Recording Skills

Published on 23/05/2015 by admin

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Last modified 23/05/2015

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Recording Skills

The Basis for Data Collection, Organization, Assessment Skills, and Treatment Plans

Chapter Objectives

After reading this chapter, you will be able to:

• Describe the clinical importance of good charting skills.

• Differentiate among the following types of patient records:

• Traditional charting

• Problem-oriented medical records (POMR), and include SOAPIER progress notes

• Computer documentation

• Discuss the importance of the Heath Insurance Portability and Accountability Act.

• Define key terms and complete self-assessment questions at the end of the chapter and on Evolve.

Key Terms

Because all health-care workers share information through written or electronic communication, the respiratory care practitioner must understand the way to document and use the patient’s medical records effectively and efficiently. The process of adding documentary information to the patient’s chart is called charting, recording, or documenting. Good charting should provide the basic clinical information necessary for critical thinking, or assessment skills—that is, good charting should be an effective way to summarize pertinent clinical data, analyze and assess it (i.e., determine the cause of the clinical data), record the formulation of an appropriate treatment plan, and document the adjustments of the treatment plan (in response to its effectiveness) after it has been implemented.

Good charting enhances communication and continuity of care among all members of the health-care team. There is a definite and direct relationship between effective charting (communication) and the quality of patient care. Good charting also provides a permanent record of past and current assessment data, treatment plans, therapy given, and the patient’s response to various therapeutic modalities. This information may be used by various governmental agencies and accreditation teams to evaluate the hospital’s patient care and prove that care was given appropriately. Accurate and legible records are the only means by which hospitals can prove that they are providing appropriate care and meeting established standards.

In addition, many health-care reimbursement plans (e.g., Medicare and Medicaid) are based on diagnosis related groups (DRGs). Under these plans, remuneration is based on disease diagnoses. Many private insurance companies use similar illness categories when setting hospital payment rates. Before providing reimbursement, insurance companies carefully review the patient’s medical record when assessing whether appropriate and efficient care was given.

Finally, the patient’s chart is a legal document that can be called into court. Even though the physician or hospital owns the original record, the patient, lawyers, and courts can gain access to it. As an instrument of continuous patient care and as a legal document, the patient’s chart therefore should contain all pertinent respiratory care assessments, planning, interventions, and evaluations.

Types of Patient Records

Three basic methods are used to record assessment data: the traditional chart, the problem-oriented medical record (POMR), and computer documentation.

Traditional Chart

The traditional record (also called block chart or source-oriented record) is divided into distinct areas or blocks, with emphasis placed on specific information. The traditional record is commonly seen in the patient’s chart as full-colored sheets of block information. Typical blocks of information include the admission sheet, physician’s order sheet, progress notes, history and physical examination data, medication sheet, nurses’ admission information, nursing care plans, nursing notes, graphs and flowsheets, laboratory and x-ray reports, and discharge summary. The order, content, and number of blocks vary among institutions. The traditional chart makes recording easier, but it also makes it more difficult to review a particular event readily and efficiently or to follow the overall progress of the patient.

Problem-Oriented Medical Record (POMR)

The organization of the POMR is based on an objective, scientific, problem-solving method. The POMR is one of the most important medical records used by the health-care practitioner to (1) systematically gather clinical data, (2) formulate an assessment (i.e., the cause of the clinical data), and (3) develop an appropriate treatment plan. A number of good POMR methods are available for recording assessment data. Regardless of the method selected, it is essential that one method be adopted and used consistently.

A good POMR method should take a systematic approach in documenting the following:

One of the most common POMR methods is the SOAPIER progress note—often abbreviated in the clinical setting to a SOAP progress note. SOAPIER is an acronym for seven specific aspects of charting that systematically review one health problem.

S Subjective information refers to information about the patient’s feelings, concerns, or sensations presented by the patient:

O Objective information is the data the respiratory care practitioner can measure, factually describe, or obtain from other professional reports or test results. Objective data include the following:

A Assessment refers to the practitioner’s professional conclusion about the cause of the subjective and objective data presented by the patient. In the patient with a respiratory disorder, the cause is usually related to a specific anatomic alteration of the lung. The assessment, moreover, provides the specific reason as to why the respiratory care practitioner is working with the patient. For example, the presence of wheezes are objective data (the clinical indicator) to verify the assessment (the cause) of bronchial smooth muscle constriction; an arterial blood gas with a pH of 7.18, a Paco2 of 80 mm Hg, an image of 29 mm/L, and a Pao2 of 54 mm Hg are the objective data to verify the assessment of acute ventilatory failure with moderate hypoxemia. The presence of rhonchi is a clinical indicator to verify the assessment of secretions in the large airways.

P Plan is/are the therapeutic procedure(s) selected to remedy the cause identified in the assessment. For example, an assessment of bronchial smooth muscle constriction justifies the administration of a bronchodilator; the assessment of acute ventilatory failure justifies mechanical ventilation.

I Implementation is the actual administration of the specific therapy plan. It documents exactly what was done, when, and by whom.

E Evaluation is the collection of measurable data regarding the effectiveness of the therapy plan and the patient’s response to it. For example, an arterial blood gas assessment may reveal that the patient’s Pao2 did not increase to a safe level in response to oxygen therapy.

R Revision refers to any changes that may be made to the original therapy plan in response to the evaluation. For example, if the Pao2 does not increase appropriately after the implementation of oxygen therapy, the respiratory care practitioner might continue to increase the patient’s Fio2 until the desired Pao2 is reached.

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