Recording Skills

Published on 23/05/2015 by admin

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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.

For the new practitioner, a predesigned SOAP form is especially useful in (1) the rapid collection and systematic organization of important clinical data, (2) the formulation of an assessment (i.e., the cause of the clinical data), and (3) the development of a treatment plan. For example, consider the case example and SOAP progress note at the bottom of this page (Figure 10-1).

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FIGURE 10-1 Completed predesigned SOAP form.

Although the SOAP form may initially appear long and time-consuming, the experienced respiratory care practitioner and assessor can typically condense and abbreviate SOAP information in a few minutes (primarily at the patient’s bedside), in just a few short statements. Typically, a written SOAP form uses only 1 to 3 inches of space in the patient’s chart. For example, the information presented in Figure 10-1 may actually be documented in the patient’s chart in the following abbreviated form:

After the treatment has been administered, another abbreviated SOAP note should be made to determine whether the treatment plan needs to be up-regulated or down-regulated. For example, if the arterial blood gas data obtained after the implementation of the plan (outlined in the SOAP form) showed that the patient’s Pao2 was still too low, it would be appropriate to revise the original treatment plan by increasing the Fio2 on the mechanical ventilator. Figure 10-2 illustrates objective data, assessments, and treatment plans commonly associated with respiratory disorders.

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FIGURE 10-2 Respiratory care protocol guide. (Used with permission of Terry DesJardins.)

SOAP Case Example*

A 26-year-old man arrived in the emergency room having a severe asthmatic episode. On observation, his arms were fixed to the bed rails, he was using his accessory muscles of inspiration, and he was using pursed-lip breathing. The patient stated that “it feels like someone is standing on my chest. I just can’t seem to take a deep breath.” His heart rate was 111 beats per minute, and his blood pressure was 170/110. His respiratory rate was 28 and shallow. Hyperresonant notes were produced on percussion. Auscultation revealed expiratory wheezing and rhonchi bilaterally. His chest x-ray film revealed a severely depressed diaphragm and alveolar hyperinflation. His peak expiratory flow was 165 L/min. Even though his cough effort was weak, he produced a large amount of thick white secretions. His arterial blood gases showed a pH of 7.27, a Paco2 of 62, an image of 25, and a Pao2 of 49 (on room air) (see Figure 10-1).

*Subjective and objective data presented in bold.

Computer Documentation

Computer-based records (also called electronic medical records, electronic health records, computer-based personal records, and electronic patient medical charts) are now commonly used throughout the health-care industry. Common uses of computer documentation include ordering supplies and services for the patient; storing admission data; writing and storing patient care plans (e.g., SOAPs and physician progress notes); listing medications, treatments, and procedures; and storing and retrieving diagnostic test results (e.g., x-ray films, pulmonary function studies, and arterial blood gas values). Many health-care facilities have incorporated software for their specific patient care needs. Such computer programs include options for starting individualized patient care plans, using automated Kardex systems, documenting acuity levels, and providing a mechanism to electronically record ongoing assessment data. There are literally hundreds of electronic medical chart solutions available today, targeted at every size and type of medical setting.

With all the patient information in a central location, computer documentation provides easy access to patient data. It greatly reduces the chance for errors, and updated patient information can easily be entered in real time. Computer-based records do away with the need to make phone calls to other departments to gather patient information or to order patient supplies or services. In addition, electronic documentation eliminates the need to read through the entire chart to evaluate the patient’s progress or to review specific data such as medication listings, treatments, diagnostic test results, and procedures. The patient’s clinical information is permanently recorded, and other health-care departments can review it and communicate with one another.

Basic computer knowledge and skills are usually taught through the hospital’s in-service education department. Each nursing station usually has a computer screen to display information, a keyboard to enter and retrieve data, and possibly a printer to produce printed copy. The entire patient record or just a part of it may be retrieved and printed. Today, many health-care practitioners use hand-held bedside computer documentation systems. Bedside computer devices, referred to as point-of-care (POC) systems, commonly include specific clinical prompts for data entry, which result in records that are more accurate and complete.

Good charting skills are essential to critical thinking and patient assessment—they provide the basic means to collect clinical data, analyze it, assess it, and formulate a treatment plan. Furthermore, good charting skills document the effectiveness of patient care and adjustments of the treatment plan in response to its effectiveness. Without good charting systems and skills, the practitioner merely administers health care without a predetermined (and recorded) goal.

Historically, respiratory care practitioners have focused on treating patients with specific disease entities and implementing physicians’ orders. Little planning was done by respiratory care practitioners to individualize their treatments for a specific patient. Today, a systematic problem-solving approach to respiratory care, based on broad theoretic knowledge, combined with technical expertise and communication skills, is essential.

Health Insurance Portability and Accountability Act

In 2003 the Department of Health and Human Services (HHS) proposed national rules that outlined the ways in which a patient’s medical files should be used or shared with others. These rules were adopted as federal standards after the passage of the Health Insurance Portability and Accountability Act (HIPAA). Today HIPAA requires that all health-care practitioners who have access to patient medical records prove that they have a plan to protect the privacy of the records. In essence, the HIPAA regulations protect the patient’s privacy with specific rules outlining when, how, and what type of health-care information can be shared. HIPAA gives the patient the right to know about—and to control—how his or her personal medical records will be used. The following provides a general overview of the HIPAA regulations:

• Both the health-care provider and a representative of the insurance company must explain to the patient how they plan to disclose any medical records.

• Patients may request copies of all their medical information and make appropriate changes to it. Patients may also ask for a history of any unusual disclosures.

• The patient must give formal consent should anyone want to share any health information.

• The patient’s health information is to be used only for health purposes. Without the patient’s consent, medical records cannot be used by either (1) a bank to determine whether to give the patient a loan or (2) a potential employer to determine whether to hire the patient.

• When the patient’s health information is disclosed, only the minimum necessary amount of information should be released.

• Records dealing with a patient’s mental health get an extra level of protection.

• The patient has the right to complain to HHS about violations of HIPAA rules.

One disadvantage of the HIPAA regulations, according to many health-care practitioners, is that the health-care provider must allocate large sums of money to comply with the HIPAA rules—dollars that might be better spent elsewhere. Critics also argue that this cost will likely be passed on to the consumer. In addition, many health-care providers believe that the quality of patient care will be compromised as a result of HIPAA, making it more difficult for various health-care practitioners to obtain vital information regarding patient care. For example, consider the potential HIPAA-related problems for a health-care team in a Miami, Florida, hospital that is trying to obtain the pharmaceutical history—in a timely fashion—of an elderly, unconscious car accident victim whose medical records are in a Detroit, Michigan, hospital. Proponents of the HIPAA regulations argue that this is the tradeoff made to ensure the privacy of an individual’s health-care information. Regardless of the pros or cons of the HIPAA regulations, the respiratory therapy practitioner—like all other health-care providers—must comply with the current HIPAA regulations.

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