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The Problem OrientedThe Problem OrientedMedical RecordMedical Record

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM

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Aim-Objectives

• Objectives:

– be able to define source oriented medical record

– be able to define problem oriented medical record

– be able to list items to be included in the medical record

– be able to discuss reasons for keeping medical records

– be able to explain the PSOAP acronym for keeping records

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It is always easier to find your way if you have a road map!It is always easier to find your way if you have a road map!

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Which data are we recording in practice?

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Why to keep records?

• Helps in medical decisions(is the size of a lymph node or nodule increasing with time?)

• Helps to share responsibility with the patient

• Legal obligation.• Protects the patient as well as doctor in

front of the court

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• Has economic benefits• Useful to produce health statistics• Provides epidemiological data• Assists practice management• Useful in QI activities• Is a communication tool• Useful in medical education

Why to keep records?

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Types According to the method;

– Source oriented

– Problem oriented

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Source oriented medical recordData taken from the source are recorded as they are (Source: patient, relative, laboratory etc.)

Easy and fast to record

Flexible

Omitting information is highly possible

Difficult to access the information

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Problem oriented medical record Structure is defined in advance. The patient with problem is in the focus It is systematic Data is easily accessible Starts with a problem list Progress notes are according to the PSOAP acronym Patients problem is in the front line Not flexible. Recording information is difficult and

time consuming

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Which data to record?Personal info age, sex, occupation, training, family...

Risk factors tobacco, alcohol, life styles...

Allergies and drug reactions

Problem list

Disease history diseases, operations

The disease process

main problem, history, exam, lab.

Management plan advice, education, medication

Progress notes in the P S O A P format

PSOAP

Problem Everything the patient reports and doctor’s findings which are regarded as problems

Subjective History of the problem; what the patient feels or thinks about the problem

Objective Doctors findings related with the problem

Assessment Evaluation of the problem; the diff. diagnosis

Plan Prescription, consultation, advice, control visit.

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Visits :21 February 2006: dyspnea, coughing and fever. Dark defecation. PE: BP 150/90, pulse 95/min, Fever: 39.3 oC.Ronchi +, no abdominal tenderness.Medications: 64 mg Aspirin/day. Possible acute bronchitis and cardiac decompensation.Possible bleeding due to Aspirin.Rx: Amoxicilline 500 mg 2x1, Aspirin 32 mg/day.4 March 2006: no cough, slight dyspnea, defecation normal.PE: light rhonchi, BP 160/95, pulse 82/min.Rx: Aspirin 32 mg/day.

Lab :21 February 2006: ESR 25 mm, Hb 7.8, Fecal occult blood +.

4 March 2006: Hb 8.2, Fecal occult blood :-.X-ray21 February 2006: Chest x-ray: no atelectasis, light cardiac decompensation findings

Patient -Source-Oriented Medical Record

Source Oriented Medical Record

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Problem 1: CoughingProblem 1: Coughing21 February 2006S: dyspnea, coughing, fever.O: pulse 95/min, Fever: 39.3 oC.Rhonchi+. ESR 25 mm.Chest x-ray: no atelectasis, light cardiac decompensation findings.A: Acute bronchitis.P: Amoxicilline 500 mg 2x1.

4 March 2006S: no coughing, slight dyspnea.O: pulse 82/min. Slight rhonchi.A: minimal bronchitis findings.

Problem Oriented Medical Record

Problem 2: DyspneaProblem 2: Dyspnea21 February 2006S: Dyspnea.O: Rhonchi+, BP 150/90 mmHg.Chest x-ray: no atelectasis, slight cardiac decompensation findings.A: Slight decompensation findings.

4 March 2006S: slight dyspnea.O: BP: 160/95, pulse 82/min.A: No decompensation.

 Problem 3: Dark colored defecationProblem 3: Dark colored defecation

21 February 2006S: Dark feces. Using Aspirin 64 mg/day.O: No abdominal tenderness, rectal exam revealed no blood, Hb 7.8 mg/dl. Fecal occult blood +A: Possible intestinal bleeding due to Aspirin.P: Decrease Aspirin dose to 32 mg/day.

4 March 2006S: Defecation normal.O: Fecal occult blood -A: No intestinal bleeding symptoms.P: Continue Aspirin dosage 32 mg/day

Rules in keeping medical records (NCQA)

1. Patient’s name or ID number.

2. Personal biographical data

3. Author’s identification

4. All entries are dated.

5. The record is legible to someone other than the writer.

6. *Problem list.

7. *Medication allergies and adverse reactions

http://www.ncqa.org/LinkClick.aspx?fileticket=dmQOrIgyvMQ%3D&tabid=125&mid=766&forcedownload=true

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National Committee for Quality Assurance (NCQA)

8. * Past medical history

9. For patients 12 years and older, there is appropriate notation

concerning the use of cigarettes, alcohol and substances

10. The history and physical examination

11. Laboratory and other studies are ordered, as appropriate.

12. * Working diagnoses are consistent with findings.

13. * Treatment plans are consistent with diagnoses.

14. Encounter forms or notes have a notation, regarding follow-up care,

calls or visits, when indicated.

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NCQA15.Unresolved problems from previous office

16.There is review for under - or over utilization of consultants.

17.Note from the consultant in the record.

18.Consultation, laboratory and imaging reports filed in the chart are

initialed by the practitioner who ordered them, to signify review.

19.* There is no evidence that the patient is placed at inappropriate risk

by a diagnostic or therapeutic procedure.

20.Immunization record

21.Preventive screening and services

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Legal Problems

• Not recorded = Not done !

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• Record everything you do (including phone consultations)

• Apply guidelines (e.g.: NCQA)

• Don't use erasable pencils

• Don’t use humiliating expressions

In order to prevent legal problems:

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Do not use vague expressions such as “the patient feels well”

If you need to make changes just strike through and record also the date of change

If you stated that the patient is not cooperative give the reason

If patient rejects a procedure or test, mention it and give the reason why you requested it

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Follow-up Charts

• It is practical to use follow-up charts for chronic diseases – DM,

– Hypertension

– Obesity

– …

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Charts - Obesity

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Medical Records are Our Road Maps

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Summary

• What are the benefits of keeping records?

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• Can you explain the meanings of PSOAP in the medical record?

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• What are the core elements requested by NCQA in the medical record?

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