Chapter 21
Documentation
After reading this chapter, you will be able to:
1. Recognize the general reasons why documentation is important.
2. Identify the expectations for documentation in the patient’s medical record required by The Joint Commission standards.
3. Explain the legal definition of negligence.
4. Identify the three major types of medical record documentation for respiratory therapists.
5. Describe the use of the subjective, objective, assessment, and plan method for documentation in the patient’s medical record.
6. Explain the assessment, plan, implementation, and evaluation method and the problem, intervention, and plan method for documentation of patient assessment data.
7. Review the use of the situation, background, assessment, and recommendation format in patient assessment.
8. Explain the federal electronic medical record mandate.
9. Identify the advantages and disadvantages of the electronic medical record.
General Purposes of Documentation
Once the respiratory therapist (RT) has completed the bedside patient assessment, consulted other members of the health care team, taken notes, reviewed the information in the medical record, and discussed the information with the patient’s physician, it is time to record the assessment and plan into the medical record. The process of collecting the data involves the mental process called critical thinking. The critical thinking process requires many skills, including interpretation, analysis, evaluation, inference, explanation, and self-regulation.1 The difficult part of assessment is over, and now all the RT has to do is describe the findings and thoughts in a concise and professional manner. Because the medical record is a legal document, the RT needs to understand some fundamental principles before making an entry into the patient’s medical record.
• To serve as a legal record of the care and service provided. The medical record is more than just a collection of data; it is a legal document.
• To collect evidence in support of the patient’s problems and needs. When the clinical facts about the patient’s condition are collected, the correct diagnosis can be confirmed, and the patient’s clinical progress can be better monitored.
• To provide communication between members of the health care team. The clinical notes, reports, flow sheets, vital signs, and test results enable the physician and other members of the team to document that the patient has received high-quality care according to each profession’s standards of care or hospital policies. Each discipline has unique perspectives to bring to the discussion of a patient’s care plan.
• To support appropriate reimbursement. The hospital is a business that must collect revenues. As a result, the medical record is also a financial document. The medical record must clearly show the nature of the patient’s needs in the form of the diagnosis. Hospital coders use the medical record to review information and assign appropriate codes in order to produce a bill. Medicare and other payers reimburse the hospital based on the patient’s diagnosis.
• To support the operation of the HCO and its allocation of internal resources and to provide documentation of compliance with TJC and regulatory standards of care. This type of documentation provides data for legally mandated reports to state and federal governmental agencies. These reviews of the medical records and related financial records, as well as the subsequent reports from these reviews, are used to show the hospital’s administration that the business is functioning effectively and in compliance with accreditation and regulatory bodies.
• To serve as an educational tool. Every health care professional must learn how to use the medical record correctly. At first, the medical record can be very intimidating, but with time, it becomes more familiar. The initial problem is often just finding the information you need. The medical record provides documentation of the clinical manifestations, course of the disease process, and the patient’s responses to interventions. For this reason, even the experienced health care worker can learn from a good medical record. By reviewing a patient’s record, you can learn what has and has not been effective for this particular patient. Furthermore, by reviewing large numbers of patient medical records, the RT or other member of the patient care team can learn how to more accurately describe each patient’s condition and determine how to better treat patients with specific diseases. Most human research is based on or related to medical records. Extracting data from medical records is a complex process that requires skill, diligence, and attention to detail.
The Joint Commission and Legal Aspects of the Medical Record
TJC surveyors review patient records for documentation of safe and high-quality patient care. The Information Management and Record of Care, Treatment, and Services sections of The Joint Commission Comprehensive Accreditation Manual for Hospitals (CAMH) outlines how the organization “…manages internal and external information, including the medical record, and includes the components of a complete medical record.”2 The individual elements required in the medical record are provided and organized in common groups. The chapter also includes the medical record structure and details for management of the medical record. How each organization accomplishes these tasks is left up to that facility. TJC’s on-site survey team evaluates an HCO’s compliance with these requirements and reviews patients’ medical records to assess the level of compliance. The survey team members may also provide consultation, including samples of how other organizations have complied with the standards. TJC survey team’s objective is to assist the HCO to comply with the standards, not to be punitive toward individuals or the organization.
The following are TJC standards from the 2012 CAMH regarding the required medical record elements.2 Periodically, there are revisions to these standards, but the basic principles of information management and documentation have remained unchanged.
• IM.02.01.01 The organization protects the privacy of health information.
• IM.02.01.03 The organization maintains the security and integrity of health information.
These standards are directed toward guarding the patient’s rights to privacy (the individual’s right to limit the disclosure of personal information) and confidentiality (the safekeeping of data and information so as to restrict access to individuals who have need, reason, and permission for such access).2 These standards are consistent with both state and federal laws and regulations. Violations of these standards, or of related laws and regulations, can result in legal action with fines for the institution or civil or criminal prosecution of the offenders (depending on the details of the incident). This legal action could result in personal fines, loss of job, loss of professional license, and possibly even jail time. The federal law, known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), details the legal expectations and professional standards regarding the transmission (verbal, written, or electronic) of protected health information (PHI).
This standard describes the use of standardized terminology, definitions, abbreviations, and symbols, including abbreviations that are prohibited.2
• RC.01.01.01 The organization maintains complete and accurate patient records for each individual patient. This standard describes the general components of the medical record.
• RC.01.02.01 Entries in the medical record are authenticated.
• RC.01.03.01 Documentation in the patient record is entered in a timely manner.
• RC.02.01.01 The patient record contains information that reflects the patient’s care, treatment, and services.
• PC.01.02.01 The organization assesses and reassesses its patients.
• PC.01.02.03 The organization assesses and reassesses the patient and his or her condition according to defined time frames.
• PC.01.03.01 The organization plans the patient’s care.
• PC.02.02.01 The organization coordinates the patient’s care, treatment, or services based on the patient’s needs.
• The defendant owed a duty of care to the plaintiff.
• The defendant breached that duty.
• The plaintiff suffered a legally recognizable injury.
• The defendant’s breach of duty of care caused the plaintiff’s injury.
• The absence of information or the lack of documented recognition of specific problems could constitute malpractice. Essentially, if a treatment, assessment finding, or clinical problem was not charted, it is generally considered not to have been done or detected.
• Clinical notes show that auto-PEEP was being monitored with every ventilator parameter.
• There was documentation of communication among the patient care team members, including the RT, physician, and nurse, about the auto-PEEP problem.
• Bronchodilator therapy was started and ventilator changes were made (both in an attempt to decrease auto-PEEP).
Then the presumption would be that appropriate care was taken and the patient’s injury or death was not caused by neglect or malpractice in this regard.
Types of Medical Records
• Date and time of test or treatment
• Drugs and their dosages, if used
• Result, or response to treatment, including adverse reactions
• Goals, objectives, or end-point criteria for the treatment
This type of documentation is ideal for aerosolized medications, secretion clearance therapy, and tracheostomy care.
The advantages of the EMR include the following:
• Increased storage capacity for longer periods of time
• Accessibility from remote sites
• Information that is concurrently available
• Built-in “alert” systems for critical tests and values
• Customized views for various users
• Increased management monitoring capabilities