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.
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.
So, first and foremost, documentation
is for the patient's benefit.
So, this is a means of tracking
the patient's care over time.
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.
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.
And more and more nowadays it's also becoming
a means of communication with the patient.
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.
There may be needs to document information
for billing purposes or payment.
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.
There is the potential that there is going to be
secondary analysis of what's in the medical record.
Institutions will do this for
quality improvement purposes.
So for instance, you know, tracking how
patients that have had cardiac surgery do.
You know, what's the outcome months or
years later after they have had surgery.
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.
They can be used for research
purposes the same way.
So health services research can help determine
how we're doing in delivering care,
the outcomes that we're getting
for particular diseases.
And lastly, it could also
be used for education.
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.
And in some jurisdictions, you know, like in the United States there
may be the need to have this for medical liability protection.
So it is evidence of
what has occurred.
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.
So if there was any challenge in the courts in the
future, you have a record of what's happened.
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.
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.
The first is
authenticating the user.
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.
So there may be different levels of clearance for different members
of the team based on their function or their responsibilities.
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.
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.
And when there are, you know, breaches
when people have violated the rules
that there is some accountability
in disciplining of the violators.