The Medical Record
A. F. Muhleman, M.D.
( phone: 475-6537; FAX 487-6647; e-mail: firstname.lastname@example.org
,office: B234, VAMC )
I. Medical Data Retrieval...... ( Your filing system )
II. The Medical Record....... ( Electronic
Med Record )
Having Your Medical Record on the Internet
a. The Medical Interview & History
b. The Medical Physical Exam
c. Other Elements
III. Quality Improvement Efforts in Hospital // Hospital & Physician Charges ( Medicare Standards )
IV. Hospital & Physician ( $ ) Charges
1. Be able to describe a system for data storage and retrieval when using information once found
to apply to a new patient’s workup.
2. Define the major purposes of the medical record.
3. Be able to cite the important elements of the medical record.
4. Be able to describe how to take and develop an appropriate medical history so that it helps you
develop an understanding of the natural history of the patient’s disease process.
5. List the major organ systems examined during a medical physical examination.
6. Cite what elements make up the problem list.
7. Describe what elements should be present in a properly written progress note.
8. Be able to discuss what is meant by the " S.O.A.P. " format of a progress note.
9. Describe the difference between an " incomplete " and " delinquent " medical
10. List at 3 elements of the occurrence screening process and 3 elements of the
ongoing monitoring process dealing with quality improvement/assurance.
11. Discuss the value of developing a differential diagnosis when working-up a patient.
I. MEDICAL DATA RETRIEVAL
a. what is your system ? notes
/ books / filing system / personal computer / Pub
b. role of hospital computer / index and contents of major clinical textbook / Harrison's
c. national medical databases / accessing / retrieving / PDQ
/ On-Line PDR
d. use of local and national electronic chat groups
e. use of home pages on the Internet, Palm Pilot, Palm/HandSpring, Casio E-125, etc.
II. THE MEDICAL RECORD ( .ppt slides )
The medical record should be viewed as an extremely important and valuable tool in patient management.
All that happens to the patient; all things done to and done for the patient; all relevant professional plans,
therapies, and advice; all invasive and noninvasive procedures; all working diagnoses and long term therapeutic
plans and goals should be detailed in the record. It must contain all elements set forth by both the medical record
committee and practice standards board of a given hospital.
The medical record is viewed as the professional and legal record of a given patient's care. It should therefore
be carefully maintained and all entries should be clearly legible. The medical record ( or chart ) should be a
clear and accurate documentation of the complete clinical course of the patient. All entries should be legibly
written, signed, dated, and timed. With the advent of the electronic medical record, legibility has become
much less of an issue.
Essential elements of the medical record would include: ( Cincinnati VA
Med Center )
a. The HISTORY & PHYSICAL
HISTORY (Complete Within 24 Hours of Admission)
Chief Complaint // Family History
Details of Present Illness // Current Medications
Past History // Allergies
Social History // All Elements Dated and Timed
An Interval History & Physical may be used if the patient is readmitted within 30 days for the same or a
related condition. A statement that the previous H&P exam was reviewed must be documented and any changes in
the patient's course must be further documented.
DRUG & ALCOHOL DEPENDENCE RECORDS ONLY
History of use, age of onset, duration, patterns, consequences of use, use by family member are to documented
as well as types of responses to previous treatment plans in the past.
b. REVIEW OF SYSTEMS
General / Breast / Musculoskeletal
Skin / Cardiac / Neurological
Head / Vascular (arterial & venous) / Hematopoietic
Eyes / Respiratory / Endocrine
Ears / Gastrointestinal / Psychological
Nose, Throat, Mouth / Genital
Neck / Urinary Tract / Other Items
Point: Remember when you interview the patient during your taking of the medical history, you
should always attempt to develop the whole story about the patient's major illnesses. If a patient tells you
she has had, for example, coronary artery by-pass surgery, find out how she presented to her doctor before the
surgery was done. How far back, and what kind of symptoms did she have that supported the diagnosis of coronary
artery disease. The patient can be a very good source of information relative to how a certain pathologic process
begins, progresses, and its response to treatment.
c. PHYSICAL EXAMINATION
Completed and Signed within 24 Hours
Vital Signs / Teeth, Gums
Skin / Joints
Extremities / Cardiovascular
Lymphatics / Abdomen
HEENT / Rectal/Genitalia
Thorax, Lungs / Neurological
Neck / Breast Exam / Lab Data
d. PROBLEM LIST ( to include at the end of listing a Differential Diagnosis for major reason patient is
Diagnoses (Initial Date of Problem and Date Resolved).
Surgeries/Procedures (Include Dates).
( can include a physical finding, a symptom, an abnormal lab result, or disease process,
personal and/or social difficulty )
Differential Diagnosis refers to a listing of different diseases which may produce similar complaints and /
e. PATIENT TREATMENT PLAN
Assessment of Needs
Long & Short Range Goals - Evidence-based Rx
Reassessment, particularly with changes in patient's condition
Discharge Planning Begins Here Also
Date, Time, Signature Clear and Legible / Identify who you are!!
Co-Signing of Medical Student orders required
Sign Verbal Orders Within 24 Hours
Is practitioner clinically privileged to do what he/she wishes to do to or for the patient ?
( How do you assure yourself that your orders are properly being carried out ? )
g. INFORMED CONSENT ( and consideration for obtaining advanced directive or living will )
Description of Operation/Procedure
Progress Note Written after Obtaining Consent
Patient's Mental Status
Procedure Discussed with Patient
Patient given Opportunity to Discuss Procedure
Patient Freely Consented to the Procedure
Medical Consequences of Refusing Procedure Discussed with Patient
h. PROGRESS NOTES * ( S. O. A. P. FORMAT )
S = subjective; O = objective; A = assessment; P = plan
Significant Changes in the patient's Condition are always Documented.
Co-signature required for Medicine Student's note, for new or adverse findings
Name Printed Clearly After Signature (M.D.) ( at VA, all signatures are electronic )
Written at Least Daily on all Critically Ill Patients or Special Management Problems.
Attending Note at Least Once a Week and at admission ( daily for billing purposes )
Resident Should Write a Brief Note Stating Attending was Consulted and when attending is seeing the patient
Physician Noted Lab Results. / must respond to nurse's observations in the note or previous note
Dated and Timed.( this is an automatic with an electronic medical record )
Signature with Title (M.D., UC II, UC III, UC IV ) / include role in patient's care
* An Inter-Service Progress Note Should Be Written and Should Include the Patient's Diagnoses, Procedures and
Treatments Pertinent to the Hospital Stay and Reason Patient is Being Transferred to Another Bed Section when a
transfer occurs such as out of the Intensive Care Unit.
DRUG AND ALCOHOL DEPENDENCE RECORDS ONLY (APPROPRIATE SCREENING TESTS AND INTERPRETATIONS)
Urine Toxicology Screen on Admission
Subsequent Breathalyzer or Urine Toxicology Screen
Interpretation of Test results
Picture or video to affirm findings
Answered Within 72 Hours
Acknowledged by Treating ( Requesting ) Service
Obtained whenever one needs help in patient management / know your limitations
Obtain at least 72 hours before patient is discharged if consulting service is to follow patient
j. OPERATIVE REPORT ( Completed immediately following surgery )
Date of Operation / Instruments Used / Nursing Staff / What is the procedure / why is it being done
Major or Minor Surgery / Time Operation Began
Surgeon / Time Operation Completed
First Assistant / Drains, types, location
Second Assistant / Sponge Count Verified
Indentify Other Staff / What Specimens Sent to Lab
Anesthetist / Preoperative Diagnosis / Post-op Match of Diagnosis
Anesthetic / Postoperative Diagnosis
Time Anesthetic Began / Operation Performed
Time Anesthetic Ended / Description of Procedure
Surgical NurseInvolved / Dated and Timed
* INFORMATION CAN BE OBTAINED FROM THE OPERATION REPORT (SF 516)
k. DISCHARGE SUMMARY ( Completed before Discharge )
Principle Diagnosis Listed / the sooner done the more accurate the information
Reason for Admission
Significant Findings ( history - physical - lab - x-ray - etc )
Operations, Procedures Performed
Condition of Patient at Discharge
Instructions to the Patient:
Signature with Title
* Death Summaries Cover Above Information Excluding Instructions Given to Patient. This is Important
for Insurance Claims, Etc., as well as, Medical-Legal Purposes.
l. OTHER IMPORTANT ELEMENTS OF THE RECORD
Diagnostic result section
Emergency room work-up sheet or note with findings
Flow sheet of outcomes or results
Pre- and Post- operative progress notes
Vital sign flow sheet
Transfusion request forms which become part of the medical record
COMPLETION OF MEDICAL RECORDS
What is an incomplete record?
Any record which does not have a completed (dictated and/or signed) Discharge Summary, History & Physical,
Operative Report, Progress Note, Physicians Order, etc.
Must have all hospital required components completed
JCAHO Standard - no more than the average of one months discharges listed as incomplete
What is a delinquent record?
Any record which is incomplete for over 30 days.
JCAHO Standard - no more than half of the average of one months discharges.
III. QUALITY IMPROVEMENTS EFFFORTS IN HOSPITAL // CHARGES
A. TOOLS THE HOSPITAL QUALITY ASSURANCE/IMPROVEMENT
COMMITTEE USES TO MONITOR OUR
QUALITY OF CARE DELIVERY AND ITS DOCUMENTATION
1. Occurrence Screens:
a. Readmission within 10 days of discharge.
b. Admission within 3 days of an unscheduled ambulatory care visit.
c. Transfer back to ICU within 3 days of being moved out of ICU.
d. Return to OR on same admission (unscheduled).
e. Cardiac or respiratory arrest.
f. Death - expected or unexpected.
2. Other Ongoing Monitors:
a. Tissue and Transfusion Committee
b. Medical Record Committee
c. Pharmacy and Therapeutics Committee - Drug Utilization Review
d. Infection Control Committee and Safety Committee
e. External Peer Review for the V. A.
f. Credentialing & Privileging - National Health Professional Data Bank
g. Need for students and residents to serve on some of these committees for educational & training value
h. Patient Representative - Complaints and compliments from patients or families
B. HOSPITAL & PHYSICIAN ( $ ) CHARGES
1. Hospital Charges
a. Utilization review – is patient acute / intermediate / boarder status
b. Standards used to document a level of care that is appropriate
c. Utilization Review staff constantly reviewing medical record
d. Medicare / Medicaid / Other Insurers have their standards
2. Physician Charges
a. Complexity of visit / consultation
b. A Given number of elememts must be recorded in the medical
record in order to charge for a complex / intermediate /
or simple visit and for physician's patient action or Rx
c. Examples of documentation requirements will be made available in the Junior Year