An adequate unit medical record shall be
maintained for every individual who is evaluated or treated as an inpatient,
outpatient, or emergency patient at the
The purposes of the medical records are:
1.
To serve as a basis for
planning patient care and for continuity of care;
2.
to furnish documentary
evidence of the course of the patient’s medical evaluation, treatment and
change in condition during the hospital stay or during an outpatient or
emergency visit;
3.
to document communication
between the responsible practitioner and any other health professional
contributing to the patient’s care;
4.
to assist in protecting the
legal interest of the patient, the hospital and the responsible practitioner;
5.
to provide data for use in
continuing education and research; and
6.
to submit accurate
diagnostic and procedural information for billing purposes.
Documentation
may be completed in the satellite Medical Record Technician (MRT) areas for
Newborn, OB/Gyn, and Pediatric services (below). Records will remain in the Newborn and
Pediatric MRT areas for 4 days after discharge and in the OB/Gyn MRT area 9
days after discharge. Records may not be
removed from these areas unless checked out by Health Information Management
personnel. From the MRT areas records
are sent to the Record Processing (RP) area in the Health Information
Management Department and remain there until complete. RP is open from
A faculty physician may request to have
incomplete medical records available for completion in his/her office between
MEDICAL
RECORD TECHNICIAN AREAS
|
SERVICE |
MRT |
LOCATION |
EXTENSION |
|
NB Nursery/ISCU |
Melinda Garland |
Pavilion 6.10 4C |
20760, 22815 |
|
OB/GYN |
Catherine Veniegas |
3.230 McCullough |
23337 |
|
Pediatrics |
Warlita Dondonay |
C 305 CHC |
23463 |
|
MRT Team Leader |
Marianna Young Almeda Simpson |
CSB #349 |
29267 |
1. History and Physical-requires completion within 24 hours of admission.
2.
Operative Reports-requires
completion immediately after surgery.
3.
Discharge Summary-recommend completion
day of discharge.
4.
Discharge Progress
Note/Final Discharge Note-recommend completion day of discharge.
5.
Telephone Orders-requires
signature within 48 hours of being given.
6.
Residents-it is recommended
that all records be completed within 14 days following discharge.
7.
Record completion by
residents and faculty is required within a period of time that in no event
exceeds 30 days following discharge.
Additional Completion Items:
a)
Completed by resident. Faculty signature required.
Note: If a certified nurse-midwife (CNM) is
responsible for the delivery and discharge of a patient, the faculty M.D. on
call must countersign the admit note, admit orders, discharge note and
discharge orders.
The OB/GYN Department employs the use of the
ClinWeb electronic medical record (EMR).
The EMR is used by the Regional Maternal & Child Health Program and
the labor and delivery area at UTMB.
GUIDELINES FOR COMPLETION OF
RECORDS PRIOR TO VACATION, EXTENDED LEAVE, OR PERMANENT LEAVE
1.
Complete all record work at
the nursing stations.
2.
Complete all record work in
Satellite MRT area, if appropriate.
3.
Report to Record Processing
and complete all available records.
4.
Return all records in your
possession to the Health Information Management Department.
5.
Faculty members notify
residents to complete all record work one week prior to your departure to
facilitate your record completion work.
6.
Physicians
permanently leaving UTMB, must obtain a UTMB Clearance & Release Form and
have it signed by Record Processing personnel.
The medical record shall contain sufficient information to identify the patient, to support the diagnosis, to justify the treatment and to document the results accurately. The following must be included:
1.
Identification data
including patient’s name, address, date of birth, name of legally authorized
representative and number identifying patient and his medical record (unit
history number);
2.
any emergency care provided
to patients prior to arrival;
3.
medical history of patient;
4.
the record and findings of
the patient’s assessment;
5.
a statement on the
conclusions or impressions drawn from the medical history and physical exam;
6.
diagnosis or diagnostic
impression;
7.
the reason(s) for admission and
treatment;
8.
diagnostic and therapeutic
orders;
9.
evidence of appropriate informed
consent; when consent is not obtainable the reason shall be entered into the
record;
10.
goal of treatment and
treatment plan
11.
clinical observations
including results of therapy;
12.
all operative and other
invasive procedures using acceptable disease and operative nomenclature that
includes etiology;
13.
reports of procedures,
tests, and the results;
14.
progress notes made by
medical staff and other authorized individuals;
15.
legal status for patients
receiving mental health services;
16.
all reassessments and
revisions of the treatment plan;
17.
response to care provided;
18.
consultation reports;
19.
every medication ordered or
prescribed for an inpatient;
20.
every dose of medication
administered and any adverse reactions;
21.
each medication dispensed to
or prescribed for ambulatory patient or inpatient on discharge;
22.
conclusions at termination
of hospitalization or evaluation/treatment;
23.
all relevant diagnoses
established during the course of care, and pre-existing conditions that impact
current care;
24.
any referrals or
communications made to external or internal care providers and to community
agencies;
25.
evidence of known advanced
directives
26.
discharge instructions to
the patient and family; and
27.
a discharge summary, a final
progress note/discharge note
or transfer summary.
Additional Documentation Guidelines
1.
When writing admit orders,
include the names of the attending and resident physicians.
2.
Use the consult form when
answering a request for consultation.
3.
If you are a resident
discharging a patient for another resident, document in the discharge order the
name of the resident for whom you are discharging the patient. The dictation can then be assigned correctly.
4. The diagnostic statement should be accurate, complete, specific, and descriptive of the patient’s condition. Be sure to indicate the following in all diagnostic statements, especially the principal diagnosis:
-acute vs. chronic
-type of condition
(congenital, acquired, late effect, etc.)
-size (be very specific,
especially with injury and neoplasm)
-size of laceration or lesions
removed
-any cause and relationship
between diagnostic statement
-current condition vs.
history of vs. status post vs. late effect
-full description, use
modifiers to accurately define
Current conditions and complications affecting the current hospital admission must be listed on the Final Discharge Note (for Internal Medicine the Discharge Progress Note is completed in lieu of the Final Discharge Note). Only significant past diagnoses/ procedures need to be listed.
5. Newborns/Obstetrics:
State statute defines “Live Birth” and “Fetal
Death” as follows:
A “Live Birth” is a product of conception,
irrespective of the duration of pregnancy, which, {after birth} breaths or
shows any other evidence of life such as beating of the heart, pulsation of the
umbilical cord or definite movement of voluntary muscles, whether or not the
umbilical cord has been cut or the placenta is attached; each product of such a
birth is considered live born.
To comply with Texas Statute, any “live
birth”, regardless of birth weight or duration of gestation, is to be admitted
to the ISCU. This includes the
preparation of a completed medical record and the assignment of a unit history
number.
A “Fetal Death” or stillborn is defined as, regardless
of the duration of pregnancy {after birth} the fetus does not breathe or show
any other evidence of life such as a heart beat, umbilical cord pulsation, or
definite movement of voluntary muscles.
Newborns born in this facility must have the
principal diagnosis of “Liveborn Infant” (include maturation, term
premature). Newborns en route to the
hospital and then admitted must have the principal diagnosis of “Newborn
Infant/Born en route to Hospital”, or something similar indicating the baby was
born prior to admission. Newborns born at
another facility and transferred here must have as the principal diagnosis, the
reason or condition of the newborn causing transfer and not a “newborn”
diagnosis (i.e., congenital heart defect, neonatal jaundice, apnea).
Abortion is defined as the expulsion or
extortion of all or part of the placenta or membrane, with or without an
identifiable fetus weighing less than 500 grams. When the weight of a nonviable fetus cannot
be determined, an estimated gestation of less than 22 completed weeks is
considered an abortion.
6. Late
Effects:
Late effects are defined as the sequelae or
residual effects of a diagnostic condition or injury that occurred after the
original diagnosis or injury has completed its actual stage. A late effect may manifest itself immediately
after the acute state or long after the acute stage has ended. Both the residual and cause must be stated
diagnostically, sequencing the residual first and the cause second.
7. Surgical/Medical
Complications:
All complications of medical
care, even if minor, readily treated, or resolved, must be stated on the Final
Discharge Note.
Complications can be principal diagnoses if they were the reason for
admission.
Complications of medical care include:
-Post-op conditions, i.e.
atelectasis, hematoma, hemorrhage, dehiscence of wound, infection, organ
failure, or insufficiency.
-Mechanical complications
which may include malfunction of devices, grafts, or implant.
-Adverse
reactions to drugs, medicines, procedures, contrast material.
8. Procedures:
All therapeutic procedures
and pertinent diagnostic procedures should be written on the Final Discharge
Note. Be sure to write full name of
the procedures, avoiding abbreviations on this
form. (For Internal Medicine the
Discharge Progress Note is completed in lieu of the Final Discharge Note).
- Biopsy done via endoscopy should
state both the biopsy and endoscopy.
This also applies to surgeries performed endoscopically (arthroscopic
menisectomy, etc.).
- All intra-operative radiology procedures must be listed.
- List intubations and ventilatory
support done for reasons other than O.R. procedures under general anesthesia.
- List all auxiliary O.R. procedures,
i.e., cardioplegia, extra corporeal circulation, endoscopy (diagnostic or
surgical), grafts (all types, harvest and recipient sites), prosthetic
devices. Operative approach and closure
need not be listed unless the approach and/or closure was unusual.
- Be sure all procedures are fully
defined, i.e., endoscopic surgery-what type of surgery, site of endoscopy;
repair of defect-what kind of defect was repaired and how, by simple suture,
graft, excision with anastomoses or other, dimension of lesions removed-size of
lacerations repaired.
Approval of Forms: Contact the UTMB
Forms Management Officer, for assistance when designing a medical record form
and for information regarding the approval process. For additional information regarding Medical
Records Forms Management, please refer to the Institutional Handbook of
Operative Procedures, Policy #9.2.8. All
reports originating in this hospital which comprise the medical record of a
patient will be original documents. If a
copy has been approved for inclusion in the record, it must be clearly marked
as an ‘Original’. Any exceptions must be
approved by the Health Information Committee.
FINAL DISCHARGE NOTE (FORM 5346)
The Final Discharge Note/Discharging Progress Note should be completed at the time of discharge by the physician. It should be signed (full signature) and dated by the resident and/or attending physician. Abbreviations should not be used on this form. The following must be recorded on the form:
Principal Diagnosis: The condition which, after study, occasioned admission to the hospital.
Complications (if present): The conditions
which developed after admission that may have extended the length of stay and
required use of additional resources, e.g., infections of any type including
urinary tract, septicemia, or complications of medical or surgical treatment.
Comorbidities (if existing): The conditions
that were present prior to admission that could extend the length of stay or
require additional resources, e.g. anemia, insulin dependent diabetes mellitus,
heart or pulmonary conditions.
Principal Procedure: The definite/therapeutic procedure most closely related to the principal diagnosis.
All other diagnoses and procedures must be
listed on the Final Discharge Note and must correspond with the results of any
tests performed as listed on the Operative Report and the Discharge Summary (if required).
The discharge plan must be documented, and
the availability of appropriate services to meet the patient’s needs after
hospitalization must be addressed.
Any revisions to diagnoses or procedures on
the Final Discharge Note must be initialed and dated by the attending
physician. (See attached example of form
in the back of this section).
The medical record shall contain evidence of
the patient’s informed consent prior to any procedure or treatment for which it
is appropriate. Consent is required for
certain procedures established by the Texas Medical Disclosure Panel. Only authorized UTMB consent forms should be
used.
Patients and, when appropriate, patients'
families, receive from their physician information necessary to give informed
consent prior to the start of any procedure and/or treatment.
Each patient’s need for translation of
consent forms will be addressed by the health care practitioner, who may be
assisted by on-site language-assistance personnel or language-assistance
through the telephone. Documentation of
translation, name of translator, date and time is recommended. Detailed
procedures regarding informed consent are available in policies 9.3.16 through 9.3.22.
In compliance with State and Federal statutes, particularly the Patient Self Determination Act, all adult inpatients and others as appropriate, are given a brochure titled, “Your Rights as a Patient, Making Critical Health Care Decisions” and are asked by a health care practitioner about the existence of Advance Directives. Related forms are available on the inpatient units for patient use if desired. Documentation of existing Directives is made on the Interdisciplinary Admission Assessment, form #5090.
Advance Directives are retained on the
current volume of the medical record and are filed behind the divider labeled
“Consents/Directives.”
HISTORY AND PHYSICAL EXAMINATION
REPORT (Form 2005)
A complete history and physical examination
shall, in all cases, be written and placed in the record within twenty-four
(24) hours after admission of the patient.
If a complete history and physical has been obtained within
thirty (30) days prior to admission in a physician staff member's office or in
a private or staff clinic, a durable legible copy of this report may be used in
the patient's hospital medical record, provided there have been no subsequent
changes or if there were changes, the changes have been recorded at the time of
admission.
Obstetrical records shall indicate prenatal
information. A durable, legible original
or reproduction of the office or clinical prenatal record is acceptable.
Patients transferred to and from the
psychiatric service must be discharged and readmitted since the psychiatry and
rehabilitation units are exempt under the Prospective Payment System
(PPS). Physicians can refer to the
History and Physical exam completed on the service prior to transferring
patients. However, any changes in
clinical findings should be documented by the receiving service.
This history and physical examination
includes at a minimum the patient’s chief complaint, present illness/injury,
review of systems, past history, family history and physical examination. The patient’s biophysical, psychosocial, cultural,
spiritual, developmental, educational, functional, nutritional, and
pain/comfort needs will be addressed as appropriate. The physician H&P will be filed in the
H&P section of the medical record.
The format for history and physical is as
follows:
1. Patient’s
Name
2. Unit
History Number
3. Date
4. Attending
Physician
5. Chief
Complaint
6. Present
Illness
7. Past
Medical History
8. Family
History
9. Social
History
10. Review
of Systems
a. General
b. Skin
c. HEENT
- Head - Nose
- Eyes - Throat
- Ears
d. Respiratory System
e. Cardiovascular
f. Gastrointestinal
g. Genitourinary
h. Musculoskeletal
i. Neurological
11. Physical
Examination
a. General
b. Vital Signs
- Blood Pressure - Pulse
- Temperature - Respiratory Rate
c. HEENT
d. Neck
e. Node Survey
f. Breasts
g. Chest
h. Lungs
i. Abdomen
j. Musculoskeletal
k. Extremities
l. Pelvic/Genital
m. Rectal
n. Neurological
o. Height
p. Weight
12. Diagnosis
or Diagnostic Impression
13. Plan
for Diagnosis and Treatment
14. A statement on the conclusion or impression
drawn from the medical history and physical exam
15. Goals
of treatment and treatment plan
16. Physician’s
name
The attending faculty physician or resident
physician must sign the History and Physical Examination.
Refer to IHOP 9.13.9 and
9.13.8 for more information.
Inpatient progress notes shall be written to
provide a chronological record of the patient’s progress and should reflect any
change in condition and the results of treatment, including reactions to
medications, procedures, or operations.
Notes should be timely, legible, relevant, and sufficiently
detailed to permit and justify continuity of care. Progress notes on procedures / operations
should also include doctor number after the signature. All notes must be timed, dated and
signed. A countersignature may be
required by the resident and/or staff physician.
A progress note should be written by a
physician everyday and more often on critical patients.
Physicians have a critical role in assuring
that the hospital is paid for all of the care rendered. It is you who create the record, and it is
the record alone which will determine whether or not the hospital is paid. Necessity for admission and elements of
quality care are two important areas to consider when documenting in the
record. Always explicitly answer this
question in your admission note: Why must this patient be admitted? The key word is must.
Examples:
1.
Lack of preoperative
evaluations.
2.
Change in patient status
reflected through observation.
3.
Lack of documented pre-discharge
training and/or planning.
4.
Acknowledgement of abnormal
findings on diagnostic testing in physician notes.
5.
Lack of documentation of
pending test results at the time of discharge with specific statements about
communication of these results to the patients.
An admit note
is required and should contain sufficient information to guide the health care
team in caring for the patient until the complete history and physical
examination is recorded. It must contain
the admitting and provisional diagnosis.
Significant clinical laboratory and
roentgenographic findings or results of any special examination should be
recorded. Any diagnostic implications,
change in treatment based on labs/radiology findings should also be recorded.
Prior to giving anesthesia, a note must be
written describing the preanesthetic physical examination by the
anesthesiologist or attending physician.
A complete detailed note on all specific procedures such as spinal
punctures, thoracenteses, biopsies, etc. shall be written immediately after the
procedure is completed.
An operative note should be written
immediately following surgical procedures describing findings at surgery,
post-operative diagnosis, complications/additional findings and conditions of
the patient following surgery.
Progress notes describing the post-operative
course of the patient should describe anything significant in the
post-operative course of the particular case.
Hospital infections and unusual occurrences should be recorded. The factual information, action taken and
treatment given should be recorded in the progress notes.
An “on-service” and “off-service” summary
progress note will be written by the resident on each patient at the time of
interdepartmental transfer of the physician and the patient. This note must be written in sufficient
detail to provide effective continuity of care to the patient, to determine at
a later date what the patient’s condition was at that specific time, and to
review the diagnostic and therapeutic procedures performed and the patient’s
response to the treatment.
Death Note: In case of
death, a death note must be written in the record at the time of death and
should include the exact date and time of death and the following:
1.
Clinical assessment of the
immediate and underlying cause of death;
2.
the major problem list
along with the clinical assessment of each problem;
3.
itemization of any suspected
or proven contagious infections, diseases, and/or radioisotopes which might
prove hazardous to personnel prosecting and embalming the body;
4.
information concerning
permission for autopsy; and
5.
request for any special
procedures or cultures to be done at the time of autopsy.
Transfusion: The rationale for ordering of transfusions is
to be documented in the progress notes.
The pertinent pre- and post-transfusion laboratory values and whether
any complications occurred should also be documented. If a transfusion reaction has occurred,
document the nature of the reaction, the evaluation, and the outcome of the
treatment.
Do Not Resuscitate/Withdrawal of
Life Support Orders:
UTMB will comply with all federal and state
requirements regarding Advance Directives, defined in state law as the
Directive to Physicians (Living Will), Medical Power of Attorney, or
Out-of-Hospital DNR Order. Competent
adult patients seeking to communicate their desires to withhold or withdraw
life support may do so orally or by using the written forms. In order to assist patients, UTMB staff
provides the necessary forms to patients who wish to execute a written directive. Refer to IHOP 9.15.5
through 9.15.8 for more information.
Certification of Terminal or
Irreversible Condition
1. The attending physician must diagnose and certify in writing in the medical record that
the patient has a terminal or irreversible condition, this is determining that the patient is qualified patient.
2. The attending physician shall personally examine the patient and enter a dated and timed statement of the patient’s medical condition in the progress notes of the medical record including but not limited to:
§ the patient’s diagnosis and prognosis;
§ diagnostic procedures confirming the diagnosis and prognosis;
§ a statement that the patient has a terminal or irreversible condition, as defined in Policy 9.15.5;
§ current physical examination;
§ brief summary of the treatment and date and results;
§ statement of treatment alternatives; and
§ description of current life-sustaining treatment being utilized.
3. If the attending physician is not
available from
Documentation of Decision
The patient's physician must obtain
documentation of the treatment decision to withhold or withdraw life-sustaining
procedures as defined in policy 9.15.6.
Physician's progress notes shall list the
person(s) who have authorized the withholding or withdrawing of life sustaining
procedures and, if other than the patient, a statement that the patient is
incompetent, comatose, or otherwise mentally or physically incapable of
providing consent.
Confirmation
The patient's physician shall confirm that
the treatment decision proposed is consistent with the preferences of the
patient. Such verification should be documented
in the medical record.
Orders
To implement an oral or written directive or
Directive to Physician or Out-of-Hospital DNR Order, a physician will write an
appropriate order.
1. Do Not Resuscitate Orders should be
signed by the attending physician (faculty or resident) and should state that
resuscitative measures are not be carried out in the event that the patient
arrests. The Levels of
Treatment form may be used to write a DNR Order.
2. Withdrawal of Life Support Orders
should be signed by the attending physician (faculty or resident) and should
state precisely which measures are to be discontinued.
3. The date and time of termination of
life support must be documented in the patient's medical records.
4. An Out-of-Hospital DNR Order must be
documented by the use of a standard form specified by the Texas Board of
Health. (See Policy 9.15.8,
Out-of-Hospital Do Not Resuscitate Orders).
Revocation of Directive
Upon receiving notice of revocation the
attending physician or a designee should record in the patient's medical record
the time and date when the attending physician received notice and should enter
the word "VOID" on each page of the copy of the Directive in the
patient's medical record. Any written
revocation should also be put in the patient's chart.
For additional information about
resuscitation and life support documentation, refer to the policies 9.15.5, 9.15.6, 9.15.7 and 9.15.8.
PHYSICIAN'S ORDERS (Form 5350)
When entering orders using the Physician
Order Entry (POE) system, physicians shall be required to enter them into the
POE system or find another physician to enter for them. While all orders should be entered into POE
or written, emergency situations do arise which require the physician to issue
an order verbally or by telephone so that patient treatment can begin.
Standing orders are not used by UTMB, and
shall not be recognized by UTMB.
Written/Electronic Orders
1. All orders for treatment written on the
Physician's Order Sheet or entered into
the Physician Order Entry system (POE) must be signed by a licensed physician
or dentist.
2. Orders by non-licensed personnel (e.g.,
medical students) shall not be recognized until countersigned by a licensed
physician or dentist.
3. All orders shall include the month,
day, year, and time of day the orders are written. Military time is used.
1.
The medication dose shall be
expressed in metric (not apothecary) units of weight (g, mg, mcg) if possible.
5. Medication orders shall include the
name of the medication, the dose (expressed in metric), the route, and the
frequency. Generic terminology should be
used.
6. For medication doses, a decimal and a
zero should not be placed after a whole number ("2mg" is correct;
"2.0mg" is not correct). Just
the opposite is true for numbers less than one: Always
place a zero before a naked decimal ("0.5 ml" is correct, ".5
ml" is incorrect).
7. Only symbols and abbreviations that
have been approved by the Medical Staff Executive Committee shall be used (see
attached). Medications should be written
as listed in the formulary.
8. The Medical Staff Executive Committee
has mandated that all orders for antimicrobials be written on the Physician's
Antimicrobial Order Sheet to include indication for use and anticipated
duration of therapy.
9. All patients who are to be transferred
within the UTMB hospitals must have new orders approved by the receiving
physician or designee. All patients who
are transferred from one physician team to a different physician team must have
orders approved by the physician team even when a room transfer is not
involved.
10. When
a time-limited order has expired, a new order must be issued.
11. The physician shall indicate the
patient's diagnosis and allergies on all admission and transfer orders.
12. All orders by physician assistants and
advance practice nurses (nurse midwives, nurse anesthetists, and nurse
practitioners) may be accepted if they are based on written protocols which
specify the criteria for therapeutic, diagnostic, or medication orders.
Verbal and Telephone Orders
1. Verbal
and telephone orders can only be given by a physician.
2. The healthcare worker receiving the
order identifies the order as a verbal or telephone order and the name of the
physician who issued it.
3. Verbal
orders for admissions must be transcribed within 60 minutes of receipt.
4. All verbal and telephone orders must be
signed, dated and timed by the physician within 48 hours. In the absence of the ordering physician, the
inpatient attending physician or another physician on the same service may sign
the order.
2.
Verbal and telephone orders
may not be given for:
§
Cytotoxic chemotherapeutic
agents
§
Biological response
modifiers
§
Do Not Resuscitate Orders
§
Investigational drugs
Transcription of Written Orders
Licensed nurses are responsible for the
correct transcription of all physician orders onto the appropriate form. All transcriptions must be signed by the
person transcribing, using the standard signature, date, and time.
The licensed nurse or pharmacist shall verify
the drugs and dosages based on recommended references.
After verification of the order, the licensed
nurse shall indicate that the transcription is accurate and complete by placing
his/her signature along with the date and time below the physician's
signature. A horizontal signature line
shall be drawn across the page below the order and the physician's signature in
such a manner as to prevent any additional orders from being inserted.
See policies 9.11.5 and
9.13.7, for additional information.
CONSULTATION REPORT (FORM 5400)
Consultation requests should be directed to a specific physician or service in general. The request and the report shall be written on the designated form and shall become a permanent part of the medical record. Consultation requests may also be directed to allied health professionals including, but not limited to Physical Therapy, Pulmonary Care Service, Nutrition, Speech Therapy, Therapeutic Recreation, Music Therapy, and Social Work.
A request for consultation signed by the
physician requesting the consultation shall include a brief statement of
information regarding the patient including:
1. diagnosis;
2. special
conditions affecting the report of the consultation; and
3. specific
information that is expected from the consultant.
A satisfactory consultation shall contain a
written opinion by the consultant that reflects:
1. patient’s
name
2. unit
history number
3. date
of consultation
4. examination
of the patient
5. review
of the medical record
6. written
report of the:
a. findings
b. diagnosis
c. recommendations
The report shall be dated and signed by the
consultant on the designated form.
Each consultation shall be acknowledged in
writing or by physician to physician contact within twenty-four hours from the
time requested and documented in the record.
The consultation requested from a specific physician, by name, is to be
answered by the individual member of the staff specified in the request or a
designee from the medical staff.
When an operative procedure is involved, the
consultation report shall be recorded prior to the operation, except in an
emergency.
Should the findings, diagnosis, and
recommendations be recorded on a special form (i.e. therapy, bronchoscopy,
etc.), reference would be made to the special report on which the information
is recorded.
The requests and reports are to be written on
the designated form (Form 5400), shall become a permanent part of the medical
record, and shall remain with the medical record at all times.
REPORTS OF PROCEDURES, TESTS, AND
THE RESULTS
All diagnostic therapeutic procedures must be recorded and authenticated in the medical record.
It is important to acknowledge abnormal
values or findings in the record and to document plans for follow-up, or
rationale for not following up. Reports
of pathology and clinical laboratory examinations, radiology, and nuclear
medicine examinations or treatment, anesthesia records, and any other
diagnostic or therapeutic procedures should be completed promptly and filed in
the medical record within 24 hours of completion, if possible. When laboratory results are obtained verbally
or through information systems, that information should be documented in the
progress note.
The pre-anesthesia note should be recorded prior to the patient’s transfer to the operating area and before preoperative medication have been administered.
In certain emergency cases, such a gross
hemorrhage or in obstetrics where delivery is imminent when the patient
arrives, the note may be deferred. In
cases of this type, the pre-anesthesia note may be included as part of a note
to be written immediately after the emergency is over.
The anesthesia record should be signed by the
responsible physician.
A visit should be documented early in the
postoperative period and once after complete recovery. A postanesthetic visit should be made after
the patient has left the postanestheisa care unit or other recovery area and
describe the presence or absence of anesthesia-related complications. Each evaluation shall be dated and timed.
When the post-anesthetic visit and record
entry by anesthesia personnel is not feasible because of early patient release
from the hospital, the physician who discharges the patient from the hospital
should be responsible for meeting the requirements.
OPERATIVE REPORTS
A preoperative diagnosis must be recorded and authenticated by the individual who is responsible for the patient prior to surgery.
An operative note must be written and
dictated immediately after surgery and should include the items listed below.
The report is signed by the appropriate physician(s).
(See attached example of form in the back of this
section).
1.
preoperative diagnosis;
2.
postoperative diagnosis;
3.
name of procedure;
4.
description of findings;
5.
technical procedure used;
6.
specimens removed;
7.
name of primary surgeon and
any assistants; and
8.
condition of patient after
surgery.
In handwritten notes and dictated reports, describe difficulties and complications as well as, appropriate action taken.
A discharge summary is required on patients discharged from the hospital and should be written , typed or dictated at the time of discharge.
The Discharge Summary must contain:
1. Name,
UH#, date of admission, date of discharge, and attending physician;
2. chief
complaint or reason(s) for admission;
3. significant
history and physical findings;
4. pertinent
laboratory and x-ray findings;
5. treatment
rendered;
6. principal
and additional or associated diagnoses (indicate principal);
7. surgical
procedures; and
8. disposition- include specific
instructions given to the patient and/or family, as pertinent (including
instructions relating to physical activity, medication, diet, and follow-up
care);
9.
prognosis.
When a necropsy is performed, provisional
anatomical diagnoses should be recorded in the medical record within three
days, and the complete protocol should be made part of the record within 60
calendar days.
The physician should read, approve, and sign
the discharge summary as soon as it is ready for review.
If dictated/typed by a resident,
it may be signed by the resident. The
discharge summary is always authenticated by the attending physician.
Dictated/typed discharge summaries are not
required on the following patients or in the following situations:
1.
Normal obstetric deliveries,
including uncomplicated cesarean
sections;
2.
normal newborns;
3.
normal gynecology, which
includes
a.
bilateral tubal ligation
b.
laparoscopic procedures
c.
conizations
d.
dilation and curettage
procedures;
4.
chemotherapy;
5.
*or other cases of a minor
nature requiring less than a 48 hour period of hospitalization (e.g.
Observation stays, Day Surgeries).
The final
discharge note or discharging progress note may be used in lieu of a dictated
or typed discharge summary in some cases.
(See related sections of this handbook). Patients admitted to the
Discharge Summaries may be completed online
through ClinWeb. If a summary is
completed online it should not also be dictated. The summary will print to the Health
Information Management Department and be delivered to the attending physician
for signature.
An Emergency Department record should be
completed for all patients who receive care in this setting. The appropriate forms are incorporated into
the patient’s permanent hospital record and made available through the
Emergency Department.
Observation is an outpatient status,
primarily intended for short-term diagnostic testing and monitoring which are
reasonable and necessary to evaluate a patient's condition in order to
determine the need for admission to the hospital.
Observation status is appropriate for:
1. Patient's whose presenting symptoms are
serious or questionable and require testing and/or evaluation to determine
their medical condition and to determine whether they should be admitted.
2. Patients who may meet inpatient admission
criteria, but are expected to stay less than 23 hours.
3. Patients with diagnosis that are
expected to respond quickly to therapeutic interventions, thus preventing
unnecessary admission (e.g., unstable angina, cardioversions, and asthmatics).
4. Post-operative ambulatory surgical
cases when the patient requires care beyond that usually found in the standard
of practice for the procedures.
Observation should not be used for:
1. Patient
holding because of social factors.
2. Patient
or physician convenience for testing or examination.
3. Routine
preparation for and recovery from diagnostic testing.
4. Substitute
for appropriate inpatient admission.
5. Routine
outpatient blood administration.
Content of observation records include:
1. Physician's
order to assign to observation status;
2. Chief
complaint;
3. Presenting
symptoms;
4. Duration
of symptoms;
5. Lab
results, if available;
6. History
and physical examination;
7. Treatment
plan (proposed intervention) and
8. Ongoing documentation in Progress Notes,
including interim evaluation of intervention (at least every six hours)
9. Discharge progress note including final
diagnosis, medications and follow-up care.
DAY SURGERY UNIT RECORD (Also applies
to Same Day Admits)
The following documentation is required on
all Day Surgery patient records.
1. a
signed informed consent;
2. complete
history and physical examination;
3. discharge
progress note including final diagnosis, medications, and follow-up care;
4. dictated
operative report; and
5. lab,
x-ray, path report, and other tests performed, if appropriate.
Medical record information is created for each patient receiving outpatient services and is immediately incorporated into the patient’s permanent hospital record.
Outpatient clinic notes may include:
1. Patient
identification;
2. relevant
history of the illness or injury and physical findings including vital signs;
3. diagnostic
and therapeutic orders;
4. clinical
observations including results of treatment;
5. reports
of procedures, tests, and results;
6. diagnosis;
7. patient disposition and any pertinent
instructions given to the patient and/or family for follow-up care;
8. immunization
record;
9. allergy
history;
10. growth
chart for pediatric patients;
11. referral
information to and from outside agencies; and
12. signature
of physician or appropriate health care provider.
A summary list of significant surgical
procedures, diagnoses, problems, medications recently and currently used, and
allergies/drug reactions must be documented and updated at the time of each
clinic visit.
Letters to referring physicians may be
dictated by calling X70000.
The Family Medicine Department and the
Community Based Clinics use the Practice Partner Electronic Medical Record to
document outpatient care.
Live donor and organ recipient: The medical
record of both the live donor and the organ recipient shall fulfill the
requirements for any surgical inpatient record.
Deceased donor: The donor
record shall include the following:
1.
The donor’s name and unit
history number where applicable or other means for identification.
2.
Date and time for
determination of legal death as defined in Texas Health and Safety Code §671.001
- .002.
3.
Identification of and
documentation by the licensed primary physician who pronounced legal death,
who, thereafter, shall not participate in organ recovery and/or transplantation
of donor organs or parts.
4.
When the basis for the
authorization is from a legally recognized donor, a copy of the donation document
serves as the consent form. If the donor
status is unclear or the decedent is deemed unsuitable and the
family/next-of-kin objects, the Consent for Organ/Tissue Donation form is
completed, indicating that the family does not wish to donate. A copy of the decedent’s donation document or
the original completed Consent for Organ/Tissue Donation will be filed in the
decedent’s medical record.
5.
For all Medical Examiner
cases, there must be documentation in the progress notes stating that
permission from the Medical Examiner for organ donation was obtained.
6.
The physician performing the
organ recovery procedure shall document a detailed note including the
description of the technique used to remove and prepare or preserve the donated
organs, and noting especially the abnormal or other appropriate findings in the
event a postmortem autopsy is required (Chapter 671, Section 671.001, Texas
Health and Safety Code).
See policies 9.15.2,
9.15.3 and 9.15.9 for additional information.
CHARTING DO’S
DO Write legibly. Physician’s signatures must be legible and
will include first name or initial, last name, and M.D.; initials alone will
not be acceptable. Write your
Dictation/Doctor number after signature on Procedure Notes to insure proper
credit for doing procedures.
Alternatively, initials may be used only of they are accompanied by a
rubber stamp, or printed/typewritten full name, as defined above (See Policy 9.2.15).
DO Correctly document retroactive
entries. If a correction is made at a
later time, the entry must reflect the date and time of documentation, the
correct information entered, and the reason for the corrected entry noted and
initialed. If any entry is made
retrospectively to the time of the event, it must reflect the date and time of
documentation, note the reason for the last entry, and be signed with a full
signature.
DO Date
and time all entries.
DO Document your doctor number after every
signature in the record.
DO Be complete, relevant, objective and
informative, but concise.
DO Document missed appointments and any other
factual instances of non-compliance by the patient.
DO Acknowledge abnormal or pending lab
results and plan of action.
DO Give a specific date when stating that
follow-up will be provided in the future.
DO Document all contacts with the
patient. Include all telephone calls and
services rendered. Document all
prescription refills.
DO Document the complete date (day, month,
and year) on each medical record entry.
DO Sign each entry with your name and
credentials/title/position.
DO Use black ink. It is best for copying, microfilming and
imaging purposes.
DO Chart all information immediately (delays
lead to inaccuracies).
DO Correct any error or mistake in charting
by drawing a single line through the
incorrect portion;
note: “disregard above"; and
initial and date the correction.
DO Record an emergency contact mechanism for
patient and next of kin.
DO Describe clearly in each chart entry:
- Mode of contact (i.e., telephone call, visit, etc.)
- Reason for contact
- Procedures done or information/advice given
- Outcome of contact
- Plan for future care/follow-up
DO Document direct statements from the
patient. Write them out and place in
quotes.
DO Fill in every blank. Record negatives as well as positives.
DO Use only standard abbreviations (See UTMB
approved abbreviations in the back of this book).
DO Note the date for referral or return
visits.
DO Chart thought processes during the
decision-making. This takes care of the
“Why” questions that patients and possibly plaintiffs ask.
DO Read nurses’ notes. Make sure they don’t contain incorrect
information or something not called to your attention.
DO Proof read verbal and telephone orders
before signing them.
DO Review, initial, and date all lab and
radiology reports.
CHARTING DON’TS
DON’T Use liquid paper, white out,
scribble over, cut off, or in any other way obliterate a chart entry which has
been made.
DON’T Document that the patient is
receiving “supportive care” or “is to receive no treatment and is to be kept
comfortable until death.” Instead,
document the patient’s conditions (i.e. seizures, comatose, etc.) and discharge
planning procedures.
DON’T Document that you don’t believe that
the patient should be in the hospital.
DON’T Document feelings about financial
reimbursements or that the patient is being discharged because of federal
requirements.
DON’T Document statements such as “Patient
awaiting weather change for discharge, or “Patient to be discharged tomorrow
because he doesn’t have a ride.”
DON’T Chart subjective comments about the
patient, i.e., “Patient is crazy;” DO quote the patient’s words, “I’m Napoleon
Bonaparte,” which will describe the behavior instead. Try to avoid adjectives and judgmental
statements.
DON’T Chart names without describing their
function in relation to the patient’s care.
Do chart “Referred to Bob Jones, M.D. of UTMB for allergy testing.” NOT “Referred to Bob Jones.”
DON’T Use the medical record to malign
colleagues or other care providers.
DON’T Make any changes to a medical record
after being notified of a lawsuit.
Contact the Legal Affairs department if you need to make changes to the
medical record.