REPORTS WRITING SEQUENCES

SEQUENCES 2

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 Sequence 02 : Writing Patient History and Reports

Lecture 01 : Patient’s Medical History

1- Introduction to Patient History and Reports

In this section, we delve into the critical role of accurate documentation in

healthcare. Proper documentation ensures continuity of care, facilitates
communication among healthcare providers, and serves as a legal record of
patient interactions. Various types of patient reports will be discussed, including
initial history and physical exams (H&P), progress notes, discharge summaries,
and consultation or referral letters. This part will also cover legal and ethical
considerations, such as patient confidentiality, privacy laws like HIPAA and
GDPR, and the potential legal implications of documentation errors.

• Importance of Accurate Documentation in Healthcare

Without proper documentation, virtually every component of our healthcare

infrastructure would suffer. From more medical errors and negative patient health
outcomes to more frequent claims denials and lawsuits, the medical industry
would only be bogged down further by poor documentation. The areas where
documentation has the greatest impact are:

• Patient care. A patient’s quality of care can suffer in many ways when
accurate documentation is lacking. Clinicians are more likely to make
medical errors if they have an incomplete picture of the patient’s health
status, and the result can range from a poorly conceived plan of care or
incorrect treatment — or even a patient’s death.
• Communication. A patient’s care is especially hindered when the different
members of their healthcare team are unable to communicate smoothly.
Patients often have multiple clinicians, and failure to implement proper

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 documentation may cause them to create conflicting treatment plans,
leading to a disruption in continuity of care.
• Profitability. When medical records such as clinical notes, progress notes,
or other medical documentation are incomplete, inaccurate, or improperly
worded, the result may be a claims denial or delay in payment. In this way,
incorrect documentation practices can destabilize your revenue cycle
management (RCM) and make your organization less profitable than it
would be if it abided by the appropriate documentation requirements.
• Liability. Malpractice lawsuits are all too common and can be very costly to
a healthcare organization. When providers exercise sound documentation
practices, they minimize their vulnerability to a lawsuit, saving themselves
all the burdens of a legal battle.

To fully grasp why documentation is important in healthcare, understand that

each factor is tied to the others. For example, breakdowns in communication
between clinicians can result in suboptimal patient health outcomes, which can in
turn lower reimbursement rates if certain quality care metrics aren’t met. Such
inferior care reduces the organization’s profitability and can also increase the risk
of a lawsuit — which further damages the bottom line — and inadequate
documentation is at the root of it all.

2- Types of Patient Reports

Given the need to properly serve patients and meaningfully support staff —
since both objectives must be achieved or neither of them will — here are eight
types of reports that help hospitals get and stay leaner:

a. Discharge Process Reports

Discharge process reports reveal the duration between discharge orders (i.e.
intent to discharge) and when patients actually leave, as well as the turnaround
time of room preparation for the next patient. This data can be used to determine
which nurse stations are meeting or exceeding goals, and which need additional
training or resources. In the bigger picture, this also prevents hospitals from setting
what amount to arbitrary — and not patient-centered — discharge time goals. In

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 an article published by [Link], Dr. Evan Fieldston, MD, MBA,
MSHP commented: “Patients should leave the hospital when they’re ready to
leave. Trying to put an absolute time on that is artificial because we’re not a hotel.”

b. ED Bed Availability Reports

ED bed availability reports highlight the time between when patients request
an impatient ED bed, to when a bed is available. Equipped with this data,
management can monitor the duration to ensure that it stays within acceptable
parameters, or if necessary implement sustainable ways to reduce the gap. As
pointed out by Alex Woodruff, MPH and Austin B. Frakt, PhD in an article
published in the American Medical Association’s open access medical journal
JAMA Network: “Long wait times are not just inconvenient. When emergency care
is delayed, there can be serious health consequences. There are numerous
reports of patients dying while they wait for emergency care because they did not
get treatment in time. Crowded EDs are also connected to increased stress on
staff, poor adherence to protocols, and clinical errors.”

c. ED Fast Track Reports

Many EDs implement a triage area to rapidly treat lower acuity patients.
However, there are times with the triage area identifies patients that need to be
transferred to the ER. ED Fast Track Reports quantify both the wait time and
physician workload that spans these Fast Track/ER areas, in order to reveal the
true costs and durations — which can differ significantly from perceived or
assumed amounts. If they fall within acceptable parameters, then workflows and
staffing configurations can be analyzed for best practices and rolled out across the
hospital/health network. When levels fall outside of acceptable parameters,
managers can take a closer look and make targeted, practical and high-impact
changes.

d. Referral to Other Acute Facilities Reports

Referral to other acute facilities reports reveal why and how often critically ill
patients (e.g. sepsis transfers and GI bleeds) are transferred from the ED. Based

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 on this information, hospitals can analyze the financial viability of expanding their
health network. For example, it may be both patient-centric and cost-effective to
create an eICU arrangement with a tertiary hospital that enables the patient to stay
in the hospital’s ICU (and receive treatment close to family members and
caregivers), while their specialized care is overseen by the tertiary’s hospital via
telehealth.

Furthermore, hospitals can generate reports to compare treatment outcomes in

the eICU vs. treatments on a regular floor (e.g. respiratory failure with BiPAP and
vent trend). This helps identify conditions and complications that should go to the
eICU. Subsequent reports can be created to monitor and ensure that staff is
complying with patient transfer policies and protocols.

e. Overtime Reports

Overtime reports provide managers with insights when employees are clocking in
early and clocking out late. While this extra work may be legitimate and warranted,
and the daily or weekly amount may be relatively small, it is nevertheless a factor
that can significantly inflate and skew budgets — especially if it is something that
multiple employees do on a regular basis.

f. Evaluation of Urgent Care Locations Reports

Evaluation of urgent care locations reports identify which offices are generating
new business and therefore should be analyzed for best practices (and possibly
opening more offices in the area), and which offices are falling below business
development expectations and should be scrutinized for potential changes.

g. Employee Performance Reports

Employee performance reports use scorecards to help teams benchmark

and evaluate their performance — both as a team vs. other teams, and individual
employees vs. the mean performance of similarly-skilled groups (e.g. comparing
a physician with a group of physicians, and a physician assistant to a group of
physician assistants). This insight can be used to identify best practices, reveal
opportunities for education and change, and make sure that chronic “slackers” are

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 identified and as necessary, re-trained, warned or ultimately removed , so that
they cannot continue sinking morale and undermining team performance.

h. Marketing Efficacy Reports

Marketing efficacy reports allow hospitals to evaluate whether they are

getting a sufficient response from their marketing efforts (e.g. using street and zip
code information to identify new patient trends from targeted communities). This
data can be used to adjust and optimize existing campaigns, and justify launching
new ones.

The Bottom Line

The eight reports discussed above give managers and other decision-makers
the actionable intelligence they need to better serve their communities and
empower their staff. Because, after all, getting leaner is not just about cutting costs
and tightening belts. It is about working smarter and maximizing results!

3. Components of a Patient History

This module focuses on the fundamental components that make up a thorough

patient history. We begin with the Chief Complaint (CC), which captures the
primary reason for the patient's visit in their own words. The History of Present
Illness (HPI) provides a detailed chronological account of the patient's current
symptoms, including onset, location, duration, character, and any factors that
alleviate or exacerbate the condition. We will explore the Past Medical History
(PMH), which includes previous illnesses, surgeries, hospitalizations,
medications, and allergies. The module also covers Family History (FH), Social
History (SH), and Review of Systems (ROS), providing a comprehensive picture
of the patient's health background and lifestyle.

• Chief Complaint (CC)

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 o Capturing the primary reason for the patient’s visit
• History of Present Illness (HPI)
o Detailed chronological account of the symptoms
o Onset, location, duration, character, aggravating/relieving factors, associated
symptoms
• Past Medical History (PMH)
o Previous illnesses, surgeries, hospitalizations
o Medications, allergies
• Family History (FH)
o Health status of immediate family members
o Hereditary conditions
• Social History (SH)
o Lifestyle factors: smoking, alcohol use, drug use
o Occupational history, living conditions
• Review of Systems (ROS)
o Systematic inquiry into possible symptoms across various body systems

4. Interviewing Techniques

Effective patient interviewing is crucial for gathering accurate and

comprehensive information. This part teaches effective communication skills,
emphasizing the use of open-ended questions and active listening to elicit detailed
responses from patients. Building rapport is essential, and participants will learn
techniques to establish trust and empathy. Addressing sensitive topics, such as
sexual history, mental health, and substance abuse, will be discussed, along with
strategies to approach these areas with sensitivity and professionalism.

• Effective Communication Skills

o Open-ended vs. closed-ended questions

o Active listening techniques
• Building Rapport with Patients
o Establishing trust and empathy
• Eliciting Comprehensive Information
o Encouraging detailed responses

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 • Addressing Sensitive Topics
o Approaching topics like sexual history, mental health, substance abuse with
sensitivity

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