/ 291 Medical Records Turan SET, Assist. Prof. Atatürk University Medical Faculty, Erzurum

/ 292 Objectives At the end of this presentation, the participants should be able to; –Define source oriented medical record –Define problem oriented medical record –List items to be included in the medical record –Discuss reasons for keeping medical records –Explain the PSOAP acronym for keeping records

/ 293 It is always easier to find your way if you have a road map!

/ 294 Which data are we recording in practice?

/ 295 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

/ 296 Has economic benefits Useful to produce health statistics Provides epidemiological data Assists practice management Useful in QI activities Is a communication tool

/ 297 Types According to the method; –Source oriented –Problem oriented

/ 298  Source oriented medical record Data taken from the source are recorded as they are (Source: patient, relative, laboratory etc.) Easy and fast to record Flexible Omitting information is highly possible Difficult to access the information

/ 299  Problem oriented medical record Structure is defined in advance. The patient with problem is in the focus It is systematic Data is easily accessible Not flexible. Recording information is difficult and time consuming

/ 2910 Which data to record? 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

/ 2911 PSOAP Problem –Everything the patient reports and doctor’s findings which are regarded as problems Subjective –History of the problem; what the patient feels or thinks about the problem Objective –Doctors findings related with the problem Assessment –Evaluation of the problem; the diff. diagnosis Plan –Prescription, consultation, advice, control visit...

/ 2912 Visits 21 February 1996: dyspnea, coughing and fever. Dark defecation. PE: BP 150/90, pulse 95/min, Fever: 39.3 o C. Ronchi +, no abdominal tenderness. Medications: 64 mg Aspirin/day. Possible acute bronchitis and cardiac decompensation. Possible bleeding due to Aspirin. Rx: Amoxicilline 500 mg 2x1, Aspirin 32 mg/day. 4 March 1996: no cough, slight dyspnea, defecation normal. PE: light rhonchi, BP 160/95, pulse 82/min. Rx: Aspirin 32 mg/day. Lab 21 February 1996: ESR 25 mm, Hb 7.8, Fecal occult blood +. 4 March 1996: Hb 8.2, Fecal occult blood :-. X-ray 21 February 1996: Chest x-ray: no atelectasis, light cardiac decompensation findings Patient -Source-Oriented Medical Record Source Oriented Medical Record

/ 2913 Problem 1: Coughing 21 February 1996 S: dyspnea, coughing, fever. O: pulse 95/min, Fever: 39.3 o C. Rhonchi+. ESR 25 mm. Chest x-ray: no atelectasis, light cardiac decompensation findings. A: Acute bronchitis. P: Amoxicilline 500 mg 2x1. 4 March 1996 S: no coughing, slight dyspnea. O: pulse 82/min. Slight rhonchi. A: minimal bronchitis findings. Problem Oriented Medical Record Problem 2: Dyspnea 21 February 1996 S: Dyspnea. O: Rhonchi+, BP 150/90 mmHg. Chest x-ray: no atelectasis, slight cardiac decompensation findings. A: Slight decompensation findings. 4 March 1996 S: slight dyspnea. O: BP: 160/95, pulse 82/min. A: No decompensation.

/ 2914 Problem 3: Dark colored defecation 21 February 1996 S: Dark feces. Using Aspirin 64 mg/day. O: No abdominal tenderness, rectal exam revealed no blood, Hb 7.8 mg/dl. Fecal occult blood + A: Possible intestinal bleeding due to Aspirin. P: Decrease Aspirin dose to 32 mg/day. 4 March 1996 S: Defecation normal. O: Fecal occult blood - A: No intestinal bleeding symptoms. P: Continue Aspirin dosage 32 mg/day

/ 2915 Rules in keeping medical records (NCQA) 1.Each page in the record contains the patient’s name or ID number. 2.Personal biographical data include the address, employer, home and work telephone numbers and marital status. 3.All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials. 4.All entries are dated. 5.The record is legible to someone other than the writer. 6.*Significant illnesses and medical conditions are indicated on the problem list. 7.*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.

/ 2916 National Committee for Quality Assurance (NCQA) 8.* Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses. 9.For patients 12 years and older, there is appropriate notation concerning the use of cigarettes, alcohol and substances (for patients seen three or more times, query substance abuse history). 10.The history and physical examination identifies appropriate subjective and objective information pertinent to the patient’s presenting complaints. 11.Laboratory and other studies are ordered, as appropriate. 12.* Working diagnoses are consistent with findings. 13.* Treatment plans are consistent with diagnoses. 14.Encounter forms or notes have a notation, regarding follow-up care, calls or visits, when indicated. The specific time of return is noted in weeks, months or as needed.

/ 2917 NCQA 15.Unresolved problems from previous office visits are addressed in subsequent visits. 16.There is review for under - or over utilization of consultants. 17.If a consultation is requested, there a note from the consultant in the record. 18.Consultation, laboratory and imaging reports filed in the chart are initialed by the practitioner who ordered them, to signify review. (Review and signature by professionals other than the ordering practitioner do not meet this requirement.) If the reports are presented electronically or by some other method, there is also representation of review by the ordering practitioner. Consultation and abnormal laboratory and imaging study results have an explicit notation in the record of follow-up plans. 19.* There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure. 20.An immunization record (for children) is up to date or an appropriate history has been made in the medical record (for adults). 21.There is evidence that preventive screening and services are offered in accordance with the organization’s practice guidelines.

/ 2918 Legal Problems Not recorded = Not done !

/ 2919 Record everything you do (including phone consultations) Apply guidelines (e.g.: NCQA) Don't use erasable pencils Don’t use humiliating expressions In order to prevent legal problems:

/ 2920 Do not use vague expressions such as “the patient feels well” If you need to make changes just strike through and record also the date of change If you stated that the patient is not cooperative give the reason If patient rejects a procedure or test, mention it and give the reason why you requested it

/ 2921 Follow-up Charts It is practical to use follow-up charts for chronic diseases –DM, –Hypertension –Obesity –…

/ 2922 Charts - Obesity

/ 2923 Medical Records are Our Road Maps

/ 2924 Summary What are the benefits of keeping records?

/ 2925 Source oriented medical record is easy. Data entry is flexible. A.Correct B.Wrong

/ 2926 Problem oriented medical record is systematic. Access to information is easy. A.Correct B.Wrong

/ 2927 Source oriented medical record contains a personal problem list. A.Correct B.Wrong

/ 2928 Can you explain the meanings of PSOAP in the medical record?

/ 2929 What are the core elements requested by NCQA in the medical record?