Electronic Medical Records & Medical Record Entries

Objectives - Identify common medical abbreviations, identify elements contained in patient records, and identify the purpose for EMR documentation.

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Common Medical Abbreviations

Awake-Hour Therapy Schedules

PRN and Around-the-Clock Schedules

Elements of Patient Medical Records

Medical record documentation includes:

• Common clinical data
• Physical complaints
• Patient assessments
• Treatments and medications
• Care plans and outcomes
• Any limitations placed on the extent of care provided in case of cardiac or respiratory arrest, such as advanced directives: DNR, DNI, or AND

Elements of a Patient Medical Record

• Admissions sheets and demographics
• Physician orders
• History and physical
• Laboratory records
• Reports of radiological procedures
• Progress notes
• Medication Administration Record (MAR)
• Records and reports of surgical procedures
• Discharge plan summary

The Joint Commission audits the quality and thoroughness of medical record documentation.

Essential Documentation Components

Medical record documentation should be:

Careless or insufficient documentation by a provider can result in:

• Misinterpretation
• Harm to patients
• Penalties, lawsuits, and negative financial consequences

Common Respiratory Documentation Elements

Respiratory documentation commonly includes:

• Pulmonary medical history and smoking history
• Vital signs: heart rate, respiratory rate, pulse oximetry, temperature, and blood pressure
• Breath sounds
• Cough effort: strong or weak, productive or non-productive
• Sputum: consistency, volume, and color
• Physical examination of the head, neck, and thorax
• Blood gas results (ABGs)
• Pulmonary function testing results (PFTs)
• Medication Administration Record (MAR)
• Therapeutic interventions:
  • Lung inflation therapy
  • Bronchial hygiene
  • Ventilator management and modalities
• Adverse reactions to therapy or medications and the responsive action taken
• Patient education administered
• Discharge planning

Example Treatment Documentation

Physician Order

• Patient: Harley Davidson
• Oxygen to maintain SpO2 above 92%
• 2.5 mg Albuterol, q4h with peak flows

Treatment Note

23 Dec 17 / 0800: Patient Davidson was given 2.5 mg Albuterol with aerosol mask as ordered with no adverse reaction.

• BBS: CTA upper lobes; rhonchi to bases bilaterally, pre- and post-treatment
• Cough: Strong and productive
• Sputum: Yellow, thick, small volume
• SpO2: 100% pre- and post-treatment
• HR: 86/91
• RR: 12/14
• Patient complaint: Nonsmoker, no history of asthma, shortness of breath, wants to stop Albuterol treatment due to tremors

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Physician Orders

Purpose

Physician orders are:

• Required for all patient care
• Accurately recorded to assure appropriate care and patient safety

Types of Physician Orders

• Written
• Verbal
• Telephone

The Joint Commission specifies documentation standards for all aspects of patient charts, including physician orders.

Verbal Physician Orders

Verbal orders may be accepted and transcribed by authorized individuals. Authorized individuals are identified by hospital policies and procedures. Respiratory therapists meet this requirement.

Verbal physician orders must be complete and include:

• Date
• Time
• Physician signature

Verbal and telephone orders are countersigned within 24 hours as specified by The Joint Commission.

When computer charting is not available, orders should be printed rather than written in cursive.

The goal is to eliminate misunderstandings, prevent mistakes, and provide a safe and effective health care environment.

Verify Physician Orders: The Five Rights

The Five Rights help eliminate misunderstandings, prevent mistakes, and provide a safe and effective health care environment.

Dose Examples

Respiratory therapists must review and understand hospital policies and procedures before receiving and recording verbal orders.

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Electronic Medical Records (EMR)

Computerized medical systems track and record patient information electronically.

Advantages

• Electronic capture of information speeds entry.
• Electronic systems improve storage and retrieval of patient information.
• Patient data is stored electronically so authorized health care providers can access it from any hospital computer or within the extended network.

EMR Charting Design

The EMR can be designed to give clinicians a list of activities and choices. EMR systems guide clinicians through charting medical care from start to finish.

Some fields are designed with hard stops.

Hard stops must be completed before proceeding to the next entry point. They require the clinician to complete an important documentation entry before committing information to the patient's permanent record.

EMR systems may use both electronic and paper records.

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High-Yield Review

Documentation

• Medical records include patient assessments, physical complaints, treatments, medications, care plans, outcomes, and advanced directives.
• Documentation should be consistent, current, and complete.
• Poor documentation can cause misinterpretation, patient harm, penalties, lawsuits, and negative financial consequences.
• Respiratory documentation should include respiratory history, vital signs, breath sounds, cough, sputum, ABGs, PFTs, interventions, adverse reactions, education, and discharge planning.

Orders and EMR

• Physician orders are required for all patient care.
• Order types include written, verbal, and telephone.
• Verbal and telephone orders are countersigned within 24 hours.
• The Five Rights are patient, medication, modality, dose, and time/date.
• EMR systems improve entry, storage, retrieval, and access to patient information.
• Hard stops require important documentation fields before the clinician can proceed.