RET 1024 Introduction to Respiratory Therapy

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RET 1024Introduction to Respiratory Therapy

• Module 5.0
• The Patients Medical Record

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The Patients Medical Record

• Medical Record Chart
• A documented account of the occurrences
  pertaining to the patient throughout his or her
  stay in a healthcare institution

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The Patients Medical Record

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

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The Patients Medical Record

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

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The Patients Medical Record

• Components of the Medical Record
• Admission Sheet
• Records pertinent patient information (e.g.,
  name, address, religion, nearest of kin),
  admitting physician, and admission diagnosis
• History and Physical
• Records the patients admitting history and
  physical examination as performed by the
  attending physician or resident

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The Patients Medical Record

• Components of the Medical Record
• Physicians Orders
• Records the physicians orders and prescriptions
• Progress Sheet
• Commonly referred to as progress notes
• Keep a continuing account of the patients
  progress for the physician

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The Patients Medical Record

• Components of the Medical Record
• Nurses Notes
• Describes the nursing care given to the patient,
  including the patients complaints (subjective
  symptoms), the nurses observations (objective
  signs), and the patients response to therapy
• Medication Admission Record MAR
• Notes drugs and IV fluids that are given to the
  patient

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The Patients Medical Record

• Components of the Medical Record
• Vital Signs Graphic Sheet
• Records the patients temperature, pulse,
  respiration, and blood pressure over time
• I/O Sheet
• Records the patients fluid intake (I) and output
  (O) over time

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The Patients Medical Record

• Components of the Medical Record
• Laboratory Sheet
• Summarizes the results of laboratory tests
• Consultation Sheet
• Records notes by specialty physicians who are
  called in to examine a patient to make a
  diagnosis

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The Patients Medical Record

• Components of the Medical Record
• Surgical or Treatment Consent
• Records the patients authorization for surgery
  or treatment
• Anesthesia and Surgical Record
• Notes key events before, during, and immediately
  after surgery

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The Patients Medical Record

• Components of the Medical Record
• Specialized Therapy Records
• Records specialized treatments or treatment plans
  and patient progress for various specialized
  therapeutic services (e.g., respiratory care,
  physical therapy)
• Specialized Flow Sheets
• Records measurements made over time during
  specialized procedures (e.g., mechanical
  ventilation, kidney dialysis)

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Flow Sheets

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The Patients Medical Record

• Legal Aspects of Recordkeeping
• Legally, documentation of care given to a patient
  means that care was given
• Legally, no documentation means that care was not
  given
• Lack of documentation can be interpreted as
  patient neglect

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The Patients Medical Record

• General Rules for Medical Recordkeeping
• Entries should be printed or handwritten. After
  completing the account, sign the chart with the
  initial of first name, complete last name, and
  your title (CRT, RRT, Resp Care Student, etc.)
• Example B. Kind, RRT
• Do Not Use ditto marks

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The Patients Medical Record

• General Rules for Medical Recordkeeping
• Do not erase!
• Erasures provide reason for questions if the
  chart is used in a court of law.
• If a mistake is made, a single line should be
  drawn through the mistake and the word error
  printed above it the correction should be
  initialed
• Example Respiratory Tx given at 1000 1030

error
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The Patients Medical Record

• General Rules for Medical Recordkeeping
• Record after completing each task for the patient
  (never beforehand) and sign your name correctly
  after each entry
• Be exact in noting the time, effect, and results
  of all treatments and procedures
• Describe clearly and concisely observations and
  assessments, e.g., the character of breath
  sounds, percussion notes, secretions, etc.

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The Patients Medical Record

• General Rules for Medical Recordkeeping
• Leave no blank lines in the charting
• Draw a line through the center of an empty line
  or part of a line. This prevents charting by
  someone else in an area signed by you
• Use the present tense. Never use the future
  tense, as in Patient to receive treatment after
  lunch.

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The Patients Medical Record

• General Rules for Medical Recordkeeping
• Spell correctly
• If you are not sure about the spelling of a
  word, use a dictionary and look it up
• Use standard, hospital-approved abbreviations
• Do not make up your own

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The Patients Medical Record

• The Problem-Oriented Medical Record
• A documentation format used by some healthcare
  institutions
• POMR contains the following
• The Database
• The Problem List
• The Plan
• The Progress Note

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The Patients Medical Record

• The Problem-Oriented Medical Record
• The Database
• Routine information about the patient
• General health history
• Physical examination results
• Results of diagnostic tests

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The Patients Medical Record

• The Problem-Oriented Medical Record
• The Problem List
• A problem is something that interferes with a
  patients physical or psychological health or
  ability to function
• Problems are identified and listed, based on the
  information provided by the database
• The problem list is dynamic new problems are
  added as they develop and others problems are
  removed as they are resolved

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The Patients Medical Record

• The Problem-Oriented Medical Record
• The Progress Note
• Contain the findings (subjective and objective),
  assessment, plans, and orders of the doctors,
  nurses, and other practitioners involved in the
  care of the patient
• The format used in often referred to as SOAP
• S subjective
• O objective
• A assessment
• P - plan

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The Patients Medical Record

• Charting Using the SOAP Format
• Subjective
• Information obtained from the patient, his or
  her relatives, or a similar source
• Objective
• Information based on caregivers observations of
  the patient, the physical examination, or
  diagnostic or laboratory tests such as ABG or PFT
  
• Assessment
• The analysis of the patients problem
• Plan
• Action to be taken to resolve the problem

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The Patients Medical Record

• Example of SOAP Entry
• Problem 1
• Pneumonia
• Subjective
• My chest hurts when I take a deep breath
• Objective
• Awake alert oriented to time, place, and
  person sitting upright in bed with arms leaning
  over bedside stand pale, dry skin respiration
  22/min and shallow pulse 110 beats/min, regular
  but thready blood pressure 130/89 (sitting)
  temperature 101? F bronchial breath sounds in
  left bases - posteriorly, occasionally
  expectorating small amounts of purulent sputum

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The Patients Medical Record

• Example of SOAP Entry
• Assessment
• Pneumonia continues
• Plan
• Therapeutic Assist with coughing and deep
  breathing at least every 2 hours postural
  drainage and percussion every 4 hours assist
  with ambulation as per physician orders and
  patient tolerance.
• Diagnostic Continue to monitor lung sounds
  before and after each treatment.
• Education Teach to cough and deep breathe and
  evaluate return demonstration

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SOAP Form