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.

The reasons for creating a record of the patient’s interactions with any health care organization (HCO) include the following:

As noted, the patient’s medical record is subject to review by different professionals for multiple reasons. By far the most common and compelling reason to scrutinize a patient’s record, or the HCO’s handling of medical records in general, is to monitor and improve the quality of medical care.

The Joint Commission and Legal Aspects of the Medical Record

The Joint Commission (TJC), formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is the largest accreditation organization in the United States. It is an independent, nonprofit organization that accredits more than 19,000 health care providers and programs in all care settings. Their mission is “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” TJC’s vision statements is “All people always experience the safest, highest quality, best-value health care across all settings” and their position statement is “Helping Health Care Organizations Help Patients.”

TJC performs on-site surveys of HCOs to assess the quality of patient care and improve patient safety. If any HCO fails to comply with TJC standards, they will require action plans, follow-up, and evidence of compliance. If an HCO does not meet the requirements of TJC, the organization may be denied accreditation. TJC is authorized by the Center for Medicare and Medicaid Services (CMS) to monitor hospitals for compliance with the federal Conditions of Participation; thus, hospitals not accredited by TJC risk losing reimbursement through Medicare and Medicaid. In addition, many state health departments use TJC survey as their on-site inspection, so there could be regulatory ramifications as well.

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.

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).

In summary, these professional standards state that what you learn about a patient is on a “need to know” basis and you are not to share that information outside of that professional context. Generally, the RT needs to refer almost all questions coming from relatives and friends to the other professional team members such as the nurse, social worker, and naturally, the physician. These issues become complex at times, particularly when dealing with a culturally diverse environment.

This standard describes the use of standardized terminology, definitions, abbreviations, and symbols, including abbreviations that are prohibited.²

This standard describes who can make entries into the medical records and how the entries are authenticated.

This standard defines in detail demographic and clinical information that must be contained in the patient record. It also includes a listing of additional documents that are required, when applicable.

Communication problems during the receipt of verbal and telephone orders have resulted in serious medical errors. This alarming problem has resulted in TJC including the expectation that all verbal orders are to be read back to the person giving the order as part of the National Patient Safety Goals. This is meant to verify that the complete and correct order is being recorded and implemented. The person who gave the order, within a specified time frame, must authenticate all verbal orders. Because of these inherent problems regarding verbal orders, there is a general movement in the health care industry to discourage the use of verbal orders.

Guidelines regarding the authority to accept verbal orders are outlined in the respiratory care practice acts in most states. The general rule is that RTs can accept orders only for those treatments and services that they directly provide. This excludes drugs that RTs do not directly administer. RTs can, however, take orders for routine laboratory tests, chest radiographs, and standardized multidisciplinary protocols that are related to respiratory care practice.

All orders (written and verbal) must be dated and timed, identifying the names of the individuals who gave and received the order. Under certain circumstances, two persons should be present to take a verbal order or be on the phone line, and then one of these persons needs to repeat the order back to the physician before recording and carrying out the order. Both persons who heard the verbal directive should cosign the order in the medical record. The medical record must also indicate who implemented the order and what time the order was carried out.

RTs should integrate the information from various assessments of the patient, such as those of the physician, nurse, and other allied health professionals, to identify and assign priorities to the patient’s care needs. Then the RT should base care decisions on the identified patient needs and care priorities. Attention should be paid to treating symptoms, such as dyspnea, and using accepted professional standards of practice, such as the American Association for Respiratory Care (AARC) Clinical Practice Guidelines.

TJC also requires that there be reassessments at regular intervals in the course of care to determine a patient’s response. Furthermore, any significant change in a patient’s condition should result in a reassessment, and the results or observations should be communicated to the other health care team members as appropriate.

These professional expectations are scrutinized carefully when the patient or family believes that the patient did not receive high-quality care or, more specifically, when it is believed that there has been some form of negligence.

Negligence is defined as an instance of failure to use the reasonable standard of care (“ordinary prudence”) that results in injury or damages to another. Negligence has been committed when someone (who becomes the defendant) has failed to live up to a required duty of care owed to another person (the plaintiff). Generally, the legal definition of negligence requires the presence of the following four conditions:

As an RT, you have a duty of care to your patients. The scope of your duty to a patient is outlined by your professional standards (e.g., the AARC Clinical Practice Guidelines, your state’s respiratory care practice act and regulations, and TJC standards). Your scope of practice is further defined or limited by your job description in your place of employment. Functioning within your job description, the limits of your state’s practice act, and the professional expectations keeps you professionally safe.

Concerns regarding ethical situations or clinical conflicts between disciplines should not be entered into the patient’s medical record. Issues such as this need to be referred to the institutions’ quality assessment or risk management department. Every HCO is required by TJC to have a performance improvement process that ensures that patient safety and quality of care issues can be brought up in a manner that is not punitive and that every employee is instructed on how to report or access this process.

If it was not charted, it was not done. For example, if it were not recognized that a patient on a ventilator had severe chronic obstructive pulmonary disease (COPD) and was at very high risk for auto–positive end-expiratory pressure (auto-PEEP) and the patient suffered injury or death, possibly as a result, the potential exists for legal liability. However, if the following occurred:

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.

The medical record must accurately reflect the course and results of the patient care provided. Therefore, the accurate recording of the date, time, and place of events is essential. Late entries into the medical record are sometimes necessary but not a recommended practice. The standard calls for all information to be entered into the medical record in a timely manner. The definition and interpretation of timely is not always clear. In one case (Joseph Brant Memorial Hospital v. Koziol [1978]), a nurse did not chart her observations for 7 hours for a postoperative patient who then died during her shift. The delay in charting was interpreted by the court as the nurse not having made the observations. Vital signs and parameters should be charted immediately. Late entries of clinical notes or observations should be clearly marked as late entries and show the time entered and the time or period covered in the note.

Types of Medical Records

The different kinds of entries into the medical record depend on the purpose of that entry. The major types that are most familiar to the RT are treatment records, flowcharts or parameter sheets, and test results.

Treatment records are concerned with a single event at a specific time. The treatment record shows when, how, and with what drugs or equipment a treatment was given. The patient’s response to the therapeutic intervention must also be included in the treatment record. The record can contain patient-subjective information on the response to the treatment, but most of the treatment record is objective information. This type of documentation should include the following:

This type of documentation is ideal for aerosolized medications, secretion clearance therapy, and tracheostomy care.

Flowcharts or parameter sheets have similar requirements for dates, times, changes in equipment settings, and, most important, the patient’s responses to the therapeutic intervention. Flowcharting and parameter charting have become increasingly important in the sophisticated environment of the intensive care unit (ICU). This type of documentation is designed to show that the clinician assessed and responded to data or trends identified. In addition, it shows that the RT responded to opportunities to reduce invasive procedures and medications or adverse events. The importance of recording accurate ventilator and monitor alarm settings is often overlooked by busy clinicians. If a patient were to die from a massive tension pneumothorax after a period of high peak pressures with an inappropriately set high peak pressure alarm, a strong case could be made for malpractice. However, accurate and timely documentation will verify that the RT appropriately assessed the patient-ventilator interface. This type of documentation is best suited for ventilator parameter monitoring, serial vital signs, or oximetry readings.

Tests are mostly objective observations of clinical laboratory results (e.g., arterial blood gas [ABG] levels or electrolytes) or physiologic responses to clinical challenges (e.g., fluid challenges or optimal PEEP studies). Because tests are seen as integral to the clinical course of the patient’s care, the date and time of the test and its subsequent reporting to the physician are very important.

Treatment records, parameter sheets, and test result forms are standard practice in most hospitals and typically do not pose a problem for most members of the patient care team. However, some RTs find documentation of patient assessments to be a challenge. Assessment notes, medical histories, and clinical notes are extremely important in conveying information and documenting that appropriate care has been given. These types of documentation demonstrate the efforts to collect all of the information about the patient and determine his or her medical needs.

Historically, the medical record was a binder or similar device stored in the nurses’ station, containing all the required and appropriate paper documents. During the past several decades, there has been a transition to a “computerized medical record,” more commonly known today as an electronic medical record (EMR) or electronic health record (EHR). The EMR stands to increase efficiencies in the health care system and improve quality of care and patient safety. Most HCOs are actively moving toward a full EMR. Most, however, are still operating with a “hybrid,” or combination of electronic and paper records. This will be rapidly changing to the full EMR over the next several years.

In addition to all the obvious advantages to the EMR, the federal government also introduced financial incentives to implementation of a full EMR. Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA), Medicare and Medicaid payments will require “meaningful use” of an EMR, accredited by a proper certification authority. The use of an EMR by 2015 is required in order to avoid losing a portion of Medicare reimbursement.

The advantages of the EMR include the following:

Although the advantages of EMR are significant, implementation and use of EMR is not without challenges. TJC outlined some of these concerns in Sentinel Event # 42 entitled “Safely Implementing Health Information and Converging Technologies.” The disadvantages of the EMR include the following: