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DOCUMENTATION AND
MEDICAL RECORDS
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Learning Objectives
▪ To discuss the importance of documentation in medical
practice.
▪ To list the main elements of documentation.
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DOCUMENTATION
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Definition of Documentation
▪ Documentation is the recording of the care delivered to a
patient by a health care professional (doctor, nurse,
physiotherapist, clinical dietitian or others) in his/her
professional capacity.
▪ This includes all forms of documentation: paper medical
records, electronic medical records, audiotapes, videotapes,
emails, images, incident reports, etc.
▪ Documentation is an instrumental part of clinical practice.
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Purpose of Documentation
▪ Communication: Documentation is the basis for
communication between different health care professionals.
▪ Accountability: Documentation demonstrates the
accountability of the health care professional and it records
his/her professional practice (clinical judgment, management
plans etc).
▪ Legislative requirements: documented information can be
used in critical incident reviews and legislated inspections.
▪ Quality improvement: Documentation can be used for
performance reviews.
▪ Research: documentation is a valuable source of data for
health care researchers.
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Appropriate Documentation Ensures

▪ A high standard of clinical care
▪ Continuity of care: allows another caregiver to understand the
condition of the patient and the rationale of the current
treatment
▪ Improved communication and dissemination of information
between and across health service providers
▪ An accurate account of treatment, intervention and care
planning
▪ Improved goal setting and evaluation of care outcomes
▪ Improved early detection of problems and changes in health
status
▪ Evidence of patient care.
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Characteristics of Documentation
▪ Documentation should be:
o Clear
o Concise
o Consecutive
o Correct
o Contemporaneous
o Complete
o Comprehensive
o Collaborative
o Patient-centered
o Confidential
o Based on professional observation and assessment with the
absence of personal judgments.
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What to document?
▪ Problem list of significant medical conditions.
▪ Medications
▪ Allergies and any adverse drug reactions
▪ Demographic information
▪ Life style such as smoking status, alcohol, exercise
▪ Immunization record
▪ Pertinent history
▪ Physical exam
▪ Assessment
▪ Management Plan including tests, medications etc
▪ Patient education
▪ Follow Up
How to document?
▪ Patient name, date and time
▪ Relevant history and physical findings
o Positive findings
o Important negative findings
▪ Assessment
o Working, differential, and final diagnosis
▪ Plan of action
o Investigations, consultations/referrals, treatment, follow-up
o Rationale for the plan
▪ Information given to patient
o verbal or written instructions, questions asked and responses given, apparent
understanding, consent
o any disagreement or refusal of care
▪ Signature of writer and position
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From SOAP to SOOOAAP

SOAP SOOOAAP

▪ S - Subjective (patient ▪ Subjective

reasons for the encounter) ▪ Objective
▪ O- Objective findings ▪ Opinion
▪ A - Assessment (problem ▪ Options
label or diagnosis) ▪ Advice
▪ P - Plan (including
▪ Agreed Plan
prescribing, therapies and
other treatments).
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CODING
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Medical Coding
▪ Medical coding is the transformation of healthcare diagnosis,
procedures, medical services, and equipment into universal
medical alphanumeric codes.
▪ Different Coding:
o ICD
o ICPC
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International Classification of Diseases - ICD

▪ Most recognized diagnostic classification; widely used in
tertiary health care facilities .
▪ It puts emphasis on the disease in terms of etiology, pathology
and morphology; hence, the challenge to use it accurately in
primary care where most of the times the problems are still ill-
defined at the end of the consultation.
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International Classification of Primary Care -

ICPC
▪ ICPC developed by a collaboration between WHO and WONCA.
▪ ICPC incorporated codes for patient reasons for encounter,
symptoms and ill-defined conditions, with the addition of the
morbidity codes.
▪ Its structure differs from that of ICD.