Medical Documentation Rules

Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint Chief complaint  Relevant history of present illness(HPI)  Physical examination  Findings  Prior diagnostic test results  Assessment, clinical impression or diagnosis.  Plan for care  Date and legible identity of the observer.

Medical Documentation Rules General principles…  The rationale for ordering diagnostic and other ancillary services should be easily inferred  Past and present diagnoses should be accessible to the treating and/or consulting physician  Appropriate health risk factors should be identified  The patient’s progress,response to and changes in treatment, and revision of diagnosis should be documented.

Medical Documentation Rules general principles…  Codes reported on the health insurance claim form or billing statement should be documented in the medical record.  Patient’s confidentionality  Plan for care should be recorded and include patient teaching and monitoring.  Dosage and treatment schedule

Medical Documentation Rules general principles…  Draw a line on mistakes, never erase the data  Record counsulting:request,render,report.

Medical Documentation Rules documentation of history  The levels of E/M services are based on four types of history:  Problem Focused  Expanded problem focused  Detailed  comprehensive

Medical Documentation Rules documentation of history…  Each types of history includes the following elements:  Chief complaint(CC)  History of present illness(HPI):  Past, family and/or social history(PFSH)  Review of systems(ROS)

Medical Documentation Rules Medical Documentation Rules  Chief complaint

Medical Documentation Rules chief complaint Medical Documentation Rules chief complaint  The CC is a concise statement describing the symptom,problem,condition,diagnosi s,physician recommended return,or other factor that is the reason for the encounter.

Medical Documentation Rules History of present illness(HPI)  HPI is a chronological description of the development of the patient’s present illness from the first and/or symptom or from the previous encounter to the present. It includes the following elements:

Medical Documentation Rules HPI  Location  Quality  Severity  Duration  Timing  context  Modifying factors  Associated signs and symptoms.

Medical Documentation Rules documentation of history  The levels of E/M services are based on four types of history:  Problem Focused  Expanded problem focused  Detailed  comprehensive

Medical Documentation Rules Past, Family and/or Social History(PFSH)  Past: the patients experiences with illnesses,operations,injuries and treatments.  Family: review of medical events in the family,(hereditary or place the patient at risk)  Social; an age appropriate review of the past and current activities

Documentation of Examination  Inspection  Palpation  Percussion  Auscultation

Documentation of Examination

Documentation of examination  The levels of E/M services  Problem Focused  Expanded Problem Focused  Detailed  Comprehensive

Documentation of examination  P F:A limited examination of the body area or organ system.  Exp PF: A limited examination of the affected body area or organ system and other symptomatic or related organ system(s).  Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s).  Com:a general multi-system examination or complete examination of a single organ system.

Documentation of disease coarse  Two methods:  1 -admit note/follow-up note/treatment note/daily note  Progress note  Final note

Documentation of Disease coarse  2-SOAP  Subjective  Objective  Assessment  Plan of treatment

Documentation of the complexity of medical decision making  The levels of E/M services recognize four types of medical decision making:  Straight-forward  Low complexity  Moderate complexity  High complexity

Documentation of the complexity of medical decision making

Documentation of Medical terminology  1-Diagnostic services  2-Surgical services

Documentation of Medical Terminology  Do not use abbreviation in:  Final examination  Management activities  External causes of emergencies  Death causes

Documentation of Medical terminology…  It is recommended do not use abbreviations in:  Discharge…(File summary sheet)  Surgical procedures…(Operation report sheet)

Documentation of Medical terminology  It is better to use the complete term at first it appears then use the abbreviations for further refers.  Clarify precisely the anatomic site and don’t use – or + for normal or abnormal findings.

Documentation of Medical terminology  Surgical terms:  Simple laceration  Intermediate laceration  Complex lacerations

Documentation of Medical  Mention also:  Tools,facilities,and duration of their usage  Kind of incisions; undermining, take down,lysis of adhesions( different tariff and codes).  Patient position;lithotomy,dorsal,vaginal…

Documentation of Medical terminology…  RUQ,LUQ,RLQ,LLQ  Right hypochondriac  Left hypochondriac, epigastric,right lumbar, left lumbar,umblical,right iliac,left iliac,hypogastric

Documentation Rules  Document while or just after performance.  Do not ask the others to complete your document.