11

The Medical RecordCHAPTER 2Michele P. West

CHAPTER OBJECTIVESThe objectives for this chapter are the following:

1. Brieflydescribethemedicalrecordinpaperandelectronicforms,includingmedicalrecordconfidentialityandsecurity

2. Reviewdocumentationstandardsforthephysicaltherapistandphysicaltherapistassistant3. Describe thedifferentcomponentsof themedical record, includingadetailedoutlineof theadmission

historyandphysical

PREFERRED PRACTICE PATTERNSThe medical record is multifactorial and applies to many body systems. For this reason, specific practice patterns are not delineated in this chapter. Please refer to Appendix A for a complete list of the preferred practice patterns to identify the most applicable practice pattern for a given diagnosis.

The medical record, whether paper or electronic, is a legal document that chronicles a patients clinical course during hospitalization and is the primary means of communication between the various clinicians caring for a single patient. More specifically, the medical record contains information about past or present symptoms and disease(s), test and examination results, interventions, and the medical-surgical outcome.1 Additionally, the medical record may be used for educational purposes and for performing quality improvement studies, conducting research, and resolving legal issues such as competency or disability.2

The widespread use of electronic health records (EHR) has been promoted by the Health Information Technology for Economic and Clinical Health (HITECH) Act, which consists of three-stage criteria, including financial incentives for hospitals to comply with an EHR. Stage 1 calls for EHR compliance by the end of 2014, with penalties for those institutions or pro-viders not in compliance.3 Stages 2 and 3 are yet to be specifically defined. In conjunction with the transition to EHR, an initiative known as meaningful use has been developed to ensure providers are able to enhance the quality of patient care with the implementation of EHR.4

Specific advantages of an EHR compared with a paper record include complete and accurate patient health data that is readily available and shared with multiple providers to improve care coordination, the convenience of electronic prescriptions, the ability to track quality data, patient empowerment (by giving them access to their own records), and the potential for improved automatic patient follow-up.5

Confidentiality

According to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, any information in the medical record that contains protected health information (PHI) should be kept confidential, and all health care providers should safeguard the availability and integrity of health care information in oral, written, or electronic forms.6 PHI includes any information that pertains to the past, present, or future physical or mental health conditions of an individual, including provision of care, payment of care, and demographics.7 A subset of the Privacy Rule is the Security Rule, which specifically addresses the confidentiality of elec-tronic PHI (e-PHI). The Security Rule states that a covered entity must ensure the integrity

CHAPTER OUTLINEConfidentialityPhysical Therapist DocumentationPhysical Therapy Considerations

Components of the Medical RecordOrdersAdmission Note FormatProgress NotesReports

12 CHAPTER 2 The Medical Record

and availability of e-PHI that it creates, maintains, or trans-mits.8 The goal of the Security Rule is to protect e-PHI as institu-tions such as hospitals adopt new and efficient technologies.8 Specific topics, such as human immunodeficiency virus status, substance abuse, domestic abuse, or psychiatric history, are privileged information, and discussion of them is subject to additional ethical and regulatory guidelines.9

The physical therapist must be compliant with HIPAA,10 the American Physical Therapy Associations Guide for Profes-sional Conduct and Code of Ethics for Physical Therapists,11,11a and any policies and procedures of the facility or state in regard to sharing medical record information with the patient, family, caretakers, visitors, or third parties.

Documentation should be free of ambiguous acronyms or abbreviations to minimize misinterpretation and prevent errors that could result in patient safety issues (Table 2-1).13

These standards apply to the examination, evaluation, and plan of care portions of physical therapist documentation, including flow sheets. A documentation entry is required for every physical therapist visit and should include the following, if applicable14: Phone calls or conversations with other health care

providers Handouts provided to the patient, including exercise pro-

grams or educational materials The use of interpreter services Therapist response and assessment of an adverse event or

situationIdeally, documentation of physical therapy intervention

should occur at point of service or as close to the time of intervention as possible. If a documentation error is noted, correct the error as soon as possible. Be familiar with your institutions policy for correcting chart errors in written or electronic formats.

Physical Therapy Considerations

Be sure to document when a patient/family member declines or refuses therapy intervention or requests a specific time of day for therapy, including a rationale for such.

Documentation of deferring or holding therapy should include a rationale and the source of the deferral, whether it is from the physician, nursing, or other providers. Deferring physical therapy when originated from the therapists per-spective should be succinctly described.

Documentation of patient unavailability (e.g., off the floor at a test) is also suggested.

Components of the Medical Record

The organization of the medical record can vary from institution to institution; however, the medical record typically is com-posed of the following basic sections.

CLINICAL TIPToensureconfidentialityofPHI intheacutecaresetting, thephysicaltherapistshouldlogoffthecomputerwhennotinuse,keepthewrittenmedicalchartandflowbooksclosedwhennotinuse,coveranypaperworkkeptonclipboardswhentravelinginthefacility,andusediscretionwhendiscussingpatientinfor-mationinsharedrooms,hallways,and/orelevators.

Physical Therapist Documentation

The physical therapist should comply with the documentation standards including, but not limited to, the policies/procedures of the organization, the state, and the American Physical Therapy Associations Guidelines for Physical Therapy Documenta-tion of Patient/Client Management.12

In general, documentation must be: Dated and timed with an authenticated signature, including

therapist credentials Legible and in black ink (in a paper chart) Clearly labeled with the appropriate patient identification Complete, accurate, and objective Cosigned for a physical therapist assistant or student

therapist

TABLE 2-1 Prohibitive Abbreviations*

Do Not Use Potential Problem Use Instead

U, u (unit) Mistaken for 0 (zero), the number4 (four) or cc Write unit

IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten) Write International Unit

Q.D, QD, q.d., qd (daily)QOD., QOD, q.o.d., qod

(every other day)

Mistaken for each otherPeriod after Q mistaken for I and the O mistaken for the I

Write dailyWrite every other day

Trailing zero (X.0 mg)Lack of trailing zero (.X mg)

Decimal point is missed Write X mgWrite 0.X mg

MSMSO4 and MgSO4

Can mean morphine sulfate or magnesium sulfateConfused for one another

Write morphine sulfateWrite magnesium sulfate

*Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms.Exception: A trailing zero may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results,

imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.Data from The Joint Commission Official Do Not Use List. www.jointcommission.org. Last accessed June 9, 2012.

http://www.jointcommission.org

CHAPTER 2 The Medical Record 13

E. Personal and social history, including occupation, lifestyle, functional mobility status, the need for home or outpatient services, and architectural barriers at home

F. Current medications, including level of complianceII. Physical examination (objective information). Negative

(normal) or positive (abnormal) findings are described in detail according to the following:A. General information, including vital signs, laboratory

findings, mental status, and appearanceB. SkinC. Head, eyes, ears, nose, throat (HEENT), and neckD. Chest and backE. Heart (cor)F. AbdomenG. Genitalia/rectal examH. ExtremitiesI. Neurologic system

III. Assessment. The assessment is a statement of the condition and prognosis of the patient in regard to the chief com-plaint and medical-surgical status. If the etiology of the problem(s) is unclear, then differential diagnoses are listed.

IV. Plan. The plan of care includes further observation, tests, laboratory analysis, consultation with additional specialty services or providers, pharmacologic therapies, other inter-ventions, and discharge planning.

Progress Notes

A progress note is a shortened version of the initial note with an emphasis on any new physical findings, an updated assess-ment, and plan. The progress note section in a written record is typically multidisciplinary, with documentation from all caregivers in chronologic order. The nursing staff documents its own admission assessment, problem list, and care plan(s). Medi-cation reconciliation sheets, flow sheets, clinical pathways, consult service notes from other physicians and allied health professionals, and operative and procedural notes are also included in this section.

Reports

A variety of reports are filed chronologically in individual sec-tions in the medical record (e.g., radiologic or laboratory reports). Each report includes an interpretation or normal refer-ence ranges, or both, for various diagnostic or laboratory test results. Other types of reports include pulmonary function tests, electroencephalograms (EEGs), and stress testing.

Orders

The order section is a log of all instructions of the plan of care for the patient, including medications, diagnostic or therapeutic tests and procedures, vital sign parameters, activity level, diet, the need for consultation services, and resuscitation status. Orders may be written by a physician, physician assistant, or nurse practitioner. An order may be taken by a nurse or other health care provider, including a physical therapist, according to departmental, facility, and state policies. In the interest of patient safety and error prevention, the process of taking a verbal order, especially for medications, has been minimized in many hospitals.15 All (telephone) orders must be dated, timed, and signed or cosigned by the appropriate personnel. In addi-tion, a telephone order should be read back to the person giving the order for the purpose of verification.16

Physical Therapy Considerations The order section of the patients medical record should be

reviewed before the initial and any subsequent physical therapy intervention(s) for the following: the order for physi-cal therapy, patient activity level, weight-bearing status (if applicable), vital sign parameters, and positioning restric-tions (if applicable). On subsequent physical therapy ses-sions, the review of the order section offers a snapshot of change(s) in a patient. Look for new or discontinued medica-tions, changes in PO status, and new laboratory or diagnostic testing orders.

If an order appears incomplete or ambiguous to the physical therapist, clarify the order before beginning physical therapy.

Admission Note Format

The following outline summarizes the basic format of the initial admission note (often referred to as the H&P, or History and Physical) written by a physician, physicians assistant, or nurse practitioner in the medical record.17 The italicized items indi-cate the standard information the physical therapist should review before beginning an intervention.I. History (subjective information)

A. Data that identify the patient, including the source and degree of reliability of the information

B. History of present illness (HPI), including the chief com-plaint and a chronologic list of the problems associated with the chief complaint

C. Medical or surgical history, risk factors for disease, and allergies

D. Family health history, including age and health or age and cause of death for immediate family members as well as a relevant familial medical history

ReferencesEHRIncentivePrograms/30_Meaningful_Use.asp#BOOKMARK1. Accessed March 20, 2012.

4. Blumenthal D, Tavenner M: The meaningful use regulation for electronic health records, N Engl J Med 363(6):501-504, 2010.

1. Roach WH et al: Medical record entries. In Medical records and the law, ed 4, Boston, 2006, Jones and Bartlett, pp 51-61.

2. Monarch K: Documentation, part 1: principles for self-protection, AJN 107(7):58, 2007.

3. Centers for Medicare and Medicaid Services: CMS HER meaningful use overview (website): http://www.cms.gov/

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14 CHAPTER 2 The Medical Record

11. American Physical Therapy Association: Code of ethics for the physical therapist (website): http://www.apta.org. Accessed March 20, 2012.

11a. American Physical Therapy Association: Guide for professional conduct (website): http://www.apta.org. Accessed March 20, 2012.

12. American Physical Therapy Association. Guidelines: Physical therapy documentation of patient/client management BOD G03-05-16-41 (website): http://www.apta.org. Accessed March 20, 2012.

13. The Joint Commission: Official do not use list (website): http://www.jointcommission.org/topics/patient_safety.aspx. Accessed March 20, 2012.

14. American Physical Therapy Association:. Improving your clinical documentation: reflecting best practice (website): http://www.apta.org/Documentaion/DefensibleDocumentaion. Accessed March 20, 2012.

15. The Joint Commision: Comprehensive Accreditation Manual for Hospitals (CAMH), Update 2. September 2011.MM.04.01.01.

16. The Joint Commision: Comprehensive Accreditation Manual for Hospitals (CAMH), Update 2. September 2011. PC.02.01.03.10.

17. Surviving the wards: evaluating the patient (H&P). In Ferri FF, editor: Practical guide to the care of the medical patient, Philadelphia, 2010, Mosby, pp 1-3.

5. U.S. Department of Health and Human Services, The Office of the National Coordinator for Health Information Technology: Electronic health records and meaningful use (website): http://healthit.hhs.gov/portal/server.pt?open512&objID=2996&mode=2. Accessed March 20, 2012.

6. U.S. Department of Health and Human Services: Health information privacy (website): http://www.hhs.gov//ocr/privacy/hippa/understanding/coveredentities/index/html. Accessed March 20, 2012.

7. U.S. Department of Health and Human Services: Summary of the privacy rule (website): http//:www.hhs.gov/ocr/privacy/hippa/understanding/summary/privacysummary.pdf. Accessed March 20, 2012.

8. U.S. Department of Health and Human Services: Summary of the security rule (website): http:www.hhs.gov/ocr/privacy/hippa/understanding/srsummary.html. Accessed March 20, 2012.

9. Rutberg MP: Medical records confidentiality. In Weintraub MI, editor: Neurologic clinics: medical-legal issues facing neurologists, Neurol Clin 17:307-313, 1999.

10. Office for Civil RightsHIPAA: Medical privacynational standard to protect the privacy of personal health information (website): http//:www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/index.html. Accessed March 20, 2012.

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2 The Medical RecordChapter OutlineChapter ObjectivesPreferred Practice PatternsConfidentialityPhysical Therapist DocumentationPhysical Therapy Considerations

Components of the Medical RecordOrdersPhysical Therapy Considerations

Admission Note FormatProgress NotesReports

References