Documenting Patient Information

00:00 When we're performing a history, doing a physical examination, making a diagnosis, making treatment recommendations, it's important for us to document that information in the medical record.

00:14 So this lecture is going to be talking about how to document and why it's important that we document in an appropriate manner, and also who has access to that documentation.

00:28 So, first and foremost, documentation is for the patient's benefit.

00:32 So, this is a means of tracking the patient's care over time.

00:36 We are gathering this data and this is going to be helpful for us as we take care of them in the future, but also for other clinicians if they also have to take care of them.

00:47 It's a good means of communicating with other clinicians, so other clinicians that are also going to have to take care of the patient they're going to learn what's happened in the past, maybe be able to verify information that's going to assist them in making their own diagnosis or treatment recommendations.

01:05 And more and more nowadays it's also becoming a means of communication with the patient.

01:11 So, if we document in the medical record, there may be the ability of the patient to access the medical record to know what our impressions have been, what we've thought, and then they can sort of use that to aid their understanding of their condition and the treatments.

01:28 There may be needs to document information for billing purposes or payment.

01:35 So, determination of the coverage for the services rendered you have to accurately describe what you did in the clinical encounter in terms of what amount of history you took, the physical exam, the features that you performed, any diagnostic test that you might have reviewed, all of that might speak to, you know, how much you might get paid for rendering that service.

02:00 There is the potential that there is going to be secondary analysis of what's in the medical record.

02:05 Institutions will do this for quality improvement purposes.

02:08 So for instance, you know, tracking how patients that have had cardiac surgery do.

02:14 You know, what's the outcome months or years later after they have had surgery.

02:21 That secondary analysis that they can collect that from the medical record generally in a de-identified way but collect all that information, collate it they can see how their institution is performing with regard to cardiac surgery.

02:35 They can be used for research purposes the same way.

02:37 So health services research can help determine how we're doing in delivering care, the outcomes that we're getting for particular diseases.

02:47 And lastly, it could also be used for education.

02:49 So, using the medical record as a means of helping trainees understand one how to document, but also learn about disease processes and any associated features.

03:03 And in some jurisdictions, you know, like in the United States there may be the need to have this for medical liability protection.

03:10 So it is evidence of what has occurred.

03:13 So, if you put it in the medical record, this is what you performed, then you could sort of demonstrate that you followed the standard of care.

03:20 So if there was any challenge in the courts in the future, you have a record of what's happened.

03:28 And the classic statement for that is "If it's not documented, it did not happen." So, very important whatever you do with the patient, for a patient, put it in the medical record or else, you know, no one's going to have evidence that it actually occurred.

03:45 Now, we're moving increasingly towards electronic information and electronic medical records so there are going to be additional security elements to consider with electronic information.

03:56 The first is authenticating the user.

03:59 So as I'm sure many of you are familiar with, you know, entering secure websites, having a password and some verification whether it's a code or a password that gets them into to the website so know who the user is of getting access to this electronic information.

04:20 Authorizing users.

04:22 So there may be different levels of clearance for different members of the team based on their function or their responsibilities.

04:30 So a physician might have one level of clearance, a medical assistant that is helping with, you know, getting vital signs but not necessarily needing access to all of the medical information may have a different level of clearance in terms of what they can see in the record or what they can document in the medical record. Third, have an audit trail.

04:53 So, there should be a means in whatever software you're using to be able to track users and track their uses of the information especially if there are going to be concerns about breaches of information and maybe a person should not have access to a particular patient's record and, you know, classic examples of, you know, celebrities that are, you know, in the hospital and somebody that is not part of their care team accessing their records, you need a means of auditing that and tracking who those users were.

05:27 And when there are, you know, breaches when people have violated the rules that there is some accountability in disciplining of the violators.