RET 1024RET 1024Introduction to Respiratory Introduction to Respiratory TherapyTherapy

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The Patient’s Medical RecordThe Patient’s Medical Record

The Patient’s Medical RecordThe Patient’s Medical Record

Medical Record – “Medical Record – “Chart”Chart”

A documented account of the occurrences A documented account of the occurrences pertaining to the patient throughout his or her stay in pertaining to the patient throughout his or her stay in a healthcare institutiona healthcare institution

The Patient’s Medical RecordThe Patient’s Medical Record

Medical Record – “Medical Record – “Chart”Chart”

It is the property of the institution and its It is the property of the institution and its contents are contents are confidentialconfidential and may not be read or and may not be read or discussed by anyone except those directly caring for discussed by anyone except those directly caring for the patient in a hospital or medical care facility.the patient in a hospital or medical care facility.

The Patient’s Medical RecordThe Patient’s Medical Record

Medical Record – “Medical Record – “Chart”Chart”

It is a legal document and must be maintained It is a legal document and must be maintained by the healthcare institution for days, months, or by the healthcare institution for days, months, or years, in case it is needed in a court of lawyears, in case it is needed in a court of law

The Patient’s Medical RecordThe Patient’s Medical Record

Components of the Medical RecordComponents of the Medical Record Admission SheetAdmission Sheet

Records pertinent patient information (e.g., name, Records pertinent patient information (e.g., name, address, religion, nearest of kin), admitting physician, address, religion, nearest of kin), admitting physician, and admission diagnosisand admission diagnosis

History and PhysicalHistory and Physical Records the patient’s admitting history and physical Records the patient’s admitting history and physical

examination as performed by the attending physician or examination as performed by the attending physician or residentresident

The Patient’s Medical RecordThe Patient’s Medical Record

Components of the Medical RecordComponents of the Medical Record Physician’s OrdersPhysician’s Orders

Records the physician’s orders and prescriptionsRecords the physician’s orders and prescriptions

Progress Sheet Progress Sheet Commonly referred to asCommonly referred to as “progress notes” “progress notes” Keep a continuing account of the patient’s progress for Keep a continuing account of the patient’s progress for

the physicianthe physician

The Patient’s Medical RecordThe Patient’s Medical Record

Components of the Medical RecordComponents of the Medical Record Nurses’ NotesNurses’ Notes

Describes the nursing care given to the patient, including Describes the nursing care given to the patient, including the patient’s complaints (subjective symptoms), the the patient’s complaints (subjective symptoms), the nurses’ observations (objective signs), and the patient’s nurses’ observations (objective signs), and the patient’s response to therapyresponse to therapy

Medication Admission Record “MAR”Medication Admission Record “MAR” Notes drugs and IV fluids that are given to the patientNotes drugs and IV fluids that are given to the patient

The Patient’s Medical RecordThe Patient’s Medical Record

Components of the Medical RecordComponents of the Medical Record Vital Signs Graphic SheetVital Signs Graphic Sheet

Records the patient’s temperature, pulse, respiration, Records the patient’s temperature, pulse, respiration, and blood pressure over timeand blood pressure over time

I/O SheetI/O Sheet Records the patient’s fluid intake (I) and output (O) over Records the patient’s fluid intake (I) and output (O) over

timetime

The Patient’s Medical RecordThe Patient’s Medical Record

Components of the Medical RecordComponents of the Medical Record Laboratory SheetLaboratory Sheet

Summarizes the results of laboratory testsSummarizes the results of laboratory tests

Consultation SheetConsultation Sheet Records notes by specialty physicians who are called in Records notes by specialty physicians who are called in

to examine a patient to make a diagnosisto examine a patient to make a diagnosis

The Patient’s Medical RecordThe Patient’s Medical Record

Components of the Medical RecordComponents of the Medical Record Surgical or Treatment ConsentSurgical or Treatment Consent

Records the patient’s authorization for surgery or Records the patient’s authorization for surgery or treatmenttreatment

Anesthesia and Surgical RecordAnesthesia and Surgical Record Notes key events before, during, and immediately after Notes key events before, during, and immediately after

surgerysurgery

The Patient’s Medical RecordThe Patient’s Medical Record

Components of the Medical RecordComponents of the Medical Record Specialized Therapy RecordsSpecialized Therapy Records

Records specialized treatments or treatment plans and Records specialized treatments or treatment plans and patient progress for various specialized therapeutic patient progress for various specialized therapeutic services (e.g., respiratory care, physical therapy)services (e.g., respiratory care, physical therapy)

Specialized Flow SheetsSpecialized Flow Sheets Records measurements made over time during Records measurements made over time during

specialized procedures (e.g., mechanical ventilation, specialized procedures (e.g., mechanical ventilation, kidney dialysis)kidney dialysis)

Flow SheetsFlow Sheets

The Patient’s Medical RecordThe Patient’s Medical Record

Legal Aspects of RecordkeepingLegal Aspects of Recordkeeping

Legally, documentation of care given to a patient Legally, documentation of care given to a patient means that care was given means that care was given

Legally, no documentation means that care was Legally, no documentation means that care was not givennot given Lack of documentation can be interpreted as patient Lack of documentation can be interpreted as patient

neglectneglect

The Patient’s Medical RecordThe Patient’s Medical Record

General Rules for Medical RecordkeepingGeneral Rules for Medical Recordkeeping Entries should be printed or handwritten. After Entries should be printed or handwritten. After

completing the account, sign the chart with the completing the account, sign the chart with the initial of first name, complete last name, and your initial of first name, complete last name, and your title (CRT, RRT, Resp Care Student, etc.)title (CRT, RRT, Resp Care Student, etc.)

Example:Example: B. Kind, RRT B. Kind, RRT

Do Not Use ditto marks – “ “Do Not Use ditto marks – “ “

General Rules for Medical RecordkeepingGeneral Rules for Medical Recordkeeping Do not erase!Do not erase!

Erasures provide reason for questions if the chart Erasures provide reason for questions if the chart is used in a court of law.is used in a court of law.

If a mistake is made, a single line should be drawn If a mistake is made, a single line should be drawn through the mistake and the word “error” printed through the mistake and the word “error” printed above it; the correction should be initialedabove it; the correction should be initialed

Example:Example: Respiratory Tx given at 10:00 Respiratory Tx given at 10:00 10:3010:30

The Patient’s Medical RecordThe Patient’s Medical Record

error

General Rules for Medical RecordkeepingGeneral Rules for Medical Recordkeeping Record after completing each task for the patient Record after completing each task for the patient

(never beforehand)(never beforehand) and sign your name correctly and sign your name correctly after each entryafter each entry

Be exact in noting the time, effect, and results of Be exact in noting the time, effect, and results of all treatments and proceduresall treatments and procedures

Describe clearly and concisely observations and Describe clearly and concisely observations and assessments, e.g., the character of breath assessments, e.g., the character of breath sounds, percussion notes, secretions, etc. sounds, percussion notes, secretions, etc.

The Patient’s Medical RecordThe Patient’s Medical Record

General Rules for Medical RecordkeepingGeneral Rules for Medical Recordkeeping Leave no blank lines in the chartingLeave no blank lines in the charting

Draw a line through the center of an empty line or Draw a line through the center of an empty line or part of a line. This prevents charting by someone part of a line. This prevents charting by someone else in an area signed by youelse in an area signed by you

Use the present tense. Never use the future Use the present tense. Never use the future tense, as in “Patient to receive treatment after tense, as in “Patient to receive treatment after lunch.”lunch.”

The Patient’s Medical RecordThe Patient’s Medical Record

General Rules for Medical RecordkeepingGeneral Rules for Medical Recordkeeping Spell correctlySpell correctly

If you are not sure about the spelling of a word, If you are not sure about the spelling of a word, use a dictionary and look it upuse a dictionary and look it up

Use standard, hospital-approved abbreviationsUse standard, hospital-approved abbreviations Do not make up your ownDo not make up your own

The Patient’s Medical RecordThe Patient’s Medical Record

The Problem-Oriented Medical RecordThe Problem-Oriented Medical Record A documentation format used by some A documentation format used by some

healthcare institutionshealthcare institutions

POMR contains the following:POMR contains the following:1.1. The DatabaseThe Database

2.2. The Problem ListThe Problem List

3.3. The PlanThe Plan

4.4. The Progress NoteThe Progress Note

The Patient’s Medical RecordThe Patient’s Medical Record

The Problem-Oriented Medical RecordThe Problem-Oriented Medical Record The DatabaseThe Database

Routine information about the patientRoutine information about the patient

General health historyGeneral health history

Physical examination resultsPhysical examination results

Results of diagnostic testsResults of diagnostic tests

The Patient’s Medical RecordThe Patient’s Medical Record

The Problem-Oriented Medical RecordThe Problem-Oriented Medical Record The Problem ListThe Problem List

A problem is something that interferes with a patient’s A problem is something that interferes with a patient’s physical or psychological health or ability to functionphysical or psychological health or ability to function

Problems are identified and listed, based on the Problems are identified and listed, based on the information provided by the databaseinformation provided by the database

The problem list is dynamic; new problems are added The problem list is dynamic; new problems are added as they develop and others problems are removed as as they develop and others problems are removed as they are resolvedthey are resolved

The Patient’s Medical RecordThe Patient’s Medical Record

The Problem-Oriented Medical RecordThe Problem-Oriented Medical Record The Progress NoteThe Progress Note

Contain the findings (subjective and objective), Contain the findings (subjective and objective), assessment, plans, and orders of the doctors, nurses, assessment, plans, and orders of the doctors, nurses, and other practitioners involved in the care of the and other practitioners involved in the care of the patientpatient

The format used in often referred to as SOAPThe format used in often referred to as SOAP S – subjectiveS – subjective O – objectiveO – objective A – assessmentA – assessment P - planP - plan

The Patient’s Medical RecordThe Patient’s Medical Record

Charting Using the SOAP FormatCharting Using the SOAP Format SubjectiveSubjective

Information obtained from the patient, his or her relatives, or a Information obtained from the patient, his or her relatives, or a similar sourcesimilar source

ObjectiveObjective Information based on caregivers’ observations of the patient, Information based on caregivers’ observations of the patient, the physical examination, or diagnostic or laboratory tests the physical examination, or diagnostic or laboratory tests such as ABG or PFT such as ABG or PFT

AssessmentAssessmentThe analysis of the patient’s problemThe analysis of the patient’s problem

PlanPlanAction to be taken to resolve the problemAction to be taken to resolve the problem

The Patient’s Medical RecordThe Patient’s Medical Record

Example of SOAP EntryExample of SOAP EntryProblem 1Problem 1

PneumoniaPneumonia

SubjectiveSubjective““My chest hurts when I take a deep breath”My chest hurts when I take a deep breath”

ObjectiveObjectiveAwake; alert; oriented to time, place, and person; sitting upright in Awake; alert; oriented to time, place, and person; sitting upright in bed with arms leaning over bedside stand; pale, dry skin; bed with arms leaning over bedside stand; pale, dry skin; respiration 22/min and shallow; pulse 110 beats/min, regular but respiration 22/min and shallow; pulse 110 beats/min, regular but thready; blood pressure 130/89 (sitting); temperature 101thready; blood pressure 130/89 (sitting); temperature 101 F; F; bronchial breath sounds in left bases - posteriorly, occasionally bronchial breath sounds in left bases - posteriorly, occasionally expectorating small amounts of purulent sputumexpectorating small amounts of purulent sputum

The Patient’s Medical RecordThe Patient’s Medical Record

Example of SOAP EntryExample of SOAP Entry

AssessmentAssessment

Pneumonia continuesPneumonia continues

PlanPlanTherapeuticTherapeutic:: Assist with coughing and deep breathing at least Assist with coughing and deep breathing at least every 2 hours; postural drainage and percussion every 4 hours; every 2 hours; postural drainage and percussion every 4 hours; assist with ambulation as per physician orders and patient assist with ambulation as per physician orders and patient tolerance.tolerance.

Diagnostic:Diagnostic: Continue to monitor lung sounds before and after Continue to monitor lung sounds before and after each treatment.each treatment.

Education:Education: Teach to cough and deep breathe and evaluate return Teach to cough and deep breathe and evaluate return demonstrationdemonstration

The Patient’s Medical RecordThe Patient’s Medical Record

SOAP FormSOAP Form