Good Clinical Documentation Practices.pptx

Good clinical documentation

1. Clinical Documentation & Good Documentation Practices. SAROJ GUPTA CANCER CENTRE & RESEARCH INSTITUTE 1

2. What is Documentation ? Anything written , printed or electronically transmitted Relied on as a record of proof for authorized persons . Vital part of p r o f e ss i o n a l practice . Initial assessment form SGCCRI 2

3. Emergency Initial assessment Form 3

4. Purposes of Documentation Quality of care provides evidence that care was necessary . describes responses to care . describes any changes made in plan of care . Coordination of care plan interventions . decision making about ongoing interventions . evaluation of patient's progress . used by all team members . Medicolegal aspects of care provides proof that care was actually provided Clinical records are reviewed to ensure the facility meets the required standards assessed for ongoing compliance . 4

5. Who Writes Clinical Documents ? Clinical documentation or documentation of a medical condition means a statement from a licensed physician , nurse or other clinical person providing information the HCO considers necessary . 5

6. Function of Medical Documentation is Important When Referring Patients . Why is important medical documentation vital? Without it, your health care would be compromised . > One doctor wouldn't know what another doctor was doing. > Without adequate documentation of visits, lab tests, treatments or surgeries, quality of care would certainly be erratic and potentially deadly. Medical documentation generally provides all the information about a specific patient that any clinician looking at a medical record would need to know to treat that patient 6

7. Documentation increases Patient Care . R ecord pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. 7

8. Ethics and Documentation Adequate medical documentation assures patient confidentiality and ensures that standards of care are being met. Doctors and other medical personnel have an obligation to treat illnesses to the best of their ability in regard to information documented in a patient's medical record. 8

9. Patient Records Helps in Planning Your Future Actions Communication . Care Planning . Quality Review . Research . Decision Analysis . Education . Legal D o c u m e n t a t i o n Reimbursemen t . 9

10. Good Documentation Increases Legal Protection Peer review . Requirements for reimbursement . Legal protection . Research & continuing education . 10

11. General Principles A . The medical record should be complete and legible . SNDT- Signature with Stamp, Name, Date, Time B. The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results; assessment, clinical impression or diagnosis; plan for care 11

12. Common standards for documentation A ssessment . P lan of care medical orders . P r o g r e s s notes . Medication Chart D i s c h a r g e summary . BHT Progress note at SGCCRI 12

13. Plan of treatment/Plan of care 13

14. Document Standardization . Legible . Follow policies and procedures to ensure confidentiality . 14

15. Documentation for Surgical Procedure 15

16. Documentation for BT & Critical care Unit 16

17. Must contain Subjective/History Past Medical History (PMH) Events leading to illness or injury Medications Allergies Illnesses Doctor Surgery Family history Substance abuse 17

18. Fill all Laboratory Requests with Sense of Responsibility . Sex D a t e N a m e xxx x A g e IP/ OP No xyz Time Ward xx123 Urgent / Routine Nature of specimen . Investigation needed . Doctor/Staff Contact No 1234567 18

19. Correct your Mistakes with Sense and Legality . Never use whitener . Never scratch out . Draw a line through the mistake . Initial above the mistake . 20

20. Patients Records are confidential do not discus s without purpose . 21 Personal biographical data include the address, employer, home and work telephone numbers and marital status. All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials. All entries are dated. The record is legible to someone other than the writer. *Significant illnesses and medical conditions are indicated on the problem list. *Medication allergies and adverse reactions are prominently noted record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record

21. Skills Used in Documentation Cognitive . Technical . Interpersonal Ethical/Legal . 22

22. Document the Patient Record with Institutional Protocols . Initial evaluation . Age and gender (Pt. is 20 y.o. white male) . Prior level of function (including occupation/ functional status . Social history (Lifestyle, home situation, home accessibility) Emotions/attitudes . Direct quotes (to illustrate confusion, denial, attitudes, etc.) . Chief complaints or complains of MOI . Onset (insidious or traumatic) DOI . 22

23. Documentation Standards Vary from Situation and Specialties . Pain scale (1-10) . Location and type of pain (burning, stinging, sharp, dull, radiating, etc.) Aggravates and alleviates pain Details since onset (history of injury) . PMHx . PRx (Past treatment) . Date of surgery (DOS) . Special tests (x-rays, MRI, CT scan) Rule out . Meds and allergies . Patient and/or family goals . 23

24. 24 Every Case sheet should contain a Minimal Data Personal info : age, sex, occupation, training, family... Risk factors : tobacco, alcohol, life styles... Allergies and drug reactions . Problem list . Disease history : diseases, operations. . . The disease process : main problem, history, exam, lab. Management plan : advice, education, medication. . . Progress notes : in the S O A P forma t. 24

25. Record all the Progress of the Patient – As Things can go Wrong Future notes Response to treatment and rehab. Reassessing subjective information from previous notes . Change in function . Change in pain (location, type) . Patient compliance issues . 2 5

26. Legal Aspects of Charting Do not erase, use white-out, or scribble out errors . Do not write retaliatory or critical comments; do not place blame on your colleagues . Correct all errors promptly . Spell correctly . Record all facts in objective terms . Be accurate about time & chart as soon as possible after an event. Document omissions (med not given or treatment not completed) & reason & actions taken. Do not leave blank spaces. Record legibly & in black ballpoint pen. 2 6

27. Court Believes your Documents only Document completely [in court - if it's not documented, it wasn't done . 27

28. 31 Record everything you do (including phone consultations) . Apply guidelines LEARN FROM YOUR SENIORS OR CONSULTANTS . Don't use erasable pencils . Don’t use humiliating expressions . In order to prevent L egal P roblems : 28

29. 32 Why to keep records? Helps in medical decisions (is the size of a lymph node or nodule increasing with time?) Helps to share responsibility with the patient Legal obligation. Protects the patient as well as doctor in front of the court . 29

30. Still you want to Correct the Errors . When a correction becomes necessary, merely draw a single line through the entry so that the original entry is still readable. Make a notation explaining the correction, or directing the reader to the appropriate addendum. Date and sign the correction. If using an addendum, place it in sequence or chronological order . 31

31. When documenting , Spell the Words Correctly . medication names 32

32. Last But Not the Least Don’t not miss spe l the words It ‘s about Your professional Accountability . clavicle c l a v i c a l X 33

33. Hand over the Matters when changing the Shifts . Change-of-shift report Accurate information Factual information Organized . What & how you say it can make a big difference in quality of care . Avoid negativism & subjectivity . Use written or printed guide to prompt thoroughness & organization . 34

34. SAROJ GUPTA CANCER CENTER & RESEARCH INSTITUTE Ward: Date: DOCTORS HANDOVER COMMUNICATION Bed No UHID NO PATIENT NAME CONSULTANT SITUATION (SYMPTOM/CONCERN BACKGROUND (EVALUATION/IMPRESSION) RECOMMENDATION (PLAN OF CARE/TO DO REQUEST) Handover Given By Handover Taken By                                                                         Hand over document SGCCRI 34

35. Medical Billing and Coding Needs Documentation . Without adequate medical documentation, your health care providers might not be reimbursed for providing you with care, leaving you stuck with the bill. There's an old saying in the health care industry: " If it's not documented, it didn't 36 happen.

36. Excellence in Medical Documentation Reduces Malpractice Allegations Excellence in medical documentation reflects and creates excellence in medical care. At its best, the medical record forms a clear and complete plan that legibly communicates pertinent information, credits competent care and forms a tight defense against allegations of malpractice by aligning patient and provider expectations. 37

37. Be Familiar with Computer Documentation as Technology is taking over every Profession even our’s . 38

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