Dr.T.V.Rao MD

What is Documentation
• Anything written or printed • Relied on as a record of proof for authorized persons
• Vital part of professional practice


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


Purposes of Documentation in Medicine
• Clinical records are reviewed to ensure the facility meets the required standards assessed for ongoing compliance

Importance of Medical Documentation
• Proper and adequate medical documentation is essential for

quality of medical care and health care services throughout the industry, from receiving proper and correct treatment

Who Writes Medical Documents
• Medical documentation or documentation of a medical condition means a statement from a licensed physician or other appropriate practitioner providing information the agency considers necessary

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 doctor looking at a medical record would need to know to treat that patient


Documentation increases Patient Care
• Medical record documentation is required to record 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.


General Principles
• A. The medical record should be complete and legible. • 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; and •

Date and legible identity of the observer.

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.

Patients Health Care Information a Vital Document
• The patient's history is a vital piece of information that enables physicians to determine the best diagnosis and treatment plan for that individual, based on information found in the medical record.

Must contain Subjective/History
• Past Medical History (PMH)
• Medications Allergies • Allergies Medications • Illnesses Pertinent past history • Doctor Last oral intake • Surgery Events leading to illness or injury

Common standards for documentation
• assessment • plan of care medical orders

• progress notes
• discharge summary

Skills Used in Documentation

•Cognitive •Technical


A Documents of all Critically ill patients be given due care in filing
• Clinical findings from the most recent medical evaluation, including any of the following which have been obtained: Findings of physical examination; results of laboratory tests; X-rays; EKG's ECG MRI CT Scans and other special evaluations or diagnostic procedures; and, in the case of psychiatric evaluation of psychological assessment, the findings of a mental status examination and the results of psychological tests, if appropriate must be filed with due care

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

Patient Records Helps in Planning Your Future Actions
• Communication • Care Planning • Quality Review • Research • Decision Analysis • Education • Legal Documentation • Reimbursement


Residents should Document
• Computer-based Records
• Standardization • Legible • Follow policies and procedures to ensure confidentiality

Fill all Laboratory Requests with Sense of Responsibility
Name xxxx Age Sex IP/ OP No xyz Time Date Ward xx123 Urgent / Routine Nature of specimen Investigation needed Doctor/Staff Contact No 1234567

Patients Records are confidential do not discuss without purpose


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

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


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


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 P S O A P format


Rules in keeping medical records as it requires Confidentiality
1. 2. Personal biographical data include the address, employer, home and work telephone numbers and marital status. All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials. All entries are dated. The record is legible to someone other than the writer. *Significant illnesses and medical conditions are indicated on the problem list. *Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.

3. 4. 5. 6.

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

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


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

Legal Aspects of Charting
• 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


Legal Aspects of Charting
• Use only approved abbreviations • Record clarification requests &/or corrections • Chart only for yourself • Avoid vague statement • Begin with time and end with appropriate signature


In order to prevent legal problems:
• 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

Why to keep records?
• Helps in medical decisions • Helps to share responsibility with the patient • Legal obligation. • Protects the patient as well as doctor in front of the court

(is the size of a lymph node or nodule increasing with time?)

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

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 • • • •

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 happen.


Why to keep records?
• Helps in medical decisions Helps to share responsibility with the patient • All reputed Hospitals Keep Your Documents for several decades. • Legal obligation.
• Protects the patient as well as doctor in front of the court


When documenting Spell the Words Correctly
medication names


Last But Not the Least
not miss spell the words It is Your Identity



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.

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


Your Scientific Documentation saves you from Many Litigations


•Created by Dr.T.V.Rao MD for ‘ e ‘ Learning for Medical Professionals in the Developing world •Email •


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