1 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 21 Documentation of Patient Assessment

2 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives After reading this chapter you will be able to:  Know why documentation is important  Identify the standards for documentation in patient’s medical record  Explain the legal definition of negligence  Identify the three major types of medical record documentation for RTs

3 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe the SOAP method  Describe SBAR in patient assessment  Describe assessment, plan, implementation, and evaluation (APIE) method  Describe problem, intervention, and plan (PIP) method

4 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Overview  Significant time and energy spent on documentation  It is an essential part of health care  Medical legal aspects of documentation  The Joint Commission (TJC) requirements  Good documentation improves communication

5 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. General Purposes of Documentation  Serve as a legal record  Collect evidence of patient’s complaints  Provide communication between members of the health care team  Support appropriate reimbursement  Support operation of the HCO  Provide compliance with TJC  Serve as an educational tool

6 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. TJC and Legal Aspects of Medical Record  TJC reviews HCOs to improve patient care  TJC may revoke HCO accreditation  No Medicare payments  No Medicaid payments  No private insurance payments  TJC looks for documentation of high- quality patient care  TJC survey team reviews medical records to confirm compliance

7 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc CAMH TJC Statements  IM.2.10 Information privacy and confidentiality are maintained  IM.2.20 Information security, including data integrity, is maintained  IM.4.10 The information management system provides information for use in decision making

8 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc CAMH TJC Statements (cont’d)  IM.6.10 The hospital has a complete and accurate medical record for every patient assessed or treated  IM.6.20 Records contain patient-specific information to the care, treatment, and services provided

9 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc TJC Statements  IM.6.50 Designated qualified personnel accept and transcribe verbal orders from authorized individuals  PC.4.10 Development of a plan of care, treatment, and services is individualized and appropriate to the patient’s needs, strengths, limitations, and goals

10 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc TJC Statements (cont’d)  PC.2.20 The hospital defines in writing the data and information gathered during assessment and reassessment  PC Diagnostic testing necessary for determining the patient’s health care needs is performed

11 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc TJC Statements (cont’d)  PC The hospital defines, in writing, the time frame(s) for conducting the initial patient assessment(s)  PC Patients are reassessed as needed

12 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Negligence  Failure to use reasonable amount of care (“ordinary prudence”) that results in injury or damages to another; requires that:  Defendant owed a duty of care to the plaintiff  Defendant breached that duty  Plaintiff suffered a legally recognizable injury  Defendant’s breach of duty of care caused the plaintiff’s injury

13 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Medical Records Entries  Most familiar medical record entries to RT  Treatment records Single event at specific time When, how, with what drugs or equipment given Patient’s response  Flowcharts or parameter sheets  Test results

14 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. SOAP  Subjective: information given by patient can tell you about how he/she feels  Major questions What is the patient’s level of consciousness? What is the patient’s chief complaint? How does the patient feel at the time of the assessment? Can the patient contribute any information that affects his/her diagnosis or treatment plan?

15 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. SOAP (cont’d)  Objective: everything you see  Vital signs  Physical examination of the head and neck, abdomen, and extremities for physical evidence of respiratory abnormality  Physical examination of the thorax (heart and lungs) by inspection, palpation, percussion, and auscultation  Review of clinical laboratory studies

16 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. SOAP (cont’d)  Objective: everything you see  Review of arterial blood gases  Review of pulmonary function test  Review of radiological procedures: chest radiographs, computed tomograms, and magnetic resonance images  Review of electrocardiograms (ECGs)  Review of ICU hemodynamic data  Review of respiratory mechanics monitoring

17 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. SOAP (cont’d)  Assessment: hypothesis about nature and cause of patient’s problems  Form a “problems list”  Major types of problems Airway management Ventilation Oxygenation Work of breathing

18 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

19 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

20 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. SOAP (cont’d)  Plan: indicate an intervention and therapeutic objective  A good medical plan must include a goal against which one can measure: The purpose of the treatment Responsiveness of the patient Objectives for knowing when to make decisions Objectives as end-point criteria for the termination of the therapy

21 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

22 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Charting Methods  SOAP  APIE  PIP

23 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. SBAR  Latest methodology for communication  Situation: What is happening now? Chief complaint or acute change  Background: What factors led to this event? Admitting diagnosis, history, vital signs, lab results, or other pertinent clinical findings  Assessment: What do you see? What do you think is going on?  Recommendation: What action(s) do you propose? What do you think should be done?

24 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Summary  Role of the RT in documentation of patient assessment is well defined and important  Documentation format should meet TJC and legal requirements  Each recording must be accurate, concise, and available to other clinicians for review  Good documentation promotes improved communication and patient outcomes