may include differential diagnoses.

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 189

• A consultation is the provision of health care services by a consulting physician whose opinion or advice is requested by another physician. A consultation report is documented by the consultant and includes the consultant’s opinion and findings based on a physical examination and review of patient records. • Physician orders (or doctors orders) direct the diagnostic and therapeutic patient care activities (e.g., medications and dosages, frequency of dressing changes, and so on). • Progress notes contain statements related to the course of the patient’s illness, response to treatment, and status at discharge. They also facilitate health care team members’ communication because progress notes provide a chronological picture and analysis of the patient’s clinical course—they document continuity of care, which is crucial to quality care. • The anesthesia record, pre- and postanesthesia progress notes, and recovery room record provide complete documentation of the administration of preoperative medications, anesthetic agents administered during operative procedures, evaluation of the patient pre- and postoperatively, and recovery of the patient from anesthesia during the immediate postoperative period. • The operative report (or operative record) describes gross findings, organs examined (visually or palpated), and techniques associated with the performance of surgery. It is to be dictated immediately following the operation and authenticated by the responsible surgeon. • The pathology report (or tissue report) assists in the diagnosis and treatment of patients by documenting the analysis of tissue removed surgically or diagnostically (e.g., biopsy), or that is expelled by the patient (e.g., products of conception). • A recovery room record delineates care administered to the patient from the time of arrival until the patient is moved to a nursing unit. • Ancillary reports are documented by such departments as laboratory, radiology (or X-ray), nuclear medicine, and so on—they assist physicians in diagnosis and treatment of patients. • Nursing documentation includes nursing care plans, nurses notes, graphic sheets, and medical administration records (MAR). Some facilities also use bedside terminal systems for nursing documentation.

• Obstetrical records include the antepartum (or prenatal) record, labor and delivery record, and postpartum record. The neonatal record includes the birth history, newborn identification, physical examination, and progress notes. • The provisional autopsy report, which contains a cause of death, is to be documented within 3 days, while the autopsy report (necropsy report or postmortem report) may take up to 60 days. • Hospital outpatient records (or ambulatory records) include a patient registration form (similar to the inpatient face sheet) and, depending on the complexity of outpatient services provided, additional reports can include ancillary reports, progress notes, physician orders, operative reports, pathology reports, nursing documentation, and so on. Some hospital outpatient departments use a short stay record, which allows providers to record the history, physical examination, progress notes, physician orders, and nursing documentation on one double-sided form. • A physician office record should contain patient registration information, a problem list, a medication record, progress notes (including patient’s history and physical examination), and results of ancillary reports. • An encounter form (superbill or fee slip) is commonly used in physician offices to capture charges generated during an office visit and consists of a single page that contains a list of common services provided in the office. • In a paper-based record system, it is imperative that each facility designate a person who is responsible for the control and design of all forms adopted for use in the patient record. This is usually the responsibility of the health information department, and in some facilities a forms committee (or patient record committee) is established to oversee this process and to approve forms used in the record.

STUDY CHECKLIST
• Read the textbook chapter, and highlight key concepts. (Use colored highlighter sparingly throughout the chapter.) • Create an index card for each key term. (Write the key term on one side of the index card and the concept on the other. Learn the definition of each key term, and match the term to the concept.)

190 • Chapter 5

• Access chapter Internet links to learn more about concepts. • Answer the chapter Exercises and Review questions, verifying answers with your instructor. • Complete the chapter CD-ROM activities. • Complete Web Tutor assignments and take online quizzes. • Complete the lab manual assignment, verifying answers with your instructor. • Form a study group with classmates to discuss chapter concepts in preparation for an exam.

8. A document that provides a summary of a patient’s hospitalization is a(n) a. clinical résumé. b. history. c. operative report. d. physical examination report. 9. A chronological description of the patient’s present condition from the time of onset to the present is a a. history of the present illness. b. medical history. c. review of systems. d. social history. 10. Preprinted orders that are placed on a patient’s record (e.g., upon admission) are called a. discharge orders. b. phone orders. c. routine orders. d. stop orders. 11. The completion of a history and physical examination is the responsibility of the a. attending physician. b. nurse. c. surgeon. d. therapist. 12. A tissue report is also known as a a. pathology report. b. postanesthesia report. c. postoperative report. d. specimen report. 13. A report documenting blood chemistry, blood gases, and blood type is a a. blood report. b. drug record. c. laboratory report. d. pathology report. 14. All patient information obtained through treatment and care of the patient is called a. administrative data. b. clinical data. c. demographic data. d. financial data. 15. A review of the medical events in the patient’s family, including disease which may be hereditary or present a risk to the patient, is part of the

CHAPTER REVIEW
Fill-In-The-Blank: Enter the appropriate term(s) to complete each statement below. 1. A graph used to record the patient’s vital signs is called a ________. 2. The ________ record contains an antepartum record, labor and delivery record, and postpartum record. 3. The anesthesia record documents the monitoring of the patient during the administration of the ________. 4. The operative report contains both the ________ and ________ diagnoses. 5. The ________ aids in the diagnosis and treatment of the patient by documenting the pathologist’s analysis of tissue. Multiple Choice: Select the most appropriate response. 6. The primary diagnosis and procedure is ________ data. a. administrative b. clinical c. financial d. identification 7. Written instruction given by a patient to a health care provider outlining the patient’s preference for care before the need for treatment is known as a(n) a. advance directive. b. consent to admission. c. consent for surgery. d. health care proxy.

Content of the Patient Record: Inpatient, Outpatient, and Physician Office • 191

a. b. c. d.

admission information. family history. medical information. social history.

18. The admitting diagnosis is also called a principal diagnosis. 19. The Patient Self Determination Act required that all patients, age 21 and over, have the right to have an advance directive placed in their record. 20. The final order that is written to release a patient from a hospital is known as a discharge order.

True or False: Indicate whether each statement is True (T) or False (F). 16. A review of systems is a chronological description of the patient’s present condition. 17. JCAHO requires that a discharge summary be completed by the attending physician within 30 days of discharge.

192 • Chapter 5

Page Left Blank Intentionally