Documentation and Medical Records
Documentation and Medical Records
Documentation and Medical Records
DOCUMENTATION AND
MEDICAL RECORDS
2
Learning Objectives
▪ To discuss the importance of documentation in medical
practice.
▪ To list the main elements of documentation.
3
DOCUMENTATION
4
Definition of Documentation
▪ Documentation is the recording of the care delivered to a
patient by a health care professional (doctor, nurse,
physiotherapist, clinical dietitian or others) in his/her
professional capacity.
▪ This includes all forms of documentation: paper medical
records, electronic medical records, audiotapes, videotapes,
emails, images, incident reports, etc.
▪ Documentation is an instrumental part of clinical practice.
5
Purpose of Documentation
▪ Communication: Documentation is the basis for
communication between different health care professionals.
▪ Accountability: Documentation demonstrates the
accountability of the health care professional and it records
his/her professional practice (clinical judgment, management
plans etc).
▪ Legislative requirements: documented information can be
used in critical incident reviews and legislated inspections.
▪ Quality improvement: Documentation can be used for
performance reviews.
▪ Research: documentation is a valuable source of data for
health care researchers.
6
Characteristics of Documentation
▪ Documentation should be:
o Clear
o Concise
o Consecutive
o Correct
o Contemporaneous
o Complete
o Comprehensive
o Collaborative
o Patient-centered
o Confidential
o Based on professional observation and assessment with the
absence of personal judgments.
8
What to document?
▪ Problem list of significant medical conditions.
▪ Medications
▪ Allergies and any adverse drug reactions
▪ Demographic information
▪ Life style such as smoking status, alcohol, exercise
▪ Immunization record
▪ Pertinent history
▪ Physical exam
▪ Assessment
▪ Management Plan including tests, medications etc
▪ Patient education
▪ Follow Up
How to document?
▪ Patient name, date and time
▪ Relevant history and physical findings
o Positive findings
o Important negative findings
▪ Assessment
o Working, differential, and final diagnosis
▪ Plan of action
o Investigations, consultations/referrals, treatment, follow-up
o Rationale for the plan
▪ Information given to patient
o verbal or written instructions, questions asked and responses given, apparent
understanding, consent
o any disagreement or refusal of care
▪ Signature of writer and position
10
CODING
12
Medical Coding
▪ Medical coding is the transformation of healthcare diagnosis,
procedures, medical services, and equipment into universal
medical alphanumeric codes.
▪ Different Coding:
o ICD
o ICPC
13