1
What is the purpose of the medical record?
The medical record is intended to provide a detailed account of the care that a patient receives and is essential for quality and continuity of care. It is also important from a billing and legal standpoint.
2
How does documentation become part of the official medical record?
There are several methods for documentation in different medical centers. In many centers documentation is recorded electronically and becomes part of the official medical record as soon as it is digitally signed by the attending physician caring for the patient. In many institutions, documentation is available online before attending review if a resident physician has verified its accuracy.
3
Who may contribute to the medical record?
Hospital staff involved in patient care are permitted and expected to contribute to the medical record. In some institutions, medical students are also permitted to contribute to the record. However, medical student documentation must be reviewed, edited for accuracy, and signed by a supervising staff member.
4
What should be included in the medical record?
Any medical decision making, as well as the basis for those decisions, should become part of the medical record. In addition, any procedures or significant interactions should also become part of the record. In the highly litigious medical system, if you do not document it, you did not do it.
5
What should be documented when a patient is admitted to the hospital?
A patient being admitted to the hospital needs a thorough admission history and physical examination. This history details the reason for the patient’s admission. The accuracy of the physical examination is particularly important as it provides the baseline to which future examinations are compared. During every admission, the past medical history, past surgical history, current medications, drug allergies, family history, social history, and code status should also be reviewed and documented.
6
What should be documented daily?
Daily documentation of the patient’s status and care provided is essential. The elements involved are a brief history from the patient regarding changes from the previous day, a physical examination, and medical decision making. The usual format for this is a SOAP (Subjective, Objective, Assessment, and Plan) note. The components of a SOAP note are displayed in Table 5-1 .
| S ubjective | Changes over the past day and events. |
| O bjective | Physical examination, laboratory results, study results |
| A ssessment | Reassessment of patient’s diagnosis, treatment and condition |
| P lan | Updated plan for care, divided by problem or by organ system |
7
Provide an example of a daily progress note
Examples of typical SOAP notes for both a surgical and a medicine service are displayed in Table 5-2 . Note that although both are brief, medicine notes tend to be more detailed. The “problem list” will tend to be longer and will include more chronic issues. Surgical notes tend to have shorter problem lists and will focus specifically on the surgical issue at hand. Also, surgical notes will focus on the surgical wound after a procedure. In both types of notes, any new results of diagnostic tests (e.g. laboratory tests and imaging) or therapeutic procedures should be recorded.
| General Surgery Note Date | Medicine Progress Note Date |
|---|---|
| S: Mr. Smith’s pain is well controlled with no events overnight. | S: Mr. Smith is doing well today, continued cough productive of yellow sputum overnight. He slept well and had no events overnight. |
| O: Gen: Awake, alert, NAD. CV: RRR, +S1,S2, no M/R/G. Resp: Soft crackles on the right. Abd: Soft, nondistended. No bowel sounds heard. Mild diffuse tenderness to palpation. Incisions clean, dry, and intact with staples in place. Ext: Distal pulses intact. No cyanosis or edema. CXR: Clear with no signs of pneumothorax. ECG: NSR. | O: Gen: Awake, alert, NAD. CV: RRR, +S1,S2, no M/R/G. Resp: crackles at right lower base, tactile fremitus to palpation on right side. Abd: Soft, nontender, nondistended. +BS. Ext: 2+ distal pulses in all 4 extremities. No cyanosis or edema. CXR: Clear with no signs of pneumothorax. ECG: NSR. |
| A/P: Mr. Smith is POD #1 s/p open appendectomy in stable condition. —Continue PCA —Advance diet to clears —Monitor bowel function | A/P: Mr. Smith is a 59 y.o. male with likely COPD exacerbation vs. PNA. 1. COPD v. PNA —Continue abx, Levaquin (day 5 of 10) —Continue O2 by NC 2. HTN —Continue home Lisinopril, HCTZ |
8
What is an order?
An order is a single specific instruction to be implemented according to a patient’s medical care protocol. Some orders may be executed only once, whereas others may be scheduled to occur at regular intervals. Examples of an order include placement of intravenous line access, addition of a medication, a blood draw, and specification of a diet.
9
How are orders managed?
Patient care orders are usually managed through a permanent record that is translated into a patient care routine. This is done in some institutions through a paper system and in others through computerized systems. Paper systems usually require one clear instruction per order line. In computerized systems, orders are usually entered through a series of prompts of possible choices. It is also possible to write “free text” orders in these systems when the prompts do not include the exact order instructions.
10
How can an order be stopped or discontinued?
In a paper system, discontinuation of an order is accomplished by stating the discontinuation of a specific instruction already in the nursing routine. For example, to stop a patient’s penicillin course, you may write “D/C penicillin.” In a computerized system, an order is usually discontinued by locating it in the list of standing orders and choosing the discontinue option. In some systems, you will be prompted for a reason for discontinuation. Often, the reason is a change in medical decision making. If an order is being discontinued because it was entered in error, that may also be specified.
11
Who can write an order?
An order is typically written by a physician on staff at the hospital. In some institutions, medical students are permitted to write orders. However, the order cannot be executed until it is reviewed and signed by a physician.
12
What are the components of a medication order?
When an order is written for a medication, it is essential that the following four components are noted in the same sequence each time: [medication name] [dose] [route] [timing/schedule]. It is also possible to specify the number of times that the medication should be administered. Examples of medications orders are the following:
- ▪
Kefzol 1 g IV Q8 hrs x 3 doses.
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Vicodin/acetaminophen 5/325 mg 1-2 tabs PO Q4–6 hrs PRN for pain
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Morphine sulfate 2–4 mg IV Q2 hrs PRN for breakthrough pain
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What are the common routes of administration?
The routes of administration and some of their common abbreviations are listed in Table 5-3 . The route of administration must be specified with each medication order.
