1. Content of the Health Record

2. FACE SHEET What information is found on the face sheet? Demographic
Financial
Reason for the visit
Admitting physician
Date of admission
Demographic Information
Patient name
DOB
Address
Telephone number
MRU
Case/Financial/Encounter #
Place of employment
Date of Admission
Admitted and Attending physician
Emergency contact/next of kin
Admission type (Inpatient, Outpatient, Day Surgery)
Financial
Insurance information
guarantor

3. ADMISSION/TREATMENT AGREEMENT
Provides information about
patient rights
Provides information about payment of services
Patient signs – patient agrees to be treated
and also agrees to pay

4. ADVANCED DIRECTIVES What is the purpose of an Advanced Directive?
What types of AD’s are there?
Living will
Power of Attorney
Purpose – to express your wishes if you were unable to express them yourself in a medical emergency.
What is it? legal documents that allow you to convey your decisions about end-of-life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion later on.
A living will tells how you feel about care intended to sustain life. You can accept or refuse medical care. There are many issues to address, including
The use of dialysis and breathing machines
If you want to be resuscitated if breathing or heartbeat stops
Tube feeding
Organ or tissue donation
A durable power of attorney for health care is a document that names your health care proxy. This is someone you trust to make health decisions if you are unable to do so (if you are incapacitated).
The patient MUST be declared incapacitated by 2 physicians or 1 physician and 1 psychologist BEFORE that person listed can make decisions for that patient or release their records.

5. HISTORY AND PHYSICAL (H&P)
Chief Complaint
History of the Present Illness
History and Physical
Must be completed by a physician ….
Inpatient stay it must be completed and placed on the patient chart within 24 hours of admission and cannot be older that 30 days old.
surgical procedure requiring general anesthesia it must be placed on the patients chart prior to surgery – must be “verified” I.e. signed/dated/timed
Chief Complaint: subjective description of the reason the patient is searching medial treatment
HISTORY OF THE PRESENT ILLNESS: summary of patient’ illness from his/her point of view.
Purpose is to gather background
PAST MEDICAL HISTORY: subjective account of current and past illnesses, injuries, surgeries, and hospitalizations, including information on current medication sand allergies
FAMINLY MEDICAL HISTORY: a subjective description of illnesses that occurred among close family members
SOCIAL AND PERSONAL HISTORY: a subjective description of the patient’s occupation, marital status, personal habits, and living conditions
GENERAL CONDITION:Physicians impressions REVIEW OF SYSTEMS: Assessment of the body system - Skin, HEENT (head, eyes, ears, neck, throat), heart, lungs, abdomen, etc… IMPRESSION: physicians impression of the illness/disease process based on all assessments above TREATMENT PLAN (COURSE OF ACTION): physician describes what will be done to evaluate and treat the patient SIGN/DATE/TIME – TJC requirement on all documentation
When did you first notice your
Timbers were shivering?

6. HISTORY AND PHYSICAL (H&P) cont…
Past Medical History
Family Medical History
Social & Personal History
General Condition
Review of Symptoms
Impression
Treatment Plan
Sign – Date – Time

9. PHYSICIAN ORDERS Medication Diagnostic Therapeutic Consultation
Standing Orders
Telephone/Verbal Orders
Required Elements
Instructions that the physician gives to the other health care professionals who carry out the order
Medication –
pharmacy dispenses the medication to the unit
nursing administers the medication
Diagnostic –
Technicians in the various diagnostic areas carry out these orders such as a Radiology Technician performing a chest xray on a pneumonia patient.
Therapeutic
Therapists carry out Therapeutic orders such as a physical therapist providing therapy ordered on a patient with a knee or hip replacement. Or a speech therapist assessing a stroke patient to determine whether or not the patient can eat/swallow.
Must be signed, dated and timed
Standing Orders – for patients that present with the same type of illness/chief complaint such as chest pain – there is a certain “best practice” standard of things to do for this type of patient, therefore a “standing order set” is created for staff to carry out immediately – these orders would be on a pre-printed order set and require the physician to sign/date/time. This saves time because the physician does not have to write out each order (leaves out potential human error of forgetting something and it does not delay treatment)
Telephone/Verbal Orders – orders can be dictated to certain licensed care givers (typically a nurse) – the nurse calls the physician to discuss the patient and the physician can give an order verbally which must be written down and read back to the physician. The physician must sign within 48 hours. Ex: Patient is experiencing pain, nurse contacts physician, physician verbally orders pain medication.
Required elements
Pt name
Date
Diagnosis or symptom
What is being ordered, quantity and duration (ex: physical therapy for 4 weeks; amoxicillin twice daily for 2 weeks)
Physician Signature (timed and dated)
NOTE: Admission Orders/discharge orders – a patient cannot be admitted and/or discharged without an order from a physician
If a patient leaves without the physician discharging him/her it is considered Leaving Against Medical Advice – ask the pt’s to sign a form, clear documentation about the AMA.
“According to my research,
laughter is the best medicine,
giggling is good for mild infections,
chuckling works for minor cuts and bruises,
and snickering only makes things worse.”

10. PHYSICIAN PROGRESS NOTES
Record Clinical Observations
Record Results
Record Conversations with
Patient and Patient Family
PROGRESS NOTES (Physician)
Clinical observations – chronological record of the patient's condition and response to treatment during his or her hospital stay.
Record the results of all diagnostic testing (lab, x-ray, etc..)
Records conversation with patient and patient family
Why? What is the purpose of the progress note?
Allows physicians to communicate their observations to other members of the health care team.
Information on progress note provides clinical necessity to keep the patient in the hospital and serves as documentation to support reimbursement

11. CONSULTATION REPORT What is a Consultation Report? Expert Opinion
Physicians often seek the advice of other physicians before making final diagnostic and therapeutic decisions.
Admitting/Attending Physician will document the request for a consultation in the patients record – an order for the consult will be written and follow up will be written in the progress notes
Give example…
Contains:
Name of physician who requested the consultation
The reason for the consultation
Date/time of consult exam
Opinion, diagnosis, or impression
Recommendations for diagnostic tests and/or treatment
Sign/date/time

12. DISCHARGE SUMMARY
What is the purpose of the Discharge Summary? What information is required in a Discharge Summary? Who is responsible for the Discharge Summary?
Purpose –
Concise account of patients illness/treatment while in the hospital
Required elements:
brief history/description of the problem
Course/response of treatment
Admission Diagnosis
Discharge Diagnosis
Discharge Medication
Procedures performed
Tests performed
Disposition of patient
Must be completed within 30 days post discharge

13. “Your insurance has run out. We’re discharging you
from the ‘Observation Care’ floor to the
‘Who Cares?’ room in the basement.”

14. PATHOLOGY REPORTS Prepared by pathologists (signed/dated/timed)
Describes the tissue examined
States the diagnosis
Prepared by Pathologists (signed/dated/timed)
Describes the tissue examined - Findings of the microscopic and macroscopic examination of the specimen
Diagnosis - Preliminary results are sometimes communicated to the surgical team while the procedure is still in progress.
Allows surgeon to modify their operative scope when the condition is more or less widespread than originally estimated.
Benign
Malignant - staging

15. AUTOPSY REPORT
Description of the examination of the patient’s body after he/she has died
Performed by
Hospital pathologist
Medical Examiner
Description of the examination of the patient’s body after he/she has died.
Case history, General Inspections, Body Cavities, organs, Endocrine, Musculoskeletal, General, Case Summary
Performed by a hospital pathologist
When there is a question about the cause of death or when needed to know more about the course of the patient’s illness
Authorization is required by family members, filed in the medical record
Performed by a Medical Examiner
if a death that is the result of a crime
All autopsy reports should be filed in the patients medical record

16. IMAGING REPORTS Types of Reports X-rays & Scans
CT Scan (Computed Tomography)
MRI (Magnetic Resonance Imaging)
PET (Positron Emission Tomography)
IMAGING REPORTS
X-rays & Scans (CT, MRI, PET)
Performed (typically) by a trained radiology technician.
Interpretation of the test is performed by a radiologist
Contains:
Name of the examination performed
Type (if used) of radiopharmaceutical administered
Interpretation of the findings
Sign/date/time
Some imaging procedures require the administration of radiopharmaceuticals, radioactive contrast medial and administered to the patient before or during the procedure to make it possible to visualize physiological processes and tissues more clearly.
If anesthesia is used that must be documented – also requires consent
MRI –
Indication
Technique
Comparison
Findings
PET - A positron emission tomography scan is an imaging study using a very small dose of a radioactive tracer attached to a sugar that is injected into the patient. ... These tests produce an image that gets interpreted by a physician (specialist Radiologist/Neurologist). The image is stored electronically and is not filed in the medical record, the interpretation/report is filed in the medical record.

17. DIAGNOSTIC REPORTS Cardiology Tests/Reports: Stress Tests
Tilt-table tests
Holter Monitor
Pacemaker Checks
Electrocardiography
Echocardiography
Myocardial imaging
Cardiac Catheterization

18. Diagnostic reports cont…
Neurology Reports:
Electroencephalography
Echoencephalography
Cerebral angiography
Myelography
Lumbar puncture

19. OPERATIVE RECORDS Pre-op Checklist Pre-op Anesthesia Assessments
Pre-operative Nursing Record
Intraoperative Anesthesia Record
Post-Anesthesia Assessments
Post-Note
Operative note
Patients who have surgery will have documentation about their surgery recorded in their Health care record from before surgery, during surgery and after surgery
Pre-operative check list – must be done prior to surgery (TJC/CMS requirement) – need to check, identification of patient, pre-op test results, diagnoses, allergies, pre-op meds, consent for surgery form, surgical goals, surgical site, resources needed (instruments), operative team (surgeon, assistance, observer, nursing, anesthesia, expected blood loss.
Pre-op Anesthesia Assessment – it is the Anesthesiologists version of an H&P - Past Anesthetic Problems/Family History, Cardiac Risk Predictors, Airway Evaluation, Pertinent medications, Allergies, discuss Anesthetic options with patient, discuss risk factors of anesthesia with patient, indicate pt understands and wishes to proceed
Pre-Op Nursing Record
Intraoperative Anesthesia Record –
Post-Op Anesthesia Assessment –
Post-Op Note - Must have an immediate Post-Operative note written right after surgery and in addition to the operative report
Operative Report
Preoperative & postoperative diagnoses and indications for the surgery
Descriptions of the procedures performed
Description of all normal and abnormal findings
Description of any specimens removed
Descriptions of the patients medical condition before, during and after the operations
Estimated blood loss
Descriptions of any unique or unusual events that occurred during the course of surgery
Names of the surgeons, assistants, anesthesiologist
Date and duration of the surgery
Signature/date and time

20. NURSING DOCUMENTATION
NURSING ASSESSMENT
The gathering of information about the patient
Performed shortly after admission –TJC, State and federal guidelines require within 24 hours
NURSING ASSESSMENT
The gathering of information – contents include:
Current illness, perception of illness
Past medical history
Physical exam, BP, temp, condition of skin, pain levels
Cognitive status (ability to communication and understand/follow directions)
Current functional status (level of physical activity, ability to ambulate, personal care, etc.)
Nutritional status (food allergies, ability to feed his/herself)
Drug allergies & latex sensitive
Current meds
NURSING CARE PLANS
Contains
Initial assessment of pt’s immediate and long-term needs
Treatment goals based on pts needs and diagnosis
Description of the activities planned to meet the treatment goals
Pt education goals
Discharge planning goals
Indicators of the need for reassessing the plan to address the pts response to treatment and/or the development of complications
NURSING PROGRESS NOTES
Nurses have frequent interaction with their patients. It is important to document comments about these interactions, any observations seen, and activities performed.

21. Nursing documentation cont…
NURSING CARE PLANS
Means of planning care and discharge planning – patient specific
Multidisciplinary tool for organizing the diagnostic and therapeutic services to be provided to a patient
CMS Conditions of participation (if you accept Medicare/Medicaid you must follow) have made this a requirement
NURSES PROGRESS NOTES
Documentation of interactions,
observations, & treatment
of the patient

22. LABORATORY REPORT Require a physician’s order
Specimen collected by RN or
phlebotomist
Contents include:
Name of tests performed
Dated test was performed
Time in/time out of the lab
Name of the lab where test was performed
Results (includes normal ranges)

23. REHABILITATIVE & THERAPEUTIC REPORTS
Include a number of different therapies :
Speech
Physical
Occupational

24. Rehabilitative & Therapeutic reports cont…
Contents:
Pertinent history
Diagnosis of disability
Rehab problems, goals and prognosis
Assessments and individual program planning
Reports from referring sources
Evidence of patient’s and/or family's
participation in decision making
Program plan
Plans from each service

25. CONSENTS FOR PROCEDURES/BLOOD TRANSFUSIONS
Patient consent is required for any invasive procedure and/or blood transfusion
Except in emergency situations
Physicians must obtain a written documentation of the patient’s consent to surgery before the operation/procedure begins
Physician must demonstrate that they explained all the risks and benefits of the procedure
Patient and physician must sign and date

26. TRANSFUSION RECORDS Type and amount of blood products received
Patient’s reaction to the transfusions
Blood group and Rh status of the patient and donor
Results of cross-matching tests
Description of the transfusion process
Adverse reaction

27. MEDICATION ADMINISTRATION RECORD
RN’s keep a separate log for each patient’s medications
All medications administered to the patient
Date and time each drug was administered
Name of medications
Form of administration
Medication’s dosage and strength
Each entry for a medication is signed or initialed and dated
the person who administered the drug
New focus by TJC – medication reconciliation – must be reconciled upon moving from one level of care to another, such as from ICU to a step down unit and on discharge

28. PATIENT PROPERTY RECORD / BELONGINGS RECORD
Lists patient’s belongings
Lists whether or not a patient has belongings locked in safe at hospital
Contains language encouraging patient not to keep valuable belongings with them at the hospital