Sample Medical Records documentation

B. MEDICAL RECORDS

A.General Documentation Rules & Guidelines

1.General – The hospital initiates and maintains a complete and accurate medical record for every individual assessed or treated. (JCAHO IM 6.10 EOP #6; COP 482.24 (b); DOH 115.31 (a); DOH 119.24) The attending practitioner will prepare a complete and legible medical record for each of his or her patients. (COP 482.24 (c) (1) The contents of all the records should be enough to identify the patient, support the diagnosis, justify the treatment, document the results of treatment accurately, and promote the continuity of care among healthcare providers. (JCAHO IM 6.10 EOP #6; COP 482.24 (c); DOH 115.32 (a).

2. Inpatient History and Physical (H&P) Requirements- (JCAHO PC 2.120) A physical exam and medical history must be done no more than 30 days before or within 24 hours after an admission for each patient by the attending physician.[1]In order for H&P’s to be transcribed and available in the EMR and on the patient record within 24 hours after admission it is recommended that physicians dictate their H&P’s no later than 12 hours after admission. (JCAHO MS 2.10 EOP #7; JCAHO PC 2.120 EOP #2; COP 482.22 (c) (5) Ref: S&C-02-15 January 28,2002; DOH 115.32 (b) A history and physical completed outside of the hospital (within 30 days of the current admission) by a licensed independent practitioner at the hospital to which the patient is admitted may be used to fulfill the H&P requirement, so long as a durable, legible copy of the history and physical is made part of the patient record within 24 hours after admission. Or when a patient is readmitted to the hospital within 30 days of the date of admission for the same or related problem, the original history and physical may be utilized provided it was not completed more than 30 days prior to the admission date.

a.Interval Note Requirements- If the history and physical being utilized for a particular admission was done more than 7 days prior to the admission date, an interval admission note must be completed documenting any additions or changes to the original history and physical. The interval note must be written within 24 hours after admission.

  1. Outpatient Surgery History and Physical (H&P) Requirements- (JCAHO IM 6.30) Before surgery there must be a complete history and physical on the chart of every patient and any indicated diagnostic tests and pre-operative diagnoses must be completed and recorded in the patient’s record. If the history and physical has been dictated, surgery cannot begin until the H&P has been transcribed and placed on the patient’s record. If the H&P has not been dictated, a written H&P must be recorded in the medical record prior to surgery. The contents of the H&P whether dictated or written must be consistent with the contents of the H&P as noted in section 7.

When practitioners do not record the H&P before an operative or invasive procedure or any diagnostic procedure requiring informed consent, the Hospital will cancel the procedure, except in emergencies or unless the attending physician/surgeon states in writing that such a delay would be detrimental to the patient. (JCAHO MS 6.3; JCAHO PE 1.8; JCAHO IM 6.30; email from 2/9/04)

a. Interval Note Requirements- If the history and physical being utilized for a particular surgery was done more than 7 days prior to the surgery date, an interval note must be completed documenting any additions or changes to the original history and physical. The interval note must be written prior to surgery.

4. H&P’s Greater Than 30 Days Old- H&P’s that are greater than 30 days old will not be accepted. A new H&P will have to be performed by an appropriate licensed independent practitioner. (JCAHO web site Q&A’s August 28,2001; JCAHO PC 2.120 EOP #6)

5. Prenatal H&P Requirements- It is recognized that the prenatal patient is a special situation in that, in and of itself, the prenatal course of care is a planned, systematic updating of the H&P performed at the first visit throughout pregnancy. As such, the entire prenatal record can be utilized as the H&P, provided that it is updated to reflect the patient’s condition upon admission. (JCAHO Q&A) For all patients having a c-section a H&P is required prior to surgery. See Section 7 for H&P Content Requirements.

6. H&P Requirements For Any Patient Admitted For Dental/Podiatric Care- Any patient admitted for dental/podiatric care must have a H&P done and recorded by a physician member of the Medical Staff. The dentist/oral surgeon or podiatrist is responsible for the part of the H&P and any other documentation related to their specialty. (JCAHO MS 6.2.2) Podiatrists are responsible for the part of the patient’s H&P that relates to podiatry. (JCAHO MS 6.2.2.3) Qualified oral and maxillofacial surgeons may perform the medical history and physical examination, if they have such privileges, in order to assess the medical, surgical, and anesthetic risks of proposed operative and other procedure(s). (JCAHO MS 2.10) A qualified and credentialed Podiatrist or Dentist can independently perform all of the inpatient and outpatient H&P, if given those privileges through the medical staff process, subject to applicable state law. Under such circumstances the medical staff is to identify any high-risk patients that would require confirmation or endorsement of the H&P by a qualified surgeon. (JCAHO MS 2.10 Q&A Effective 12/22/00 Updated 8/5/02)

7. H&P Content Requirements-

  1. Chief complaint. (COP 482.24 (c) (2) (iii)
  2. History of present illness.
  3. Relevant past, social, family history. (appropriate to the patient’s age)
  4. Inventory by body systems or review of systems.
  5. Physical Exam. (JCAHO MS 2.10; JCAHO IM 6.30)
  6. Conclusions/impressions drawn from the history & physical.
  7. A treatment plan.

8. Operative Documentation Requirements- In addition to the history and physical, the medical record thoroughly documents operative or other procedures and the use of moderate or deep sedation or anesthesia. (JCAHO IM 6.30)

  1. A provisional diagnosis is recorded before the operative procedure by a licensed independent practitioner (LIP) responsible for the patient. (JCAHO IM 6.30 EOP #1)
  2. An operative progress note should be dated and timed and entered in the medical record immediately after the procedure and the note contains the following: (JCAHO IM 6.30 EOP #2)
  3. Name of primary surgeon and assistants.
  4. Findings.
  5. Procedures performed.
  6. Description of the procedure.
  7. Estimated blood loss.
  8. Specimens removed.
  9. Postoperative diagnosis.
  10. Operative reports dictated or written immediately after a procedure record the following:
  11. Name of the primary surgeon and assistants.
  12. Findings.
  13. Procedures performed.
  14. Description of the procedure.
  15. Estimated blood loss.
  16. Specimens removed.
  17. Postoperative diagnosis. (JCAHO IM 6.30 EOP #3)
  18. The completed operative report is authenticated by the surgeon and made available in the medical record as soon as possible after the procedure. (JCAHO IM 6.30 EOP #4)
  19. Postoperative documentation records the following:
  20. Patient’s vital signs and level of consciousness.
  21. Medications. (Including intravenous fluids)
  22. Blood and blood components administered.
  23. Any unusual events or complications, including blood transfusion reactions and management of those events. (JCAHO IM 6.30 EOP #5)
  24. Postoperative documentation records the patient’s discharge from the postsedation or postanesthesia care area by the responsible LIP or according to discharge criteria approved by the Medical Staff. (JCAHO IM 6.30 EOP #6)
  25. The use of approved discharge criteria to determine the patient’s readiness for discharge is documented in the medical record. (JCAHO IM 6.30 EOP #7)
  26. Postoperative documentation records the name of the LIP responsible for discharge. (JCAHO IM 6.30 EOP #8)

9. Informed Consent- The physician will complete an informed consent form (and have the patient sign the form) for all procedures, investigative drugs therapyand other treatments for which policy requires informed consent. (COP 482.24 (c) (2) (v); JCAHO RI 2.40) An informed consent for surgery shall be part of the patient’s chart before the surgeon starts the surgery. (COP 482.51 (b) (2)

  1. Duty of physicians- Except in emergencies, a physician owes a duty to a patient to obtain the informed consent of the patient or the patient’s authorized representative prior to conducting the following procedures: (DOH 40 P.S 1303.504)
  2. Performing surgery, including the related administration of anesthesia.
  3. Administering radiation or chemotherapy.
  4. Administering a blood transfusion.
  5. Inserting a surgical device or appliance.
  6. Administering an experimental medication, using an experimental device or using an approved medication or device in an experimental manner.
  7. Description of procedure- Consent is informed if the patient has been given a description of a procedure set forth in subsection (a) and the risks and alternatives that a reasonably prudent patient would require to make an informed decisions as to that procedure (40 P.S. Section 1303.504 (a), (b)).

10. Signatures- All entries in the medical record must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. (JCAHO IM 6.10 EOP #1, DOH 115.33 (b), COP 482.24 (c) (i) (1), DOH 115.32) The responsible practitioner will accurately date and authenticate all clinical entries in the patient’s medical record. (JCAHO IM 6.10 EOP #2 and EOP #3, DOH 115.33 (e) Authentication can include signatures, Signature stamps (See on-line HIM P&P entitled Physician Stamp Signatures) written initials, or computer entry. (COP 482.24 (c) (1) (ii) Physicians may use electronic signatures to authenticate their transcribed reports. (See on-line HIM P&P entitled Physician Electronic Signature) Entries in patient charts concerning care (40 P.S.1303.511 (a.) [Act 13]) rendered shall be made contemporaneously or as soon as practicable after the care. Abbreviations and symbols in the patient record should adhere to the on-line abbreviation list. (DOH 115.33 (c) See Section 25 for specifics. It is preferred that practitioners will make all entries in blue or black ink using a ballpoint pen. The supervising physician must countersign all documentation by residents, nurse practitioners, and physician assistants. CNM’s do not have to have their documentation countersigned. (PA Bulletin Doc. No. 97-1212) At a minimum, the following must be authenticated: history and physical, operative report, consultations, and discharge summaries. (JCAHO IM 6.10 EOP #5) Verbal orders are the only entry that may be authenticated by someone other than the attending physician. For example, the physician covering rounds may sign verbal orders.

11. Faxed Signatures- Faxed signatures are an acceptable method of authorization (28 Pa. Code 115.23 (a)). When a faxed document/signature is included in the health record, the document with the original signature should be retrievable from the original source. (AHIMA Practice Brief: Maintaining a Legally Sound Health Record) Only under rare circumstances will the HIM Department fax incomplete records to physician offices to be signed and faxed back to the HIM Department. An example of a rare circumstance would be when a physician is not scheduled to return to the hospital for multiple weeks or when a physician or a group of physicians come to the hospital infrequently and their home practice is based outside of the Chambersburg/Waynesboro area. Physicians are strongly encouraged to use electronic signatures and to keep faxed signatures to a minimum.

12. Error Correction- Errors should be corrected as follows:

  1. Draw a line through the entry- a thin pen line. Make sure the inaccurate information is still legible.
  2. Sign and date the lined out entry using the current date and time.
  3. State the reason for the error in the margin or above the note if room permits.
  4. Document the corrected information. If the error is in a narrative note, it may be necessary to enter the correct information on the next available line/space documenting the current date and time and referring back to the incorrect entry.

Do not obliterate or otherwise alter the original entry by blacking out with marker, using whiteout, writing over an entry, etc. (AHIMA Practice Brief: Maintaining a Legally Sound Health Record) 40 P.S. 1303.511 (b) (2)[Act 13]).

13. Late Entries- (40 P.S. 1303.511 (b)(2) [Act 13]). When adding information to the chart which was not available or was otherwise not recorded contemporaneous with the events or shortly thereafter, late entries should be used. A late entry should:

  1. Identify the new entry as a “late entry”.
  2. Enter the current date and time.
  3. Specify the date and time when the documented events occurred.
  4. If the late entry is being used to document an omission, identify the source of the additional information as much as possible. (for example, where you obtained the information contained in the late entry)
  5. When using late entries, document as soon as possible. There is no time limit to writing a late entry.
  6. The late entry must contain the full signature of the author.

14. Addendums- An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry. With this type of correction, a previous note has been made and the addendum provides additional information to address a specific situation or incident. An addendum is documented in the following manner:

  1. Document the current date and time.
  2. Write “addendum” and refer to the original entry.
  3. Identify any sources of information used to support the addendum.
  4. When writing an addendum, complete it as soon after the original note as possible.

15. Legibility- All entries in the health record must be legible. (49 Pa. Code 16.95 (a)) If an entry cannot be read the following steps should be taken:

  1. The author should rewrite the entry on the next available line.
  2. Define what the rewritten entry is for, referring back to the original documentation.
  3. Legibly rewrite the entry.

Example: “Clarified entry of (date)” and rewrite, date and sign. The rewritten entry must be the same as the original. (AHIMA Practice Brief: Maintaining a Legally Sound Health Record)

16. References to Another Patient- If it is necessary to refer to another patient to describe an event, the other patient’s name should not be used. If necessary, the medical record number of the patient can be referenced. (AHIMA Practice Brief: Maintaining a Legally Sound Health Record)

17. Progress Notes- Practitioners will record progress notes at the time of observation. They should report (in pertinent chronological style) the patient's course in the hospital and reflect any changes in condition and the results of treatment. Practitioners will write, date and sign progress notes on a daily basis. All should be timed as well. The Hospital recommends that practitioners time the progress notes when they write multiple notes in a single day.

18. Patient Transfers- Transfer of a patient to another physician's service require awritten order by the transferring physician. The orders of transfer must be in the patient's medical record. Until physicians follow this sequence, the original physician is responsible for the patient.

19. Orders- The appropriate Medical Staff Department will formulate standing orders, which shall be reviewed by the Pharmacy & Therapeutics Committee and approved by the Medical Executive Committee. The attending physician will date and sign these orders. The Hospital will publish all standing orders and be available in each department at each nursing station. All orders for drugs and biologicals must be in writing and signed by the practitioner or practitioners responsible for the care of the patient. (COP 482.23 (c) (2) Practitioners will date and sign all non-standing orders or Physician Preference Protocol orders. (COP 482.24 (c) (2) (vi), DOH 115.33, DOH 107.62-107.65, DOH 107.61, JCAHO IM 6.50)

  1. Oral/Telephone Orders- (DOH 107.62)
  1. Oral orders for medication and treatment shall be accepted only under urgent circumstances when it is impractical for the orders to be given in written manner by the responsible practitioner. Oral orders shall be taken only by personnel qualified according to the medical staff bylaws who shall transcribe the orders in the proper place in the medical record of the patient. The order shall include the date, time and full signature of the person taking the order and shall be countersigned by a practitioner within 24 hours. If the practitioner is not the attending physician, he must be authorized by the attending physician and must be knowledgeable about the patient’s condition. (DOH 107.62) (JCAHO IM 6.50 EOP #2 and EOP #3)
  2. The medical staff bylaws shall specify personnel who are qualified to accept oral orders and shall specify that acceptance of orders is limited to personnel listed in this subsection, with restrictions as noted: (JCAHO IM 6.50 EOP #1)
  1. A licensed independent practitioner.
  2. A professional nurse.
  3. A licensed practical nurse.
  4. A pharmacist who may transcribe oral orders pertaining to drugs.
  5. A physical therapist who may transcribe oral orders pertaining to physical therapy regimens.
  6. A respiratory therapist who may transcribe oral orders pertaining to respiratory therapy treatments.
  7. A paramedic practicing under DOH 117.30 (relating to emergency paramedic services)

b. Outpatient Orders- Pending.

20. Consultations- (DOH 115.32 d; DOH 107.12 16) Consultants will dictate or record a consultation report within a timely manner. The consult report will record the pertinent findings of the examination of the patient and the consultant's opinions and recommendations. When operative procedures are involved, consultants will record the consultation note before the operation, except in emergencies so verified in the record. Physicians are encouraged to dictate their consultations so that they will be available in the MIG and the EMR.

21. Reports of Pathology, Clinical Lab Examination, Radiology, Nuclear Medicine, or other Diagnostic or Therapeutic Procedures- Diagnostic testing and procedures are performed as ordered. Diagnostic testing and procedures are performed in a timely manner as defined by the hospital. When a test report requires clinical interpretation, relevant information is provided with the request. (JCAHO PC.3.230 EOP #1 and EOP #2 and EOP #3) The radiologist or other practitioner who performs radiology services must sign reports of his or her interpretations. (COP 482.26 (d) (1) Signed x-ray reports of all examinations performed shall be made a part of the patient’s hospital record. (COP 482.25 (d) The hospital must maintain signed and dated reports of nuclear medicine interpretations, consultations, and procedures. The practitioner approved by the medical staff to interpret diagnostic procedures must sign and date the interpretation of these tests. (COP 482.52 (d), COP 482.53 (d) (2)

22. Final Diagnoses- The attending physician will record final diagnoses for all patient types (i.e., inpatients, outpatients) at the time of discharge. Practitioners will record the final diagnoses in full by dictating the discharge summary or writing the final diagnosis on the face sheet of the medical record . (DOH 115.32 f)