Lecturer Of Physical Therapy

Basic Science Department

 Application Types of Medical Records
There are three types of medical record which are:-
a) Paper based medical record
b) Electronic medical record
c) Hybrid medical record
 a) Paper based medical record:-
1- Information about a patient health treatment
produced, stored and accessed in paper format
within a healthcare institution.
Paper-based record management systems have been
the traditional and primary method of storing
business records and other documents until the later
part of the 20th century. Usually, it includes the
processes of maintaining and storing physical or
hard-copy documents.
a) Paper based medical record:-
s of Medical Records?
Advantage:
1. Easy
2. Simple
3. Not cost
4. Not require training
5. Available
6. No downtime
a) Paper based medical record:-
Disadvantage:-
1- Content:
• Data:-Missing, Never acquired, not recorded, lost, Illegible,
Inaccurate, incomplete
2- Format:
• Data fragmented and not designed for dealing with multiple
problems over time.
• Usually organized chronologically NOT problematically
3- Access, Availability and Retrieval:
• Records unavailable 10-30% of the time record movement
• Simultaneous use impossible
4- Linkages and integration:
Discontinuity
 b) Electronic medical record:-
An electronic medical record (EMR) is a digital
version of the traditional paper-based medical record
for an individual. The EMR represents a medical
record within a single facility, such as a doctor's
office or a clinic.
Electronic components of the Medical Record
consist of patient information from multiple
Electronic Health Record source systems.
 Advantages of Electronic medical record:-
1. Providing accurate, up-to-date, and complete information
about patients at the point of care
2. Enabling quick access to patient records for more
coordinated, efficient care
3. Securely sharing electronic information with patients and
other clinicians
4. Helping providers more effectively diagnose patients,
reduce medical errors, and provide safer care
5. Improving patient and provider interaction and
communication, as well as health care convenience
6. Enabling safer, more reliable prescribing
 Advantages of Electronic medical record:-
7. Helping promote legible, complete documentation and
accurate, streamlined coding and billing
8. Enhancing privacy and security of patient data
9. Helping providers improve productivity and work-life
balance
10. Enabling providers to improve efficiency and meet their
business goals
11. Reducing costs through decreased paperwork, improved
safety, reduced duplication of testing, and improved health.
Disadvantages of electronic health record:-
1- Potential Privacy and Security Issues: As with just about
every computer network these days, EHR systems are
vulnerable to hacking, which means sensitive patient data
could fall into the wrong hands.
2- Inaccurate Information: Because of the instantaneous
nature of electronic health records, they must be updated
immediately after each patient visit — or whenever there is
a change to the information. The failure to do so could mean
other healthcare providers will rely on inaccurate data when
determining appropriate treatment protocols.
Disadvantages of electronic health record:-
3- Frightening Patients Needlessly: Because an electronic
health record system enables patients to access their
medical data, it can create a situation where they
misinterpret a file entry. This can cause undue alarm, or
even panic.
4- Malpractice Liability Concerns: Issues associated several
potential liability with EHR implementation. For
example, medical data could get lost or destroyed during
the transition from a paper-based to a computerized EHR
system, which could lead to treatment errors. Since
doctors have greater access to medical data via EHR, they
can be held responsible if they do not access all the
information at their disposal..
c) Hybrid medical record
Hybrid record consisting of both electronic and
paper documentation. Documentation that
comprises the Medical Record may physically exist
in separate and multiple locations in both paper-
based and electronic formats.
c) Hybrid medical record
Advantages of Hybrid medical record:-
• Attractive option for hospitals to avoid huge costs
of conversion of paper medical records into digital
record.
• Provide alternative to professionals to use both
paper and electronic medical record.
c) Hybrid medical record
Disadvantages of Hybrid medical record:-
• It’s difficult to use both paper and electronic for
professional health
• Cost needs extra staff to maintain both manual
and electronic record.
examples of SOAP notes to provide a better understanding
of how they are structured:
Example 1:
Subjective: Patient reports persistent cough and mild chest
pain for the past week. Denies fever or shortness of breath.
No significant medical history.
Objective: Vital signs within normal limits. Clear breath
sounds on auscultation. Chest X-ray reveals no
abnormalities.
Assessment: Diagnosis of acute bronchitis.
Plan: Prescribe cough suppressant medication and advise on
rest and hydration. Follow up in one week for reassessment.
Example 2:
Subjective: The client's chief complaint is anxiety and difficulty
sleeping. Reports feeling overwhelmed and stressed due to
work-related issues.
Objective: Elevated heart rate and blood pressure. Difficulty
maintaining eye contact during the session. Observable signs of
agitation and restlessness.
Assessment: Diagnosis of generalized anxiety disorder.
Plan: Initiate cognitive-behavioral therapy sessions and consider
medication management. Encourage relaxation techniques and
stress-reducing activities. Follow up in two weeks for progress
evaluation.
Example 3:
Subjective: Patient presents with a history of dental pain
and discomfort in the lower left molar.

Objective: Visible cavity and signs of inflammation on

dental examination. X-ray reveals decay and potential
infection.
Assessment: Diagnosis of dental caries with pulp
involvement.
Plan: Schedule root canal therapy and prescribe antibiotics
for infection control. Provide post-treatment care
instructions and schedule a follow-up appointment for
restoration.
Progress Notes:
Progress notes are written records by healthcare
professionals, including physical therapists, that document
the details of a session with a patient. They provide insights
into a patient's well-being, the interventions utilized, and the
subsequent plan of action. These notes assist in monitoring
the client's progress and form the backbone of effective
treatment documentation.
Importance of Progress Notes:
Progress notes are crucial for several reasons.
• They help evaluate the effectiveness of treatment and decide
whether changes to the treatment plan are to be made.
• They assist the therapist in keeping sessions on track,
preventing them from escalating into irrelevant discussions.
Without notes, therapy sessions could easily lose their focus.
• They also highlight basic details of a therapy session,
diagnosis and assessment information, clinical test results, as
well as clinical observations about the patient's current mental
health and progress in their treatment plan.
Here are some key components that should be included in progress notes:
 Time and Date of Entry: This provides a clear timeline of care and
verifies when the session took place.
 Duration of Sessions: This gives an idea of the length of each therapy
session.
 Signature: This authenticates the note and verifies the professional who
provided the care.
 Patient's Progress: This includes details on the patient's progress overall,
important identifiers, and relevant notes from the session that took place.
 Plan for Next Session: Note what you plan to discuss in the next
appointment and whether you assigned any exercises for your patient to
complete before their next session.
 Additional Notes: These could include any coordination with other
healthcare professionals, such as psychiatrists, to discuss the current
medication's effectiveness and side effects.
Here are some different formats and templates commonly used
for progress notes:
SOAP Format: SOAP stands for Subjective, Objective,
Assessment, and Plan. This format organizes the note into
these four sections, allowing for a comprehensive overview
of the patient's condition and the treatment plan.
DA(R)P Format: This format includes Data/Describe,
Assessment, (Reaction), and Plan. It provides a structured
way to document the client's progress and the clinician's
response and plan for further treatment.
DART Format: Description, Assessment, Response, Treatment
Implications/Plan. This format focus on describing the
client's condition, assessing their progress, documenting the
response to treatment, and outlining the implications for
further treatment .
BIRP Format: Behaviors, Intervention, Response, Plan. This
format emphasizes documenting the client's behaviors, the
interventions used, the client's response to the interventions,
and the plan for future treatment.
Basic Note Format: This is a simplified format that provides a
structured way to document a client's progress in therapy. It is
designed to create professionally narrated notes and is
available in Note Designer software.
Psychotherapy Progress Notes Templates: Many treatment
software solutions offer a variety of formats and outlines for
different healthcare subsectors, such as psychiatry and
counseling. For instance, Therapy Notes comes with
Psychotherapy Progress Notes templates and a step-by-step guide
to help psychologists write effective progress notes