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

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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)

12. Flow Sheets

13. 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

14. 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 – “ “

15. 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: :30
error

16. 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.

17. 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.”

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. SOAP Form