RET 1024 Introduction to Respiratory Therapy Module 5.0 The Patient’s Medical Record

The Patient’s Medical Record Medical Record – “Chart” A documented account of the occurrences pertaining to the patient throughout his or her stay in a healthcare institution

The Patient’s Medical Record Medical Record – “Chart” It is the property of the institution and its contents are confidential and may not be read or discussed by anyone except those directly caring for the patient in a hospital or medical care facility.

The Patient’s Medical Record Medical Record – “Chart” It is a legal document and must be maintained by the healthcare institution for days, months, or years, in case it is needed in a court of law

The Patient’s Medical Record Components of the Medical Record Admission Sheet Records pertinent patient information (e.g., name, address, religion, nearest of kin), admitting physician, and admission diagnosis History and Physical Records the patient’s admitting history and physical examination as performed by the attending physician or resident

The Patient’s Medical Record Components of the Medical Record Physician’s Orders Records the physician’s orders and prescriptions Progress Sheet Commonly referred to as “progress notes” Keep a continuing account of the patient’s progress for the physician

The Patient’s Medical Record Components of the Medical Record Nurses’ Notes Describes the nursing care given to the patient, including the patient’s complaints (subjective symptoms), the nurses’ observations (objective signs), and the patient’s response to therapy Medication Admission Record “MAR” Notes drugs and IV fluids that are given to the patient

The Patient’s Medical Record Components of the Medical Record Vital Signs Graphic Sheet Records the patient’s temperature, pulse, respiration, and blood pressure over time I/O Sheet Records the patient’s fluid intake (I) and output (O) over time

The Patient’s Medical Record Components of the Medical Record Laboratory Sheet Summarizes the results of laboratory tests Consultation Sheet Records notes by specialty physicians who are called in to examine a patient to make a diagnosis

The Patient’s Medical Record Components of the Medical Record Surgical or Treatment Consent Records the patient’s authorization for surgery or treatment Anesthesia and Surgical Record Notes key events before, during, and immediately after surgery

The Patient’s Medical Record Components of the Medical Record Specialized Therapy Records Records specialized treatments or treatment plans and patient progress for various specialized therapeutic services (e.g., respiratory care, physical therapy) Specialized Flow Sheets Records measurements made over time during specialized procedures (e.g., mechanical ventilation, kidney dialysis)

Flow Sheets

The Patient’s Medical Record Legal Aspects of Recordkeeping Legally, documentation of care given to a patient means that care was given Legally, no documentation means that care was not given Lack of documentation can be interpreted as patient neglect

The Patient’s Medical Record General Rules for Medical Recordkeeping Entries should be printed or handwritten. After completing the account, sign the chart with the initial of first name, complete last name, and your title (CRT, RRT, Resp Care Student, etc.) Example: B. Kind, RRT Do Not Use ditto marks – “ “

The Patient’s Medical Record General Rules for Medical Recordkeeping Do not erase! Erasures provide reason for questions if the chart is used in a court of law. If a mistake is made, a single line should be drawn through the mistake and the word “error” printed above it; the correction should be initialed Example: Respiratory Tx given at 10:00 10:30 error

The Patient’s Medical Record General Rules for Medical Recordkeeping Record after completing each task for the patient (never beforehand) and sign your name correctly after each entry Be exact in noting the time, effect, and results of all treatments and procedures Describe clearly and concisely observations and assessments, e.g., the character of breath sounds, percussion notes, secretions, etc.

The Patient’s Medical Record General Rules for Medical Recordkeeping Leave no blank lines in the charting Draw a line through the center of an empty line or part of a line. This prevents charting by someone else in an area signed by you Use the present tense. Never use the future tense, as in “Patient to receive treatment after lunch.”

The Patient’s Medical Record General Rules for Medical Recordkeeping Spell correctly If you are not sure about the spelling of a word, use a dictionary and look it up Use standard, hospital-approved abbreviations Do not make up your own

The Patient’s Medical Record The Problem-Oriented Medical Record A documentation format used by some healthcare institutions POMR contains the following: The Database The Problem List The Plan The Progress Note

The Patient’s Medical Record The Problem-Oriented Medical Record The Database Routine information about the patient General health history Physical examination results Results of diagnostic tests

The Patient’s Medical Record The Problem-Oriented Medical Record The Problem List A problem is something that interferes with a patient’s physical or psychological health or ability to function Problems are identified and listed, based on the information provided by the database The problem list is dynamic; new problems are added as they develop and others problems are removed as they are resolved

The Patient’s Medical Record The Problem-Oriented Medical Record The Progress Note Contain the findings (subjective and objective), assessment, plans, and orders of the doctors, nurses, and other practitioners involved in the care of the patient The format used in often referred to as SOAP S – subjective O – objective A – assessment P - plan

The Patient’s Medical Record Charting Using the SOAP Format Subjective Information obtained from the patient, his or her relatives, or a similar source Objective Information based on caregivers’ observations of the patient, the physical examination, or diagnostic or laboratory tests such as ABG or PFT Assessment The analysis of the patient’s problem Plan Action to be taken to resolve the problem

The Patient’s Medical Record Example of SOAP Entry Problem 1 Pneumonia Subjective “My chest hurts when I take a deep breath” Objective Awake; alert; oriented to time, place, and person; sitting upright in bed with arms leaning over bedside stand; pale, dry skin; respiration 22/min and shallow; pulse 110 beats/min, regular but thready; blood pressure 130/89 (sitting); temperature 101 F; bronchial breath sounds in left bases - posteriorly, occasionally expectorating small amounts of purulent sputum

The Patient’s Medical Record Example of SOAP Entry Assessment Pneumonia continues Plan Therapeutic: Assist with coughing and deep breathing at least every 2 hours; postural drainage and percussion every 4 hours; assist with ambulation as per physician orders and patient tolerance. Diagnostic: Continue to monitor lung sounds before and after each treatment. Education: Teach to cough and deep breathe and evaluate return demonstration

SOAP Form