Continuity of Care

The medical record is a communication device by which health care professionals share their knowledge, assessment, and care of a patient. It allows for continuity of care in the outpatient setting as well as in an inpatient setting. For example, in an office setting, the patient may be seen in January for an ear infection and not return to the office until late November for another ear infection. By looking back on the documentation of the January visit, the physician might select the same antibiotic that worked previously. Or, for example, the patient may have a serious wound infection that is not healing. By looking at the medical record and reading the documentation, a new team member can eliminate things that previously failed to work and then can recommend a different treatment.

Legal Protection

The primary evidence used in court is the medical record. In a trial, your written communication will either help your care or hurt it. The golden rule in charting is “If it was not charted, it was not done.” Jurors from medical malpractice cases have been polled after the verdict has been rendered and the most important piece of evidence in their decision was the medical record.

You cannot depend on your memory to recall the facts. Malpractice suits often take years to come to trial. At minimum, you must document what was done, when it was done, who did it, and the patient’s response to the treatment.

Reimbursement Documentation

Accurate written documentation communicates to insurance companies what care was provided and what supplies were used. Third party payers review the medical record to determine what supplies were used, if they were needed, or if the tests (e.g., x-ray, blood work) were necessary and delivered appropriately. After the review, the insurance company will decide if the medical setting is eligible for reimbursement. Reimbursement is the payment made by an insurance company to a health care setting for medical services.

For example, assume that a patient develops a moderate nosebleed and needs a posterior nasal balloon. The chart note stated, “Pt had a nose bleed. Pressure applied. Dr. Jones into see pt.” Nowhere in the medical record did anyone document that a posterior nasal balloon was inserted. The third party payer can refuse to pay (reimburse) for the balloon costs.

Patient education must also be documented for the insurance company to reimburse the health care setting for this service. For example, assume that you are working in a clinic and spend an hour educating a patient about a particular skill. In some situations, the physician’s office can bill the insurance company for that teaching. However, if the medical record does not reflect that the education occurred and the length of time, the insurance company will not reimburse for the education.

In the hospital setting, peer review organizations (PRO) will examine charts to determine whether the patient’s length of stay was appropriate. Unless documentation supports additional hospital stay, the institution or setting may not be compensated for the difference. For example, assume that Paula Morrello was admitted to the hospital for pneumonia. The morning that she was to be discharged, she developed a rash and thus was kept overnight for observation. According to the Diagnostic Related Groups (DRG) (Box 7-1) standards, patients with pneumonia should be discharged in 3 days, but because of this rash this patient remained in the hospital for another day. Unless the documentation clearly states the need for the additional hospital stay, Medicare will not cover the extra day in the hospital. It will claim that it was simply “an allergic rash and that the treatment could have been managed at home” and the hospital will lose that money. Make sure you document any change in the patient’s condition that would warrant a change in the plan of care.

Quality Improvement Data Collection

Health care settings look at medical record documentation for quality improvement purposes. Quality improvement is the process of identifying a problem, educating staff about the problem, and then reevaluating to see if the problem has been improved or resolved. Quality improvement programs are required by many regulatory agencies. For example, assume that you are working in an outpatient clinic and your supervisor has reviewed medical records and identified that “allergies to medications are not being documented.” She can create a quality improvement program to fix this problem. She would start by communicating this problem to her staff and explaining why charting this information is important. And then, she would review new charts to see if the problem has been corrected. If the problem has not been corrected, she could do additional staff education or impose disciplinary action.

Staffing and budgetary needs can also be evaluated based on documentation. For example, assume that you are working in an outpatient mental health clinic that has two shifts (days and evenings). By comparing the number of patient visits and procedures done on various shifts, the supervisor can request more staffing during peak hours.

Regulatory Requirements

Regulatory agencies review medical records for documentation accuracy. They review medical records because documentation is an essential component of communication in the medical community. Failure to properly document in the medical record can result in fines and loss of certification to a health care setting. The types of regulatory agencies that affect your job will vary based on your job title and employment site.

Use Military Time

Many health care facilities require that time entries be listed in military format. Military format is a 24-hour-clock system that allows each hour to be listed clearly without the confusion of a.m. versus p.m. (Fig. 7-1). Following is an example of a communication mishap that can occur when military time is not used. Which charting example gives a clear picture of when the patient fell?

Use Approved Abbreviations and Symbols

Abbreviations are short cuts to writing a complete word or phrase. When used correctly, they can save time, but if used incorrectly they lead to confusion. Incorrect abbreviations have led to errors in surgery (wrong limbs removed), wrong dosages of medications ordered or given, and incorrect tests or therapies initiated or cancelled.

On January 1, 2004, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released new standards regarding the use of abbreviations within health care settings. These standards were developed to improve patient safety. Table 7-1 lists the abbreviations that may not be used. It is important to stress that this list changes periodically and the standards are updated frequently. It is your responsibility to remain current. Failure to comply with JCAHO standards can result in fines and loss of an institution’s accreditation.

In addition to the above JCAHO standard, all health care settings, both inpatient and outpatient, are required to have a policy stating which abbreviations can be used and what the abbreviation means at that institution. Failure to follow the policy can affect your performance evaluation, your job security, and, most importantly, the patient’s safety.

Symbols can also save time. Common symbols are > (greater than), < (less than), (female), and (male). These must be listed in the policy manual as well.

Following is an example of a communication mishap related to abbreviations.

This sentence was charted; “Pt had normal bs this pm.” What was normal this morning?

The answer is unclear and ambiguous.

Here is another example. What does the abbreviation pm mean?

If you are using abbreviations, be sure to use only ones acceptable at your health care setting, and write them neatly.

Use Correct Punctuation

The placement of a comma or period can completely change the message. Pay special attention to punctuation marks. Following is an example of a communication mishap related to the lack of a period.

This sentence was charted; “Foley catheter removed in cardiac chair reading a magazine.” Where was the Foley catheter removed … in the cardiac chair? In reality, it should have been recorded: “Foley removed. In cardiac chair reading a magazine.” It may seem a small mistake, but imagine defending yourself in court that you removed the catheter in bed and then put the patient into the chair. It is important not to leave any potential area for confusion or speculation.

The lack of a period or a period in the wrong place can lead to serious patient injury. For example, assume that you are working in an outpatient clinic and chart that you gave the patient 25 milligrams of a medication. However, the correct dosage was 2.5 milligrams. You may actually have given the correct dosage, but you charted it incorrectly. From a legal standpoint, you gave the patient 25 milligrams. The difference between those two dosages can be fatal.

Use the Active Voice

When writing in a medical record, use the active voice. An active voice conveys a natural and direct portrayal of events. The passive voice is an indirect and obscure recording. For example, “dressing changed” (passive) should be written as “changed dressing,” which is in the active voice. Rather than writing “Dr. Rodriquez contacted,” write “Contacted Dr. Rodriquez.” An easy way to remember this is to start your charting sentences with a “verb.”

Spell Correctly

Errors in spelling are unacceptable. They convey unprofessionalism, laziness, and poor judgment.

This sentence was charted: “A fowl smelling drainage was noted.” Was the drainage foul smelling or did it smell like a fowl? The answer may seem obvious, but a prosecuting attorney will be able to place doubt in the mind of the jurors. Here are a few examples of spelling errors: