Dynamics of Care in Society

Written Communication &

Medical Documentation1

Written communication “practical writing”… for a specific purpose,

ex:ReportsBusiness lettersInteroffice memosManualsFormsApplicationsChart documentation

“Practical Writing” TypesNarrative writing…tells what happened,

paragraph form, Descriptive writing…details of person, object,

eventInformative writing…giving directions,

explaining how to, answering questions, making something easier to understand, use bullets or steps,

Persuasive writing..giving an opinion or stating a point of view and supporting it with reasons in order to persuade the reader to accept or possibly take action on it

Recording and ReportingRecord patient information completely & precisely

Record information only in secure & appropriate locations

Record any action you take concerning a patient (“if it is not documented…it didn’t happen”)

Just the facts…Minimize medical jargon (if for a patient)

Get started… get comfortable, be concise, have logical transitions of thought

Outline ideas… organize before you write * brainstorm* group similar ideas together* find unifying themes* have a beginning, middle, end

Revising…check for…* clarity* sentence & paragraph structure

Proofreading… refinement…check for…* grammar, punctuation, spelling* final touches

Drafting hints…

Tips for… “Well & Clearly Written”

- create an outline to clarify and order your concepts

- write a really bad first draft with no rewriting

- rewrite, read out loud, rewrite, read again and rewrite

- have colleagues comment on your draft

- trust feedback from reviewers and rewrite again

- let it sit, return for a fresh read out loud, and finalize

Ideas for Learning to Write Better

• Read examples you like and also review your colleague’s draft papers and edit them.

• Take course in essay writing - good analysis, clear arguments and exposition, and convincing conclusions.

• Write for broad audiences too - if you can capture them, you can capture professionals

• Read your writing out loud and then edit!

For Research Assistance…

UCLA Libraryunder services menu tab choose references & research help

MEDICAL DOCUMENTATION

Purposes of documentation in HC

1. Communication among the health care team

2. Assessment (vital signs, hx, symptoms…)

3. Quality Assurance (competence & quality of care)

4. Reimbursement (verification for insurances…)

5. Legal Record (admission of evidence)6. Education (use for training)7. Research: Useful Data Gained From

Patient Records

Examples:Nurse updates patient’s record with new info from patient

Doctor sees nurse’s note & orders cholesterol test

Pharmacist views medical history before filling prescription

Discharge planner evaluates physical therapist’s notes on progress in ambulation

(note the communication process w/in the medical record)

Electronic Medical Records are here…

Ease of access to dataMultiple users simultaneouslyDifferent locationsVarious devices

Easy storage & retrieval; faster recording of data

Nearly unlimited file spaceEasy back-up for securityEasy to add or attach infoImproved legibility

Advantages of Computerized Documentation

Safe Computer Recordkeeping

1.Don’t share passwords/computer signature

2.Don’t leave logged-on terminal unattended

3.Follow protocol for correcting errors4.Allow only authorized personnel to

create, change, or delete files5.Back up records regularly6.Don’t leave patient info displayed on

monitor in view of others7.Keep running log of electronic copies

made of files8.Never use unencrypted email to send

protected health info9.Follow confidentiality procedures for

sensitive material

What you’ll find in the medical record…

Admission sheet – general demographic info, insurance info…

Graphic sheet – aka Flow sheet - for vital signs…

MD orders – for medications, instructions, procedures…

Progress notes – on patient’s progress, new or changing info from multiple health care team members

Medical history and exam –"Listen to your patient, he is telling you the diagnosis," Sir William Osler, M.D. – Johns Hopkins

Allergies, Immunizations, Childhood diseasesCurrent & past medicationsPrevious illnesses, Surgeries, Hospitalizations

Family medical historyReports – test results, lab results, consultations…

Psycho-Social History Marital status

OccupationEducationHobbiesDietAlcohol, drug & tobacco use/misuseSexual historyMiscellaneous – correspondence, AD, organ donor…

Good Medical Documentation Tips1.It is accurate (ex. Correct

spelling, Errors marked through, labeled with “error,” initialed, & dated…)

2.It is complete (ex. All supporting information – lab results …)

3.It is concise (ex. Only relevant information), just the facts

4.It is legible5.It is organized (ex. Most recent

information first, date stamped…)6. It is signed, initialed, dated

and/or timed *– as required

See article about accurate documentation

Progress Notes --- 3 Types

1. SOAP notesSubjective data

Statements from patient describing conditionSymptoms experienced

Objective dataData that provider can measure, see, feel, or smellTest results

Vital signs Assessment

Patient’s diagnosisPossible disorders to be ruled out

PlanDescription of what should be doneDiagnostic testsTreatmentsFollow-up

2. Charting by exception

• Covers only significant or abnormal findings

• Decreased charting time• Greater emphasis on significant data

• Easy retrieval of significant data• Timely bedside charting• Standardized assessment• Greater interdisciplinary communication

• Better tracking of important patient responses

• More cost effective

3. Narrative

Paragraph format Includes:

Contact with patientWhat was done for patientOutcomes

Can be time-consuming to write & difficult to read

It is the oldest & least structured type

Handout…

PROPER TELEPHONE COMMUNICATION

ANSWERING….

1.ANSWER PROMPTLY2.IDENTIFY SELF3.FIND OUT WHO IS CALLING 4.SPEAK COURTEOUSLY, CLEARLY &

PLEASANTLY5.USE DISCRETION IN RELEASING

INFORMATION, REMEMBER CONFIDENTIALITY

6.END CALL GRACEFULLY

Handout… SCREENING….

1.DON’T OFFEND CALLER2.ASK WHO IS CALLING, NATURE OF

BUSINESS OR EMERGENCY3.ANSWER QUESTIONS TACTFULLY4.ASK IF MESSAGE CAN BE LEFT5.PLACE ON HOLD AND GET GUIDANCE,

HELP IF NEEDED

TAKING A MESSAGE….

1.OBTAIN TIME, DATE, NAME OF CALLER , PURPOSE OF CALL

2.TAKE NOTES, REPEAT INFO BACK TO CALLER FOR ACCURACY

3.USE MESSAGE FORMS & FOLLOW THOUGH WITH PASSING MESSAGE TO CORRECT RECIPIENT.

Handout…

HANDLING COMPLAINTS….

1.STAY CALM2.GATHER INFO3.BE SYMPATHETIC4.OFFER TO FIND OUT

WHAT CAN BE DONE5.END CALL ON

PLEASANT NOTE

Handout…

Assign:What is the message for each?

Handout…