Medical documentation presentation

This presentation is about different ways of medical documentation and medical records.

1. WELCOME

2. Presented By Dr. Shah Poran Khan Honorary Medical Officer, SU-1 Department of Surgery, ShSMCH Edited by- Dr. Mansurul Islam Asst. Reg. SU-1, ShSMCH Weekly Presentation Department of Surgery

3. What is Medical Documentation? Medical documentation refers to any written or electronically generated information about a patient regarding history including past and present illnesses examinations tests treatments and outcomes .

4. Purpose Of Medical Documentation To evaluate and plan immediate treatment To monitor healthcare over the time Communication and continuity of care among physicians Proper follow up Collection of data for research and education For audit Legal safeguard

5. Quality of Medical Documentation F ive factors that improve the quality - 1.Accuracy- no mistake is acceptable. 2.Relevance-inappropriate information could result in legal action. 3. Completeness-all records must be documented, there should not be any gap.

6. Quality of Medical Documentation(Cont.) 4.Timeliness History and Physical – completed and signed within 24 hours of admission Post-Operative Note – written immediately following surgery 5. Confidentiality Don’t leave patient-identifiable information on your computer screen Don’t talk about patients or families in hallways, elevators, or in other public places. Don’t release medical record information without the patient’s consent.

7. Types Of Medical Documentation Problem Oriented Medical Record ( POMR ) SOAP SOAPIER  ( Subjective, Objective, Assessment, Plan,Implementation   ,  Evaluation  ,  and  Revision) Narrative Format DAP ( Data,Assessment,Plan ) ADIME ( Assessment,Diagnosis,Intervention , Monitoring,Evaluation )

8. POMR I ntroduced in 1968 by Dr. Lawrence Weed to standardize the way physicians record and organize patient information. 5 components: 1.Database C ontains the patient’s medical history, including their lab results, x-rays, physical exam results, etc. 2.Problem List This is a complete problem list outlining the patient’s medical issues after the hospital admission. It will also include information from the database .

9. POMR(Cont.) 3.Initial Plans Based on the problem list, the physician will then write out a complete plan of action for the patient’s care. 4.Daily Progress Notes The clinic will then update the POMR with the patient’s progress as well as their medical problems 5.Discharge Summary Finally, the discharge summaries will outline the patient’s care over the time.

10. SOAP A SOAP is used for admission notes, medical histories and other documents in a patient’s chart . SOAP comprises of 4 parts: 1.Subjective This refers to subjective observations that are verbally expressed by the patient, such as information about symptoms . 2. Objective I nclude vital signs , information from a physical exam, r esults of diagnostic tests .

11. SOAP(Cont.) 3.Assessment   An assessment is the diagnosis of condition the patient .There may be times where a definitive diagnosis is not yet made, and more than one possible diagnosis is included in the assessment . In a hospital environment with an admitted patient, the doctor will take note of how the patient is progressing following treatment . 4. Plan This step may include assigning treatments, requesting additional tests, or referrals to specialists.

12. Medical Records Admission Form Progress Notes Nursing Notes Operative Notes Medication record Discharge Summary Lab & Radiology Reports Order Sheet

13. Consent Form Informed Written Consent Patient must be informed about- Diagnosis Available options of treatment (Advantage & Disadvantage) Operation procedure and prognosis Risk of compilation of operation and anaesthesia Outcome of not doing the treatment

14. Consent Form(Cont.) Then all above mentioned information with time and date should put into the consent form Adult person over 16 years must sign the consent paper himself Consent form should be filled not matter how minor the procedure

15. WHO Surgical Safety Checklist There are three phases to the checklist: Sign in – before induction of anaesthesia, ideally with surgeon present, but not essential’ Time out – after induction and before surgical incision, entire team. Sign out – during or immediately after wound closure, before moving the patient out of the operating room, whilst surgeon still present.

16. Operation Note This includes Date and Time Name of Indication Name of surgery Anaesthesia Name of Surgeon and Assistant Name of Anaesthetist Operation finding Operatation Procedure Post operative diagnosis

17. Operation Note (Cont.) Operative note must be written in detail regarding- Incision Findings, eg . ascites, site of pathology. Procedure, eg anastomosis site, sutures used. Specimen removed Blood loss Drain

18. Histopathology Requisition Form Always tissue has to be sent with a proper requisition form, given an identification number. All relevant details like site, size, shape, dimensions etc. of specimen must be mentioned. Dimensions as seen clinically and after tissue has been excised has to be mentioned clearly as tissue may swell up or shrink in fixative.

19. Histopathology Requisition Form (Cont.) Some specimen needs proper marking with sutures. A brief history with suspected diagnosis must be added. With historical background, physical findings and precise orientation of anatomic relations, the pathologist can block the tissue in the plane that will give meaningful sections.

20. Resected Specimen of Brest

21. Histopathology Requisition Form (Cont.) The urgency of the report should be mentioned. Contact details of the surgeon must be mentioned so that pathologist can consult regarding any query. In case of review of any report the cause of review and previous report must be delivered. The surgeon may already know the microscopic diagnosis and is now interested in information such as extent of lesion, invasion of neighboring structures, presence of tumour at surgical margins, vascular invasion and lymph node metastasis, these things must be mentioned.

22. Discharge Paper Discharge Paper must include- Patient Details- Name, Age , Reg.no., Serial no. etc. Diagnosis on admission Brief History Investigations with findings Preoperative Diagnosis

23. Discharge Note (Cont.) Operative Note Postoperative Diagnosis Histopathology Report Referral Notes from other departments Medication Advice Follow up