Understanding Hospital Medical Records:A Guide for the Legal Profession

Margaret Rhone Wood, Ph.D., R.N.

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The Chart is in Your Hand

• FIRST: paginate it in the order it came from the hospital.

• Do not separate sections or pages.• Do not take out pages you think may not be

relevant.• Begin to build a glossary and index. • Do the chronology by going through each section

systematically.

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Translate the Medical Terms

• The Merck Index Internet Edition themerckindex.cambridgesoft.com/ http://www.merckmanuals.com/professional

• http://www.reference.com/• http://www.dictionary.com/• http://www.acronymfinder.com/

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Glossary and Index

Look up acronyms in www.acronymfinder.com•“NIBP” – write the page # the 1st time you see an acronym. “Non-invasive blood pressure” •“ORIF” – “open reduction internal fixation.”The procedure noted on the face sheet, operative record, care plan – consistent?

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Ask Questions: Note the Page• Start formulating basic questions for the

Examinations for Discovery. Different handwriting? Whose? The “?” before a

term means “query.” “? Arterial injury.” “? Late decelerations.”

Whose thought? Any follow-through on the query or suspicion? Did others suspect it as well? If not, why not? -- especially important if this is in fact the problem and it goes undiagnosed. Was the patient asked appropriate questions? Was a train of enquiry set up? Was the suspicion ruled-out? How? Was the MRP informed? When? Response?

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Build Your Questions• Who wrote? When? Why? • Whose handwriting? Initials? Category? • First mention of “query” – was it followed?• Were signs overlooked? Thought about? Talked

about? Tracked? Trended? Treated?• Sequential? Logical? • Were assessments complete?

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Components of the Chart

Outpatient Records▫ Emergency Room

Ambulance Report if the ambulance was used. Time, method of arrival; Triage code, time of 1st

assessment, findings, diagnosis, time of disposition, signatures.

▫ Tests Non-stress Test (NST); cardiac stress tests;

Ultrasounds, x-rays; Pre-operative tests, ECG, blood work, diagnostic imaging.

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Components of the ChartInpatient Records

Admission/Discharge Record (2 Parts): Top Hospital name & #; Patient’s name & identification #; Patient’s demographics; OHIP #; person

to call in an emergency; accommodation; Date & time of admission; Diagnosis; attending physician.

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Components of the ChartInpatient Records

Admission/Discharge Record: Lower half: Completed at discharge: Date and time of discharge; Most responsible diagnosis at admission; Complicating diagnoses arising after

admission; Other diagnoses present on admission; Operations and procedures.

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15 Components of the Chart

1) Discharge Summary (MD);2) Master Signature Record (Nurses);3) History of present illness (HPI) & physical

examination (PE) on admission (MD);4) Consultation Report (MD specialist);5) Physician’s Orders (most responsible

physician -- MRP) dated, timed, & noted.

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15 Components of the Chart

6) Operative Report (Surgeon);7) Progress Notes (Interdisciplinary, not always);

Chronological.8) Vital Signs Record (graphic) (Nurse);9) Patient Care Plan (kept); Kardex (not always

kept);10) Flow sheets (Nurse);

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15 Components of the Chart

11) Medication Administration Record (MAR);12) Patient Controlled Analgesia (PCA) Flow Sheet;13) Fluid Balance Record if IV fluids (hourly, 8-hour,

& 24-hour cumulative);14) Laboratory Reports (cumulative, summary);15) Monitor strips: Cardiac, fetal heart.

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Documentation Standards• College of Nurses of Ontario • The Hospital’s policies or protocols• Areas of nursing’s special interest:

▫ Labour and delivery; post-partum; pediatrics; post-anaesthetic recovery unit (PACU); intensive care (ICU); orthopedics; neonatal intensive care unit (NICU); psychiatry; emergency room; operating room; rehabilitation, etc.

▫ Q: Are the hospital’s policies adequate? Did the nurses follow them?

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Documentation Methods1) Charting by Exception: is only appropriate when assessment

norms or standards of care are explicitly written and available within the agency. Never acceptable for medication administration.

2) Focus Charting – DAR (Data, action, response): Problem oriented.

3) SOAP / SOAPIER: subjective (chief complaint); objective (findings); assessment (diagnosis); plan; implementation; evaluation; revision

4) Narrative Notes: nursing interventions and the outcomes of these interventions are recorded in chronological order covering a specific time frame.

5) Critical Path & Variance Analysis Care Mapping

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Hospital Documentation Policies• Provide direction to nurses to document the nursing care provided

and the process of clinical decision-making. • Policies include:

▫ description of the method of documentation;▫ expectations for the frequency of documentation;▫ processes for “late entry” recording;▫ listing of acceptable abbreviations;▫ acceptance and recording of verbal and telephone orders; and▫ storage, transmittal, and retention of patient information.

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Flow Sheets—>Progress NotesDecision

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Assessment Data

Normal?

Flow Sheet

Abnormal?

Flow Sheet &Progress Notes

Where is the chart kept?Communications and Continuity

• Nurses’ Station? When is charting done? Who has access to the chart? Charting should be contemporaneous.

• Patient’s bedside? Whole chart? Flow Sheets? Computer?• Separate Places? Lab reports, MD orders, nurses notes?• Is it reviewed by the MDs & nurses? How often? Where?

How & when is report received? Erasable tape? Kardex? • Fetal monitor strips? Paper? Electronic? Central viewing

system? • What is the policy re: communications. Are they always

charted? Should be.

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Charting by Exception

• Uses a care plan and standard protocols for that patient situation;

• Cannot be used otherwise;• ALL assessments & findings are charted on a

flow sheet (normal or not);• ALL abnormal findings are detailed on a

narrative record (Focus, SOAP, narrative progress).

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Charting by ExceptionComponents of Charting by Exception:1) Database: history & assessment data;2) Care Plan: to communicate required care

beyond one shift;3) Flow sheets: graphic record, assessments;4) Narrative Notes: Focus on the exception (the

complaint), Progress Notes;5) Profile of care: Kardex;6) Protocols & Standards: expected assessment

data, interventions, responses.

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Narrative Record

Examples of Narrative Notes:1) Focus charting (DAR)2) SOAP or SOAPIER3) Narrative

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Narrative Record

Focus Charting:Based on assessment – a patient concern;Organizing structure:D = Data (subjective & objective assessment);A = Action or intervention done;R = Response of the patient to the action or

intervention.

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Narrative Record

SOAP format: A problem-oriented approach – charting is according to the problem.

Organizing structure:S = Subjective data;O = Objective data;A = Action or intervention;P = Plan.

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Narrative Record

SOAPIER format: • S = Subjective data (What the patient says)• O = Objective data (Exam, lab, vital signs)• A = Assessment (diagnosis); • P = Plan (Revision in plan needed?)• I = Intervention (Actions taken by the provider.)• E = Evaluation (The result of the action.)• R = Revision (Changes in care plan needed?)

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Narrative Record

• Progress Notes.• Chronological sequence of assessments, actions,

and responses.• May stand alone or • May be supported by flow sheets.

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Critical Path & Variance Analysis Care Mapping• Similar to Charting by Exception, but more

directive.• Specifies the care that will be given (to do list).• Specifies the expected outcome within a

specified time frame.• The path is based on the usual patient within

that case type or case group.

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If the Patient Has SurgeryPre-operative checklist (RN) with chart

components included in the chart:▫ Informed consent; Patient care plan;

Medication Record; Addressograph (Bradma plate); Face sheet; HPI & physical exam; consultation; allergy band; old chart; blood work results; other lab, x-ray, ECG results if done; latest vital signs; teaching; patient voided; any limitations, contact with infectious diseases.

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If the Patient Has Surgery• Anesthetic Record: American Society of

Anesthesiologists (ASA) Classification of Physical Status I, II, III, IV, or V pre-op.▫ I: Normal healthy person;▫ II: Mild systemic disease;▫ III: severe systemic disease limiting but not

incapacitating activity;▫ IV: incapacitating system disease that is a constant

threat to life;▫ V: Moribund, not expected to live 24 hours with or

without operation.

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If the Patient Has Surgery

• Anesthetic Record (cont’d)▫ Start time, end time;▫ Type of Anaesthesia, airway, ventilation,

monitoring, protection of eyes, equipment; ▫ Graphic record of vital signs;▫ Drugs, intravenous fluids, estimated blood loss

(EBL);▫ Intra-operative lab data if done;▫ Post-op condition and disposition.

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If the Patient Has Surgery

• Operating Room Record (RN):▫ Operating room number;▫ Time patient entered and left OR;▫ Pre-operative diagnosis; Procedure;▫ Names: surgeon, assistant, anesthetist, scrub

nurse or tech, circulating RN;▫ Positional aids; position of table; disinfections;

warning devices; specimens; diathermy; irrigation; drains; packs; tourniquet on & off.

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If the Patient Has Surgery

• Operating Room Count Sheet (RN):▫ Date and time;▫ Sponges, sharps (needles, pins, blades,

angiocatheters, etc.);▫ Drains, clamps; tapes, cautery tips, packing;Counted before the cut, before the closure, and at

the end. Signed by circulating and scrub nurses.

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If the Patient Has Surgery

Post-Anesthetic Record (RN): (Post-anesthetic recovery unit – PACU)▫ Date, time of admission to PACU, procedure;

surgeon, anesthesiologist; type of anesthetic; IV solution & amount to be absorbed (TBA);

▫ Post anesthetic score on arrival in the PACU & at discharge to the surgical unit.

▫ Drugs administered; Intravenous fluids; vital signs graph; pain score.

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Frequency of Documentation• “Routine Vital Signs (VS)” every four hours (TPR,BP).

• Post-operative: After transfer from the PACU to the surgical unit, VS > 15 minutes until stable, then, if stable, hourly for four hours, then, if stable, routine. Looking for shock. Abdominal assessment (bowel sounds). Respiratory (rate, depth, air entry; gas exchange). Level of consciousness (LOC); orientation; patency of tubes; drainage (characteristics); dressings; etc.

• Bone or joint injury or surgery: circulation, sensory nerve function, motor nerve function (CMS) more frequently. Looking for blood vessel and nerve compression.

• Pain assessments (PQRST) characteristics frequently.

• Labour and delivery: maternal & fetal; stages, factors.

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Routine Vital Signs (TPR;BP)

• Temperature (method; trend)• Pulse (characteristics; trend)• Respirations (characteristics, trend)• Blood Pressure (Electronic? Trend MAP

(mean arterial pressure). NIBP? Trend pulse pressure).

Some agencies use different coloured inks – most do not.

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VSS? CMS satisfactory?• Check the narrative note, “VSS” (vital signs

stable) against the graphic record.• Check all Flow sheet entries against the

narrative notes. Do they agree? Where did the nurse chart first? What note, if any, was current? What do the providers rely on for info & continuity?

• Flow sheet entry: “Neurovascular – meaning all is okay.” Narrative note, “right thumb blue with 3 second capillary refill.”

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Pain Assessment PQRST

• P = provokes, palliates – what makes it better or worse

• Q = quality – stinging, dull, sharp, burning• R = Location and radiation.• S = Severity (scale 1-10 or similar)• T = Timing – when does it start – e.g., when was

the last pain medication.

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Nursing DocumentationCollege of Nurses of Ontario• Date & time care given, when charted if

different;• Timely, chronological;• A complete record, meaningful, accurate;

▫ Assessments, identification of problem, care plan, implementation, evaluation [Nursing Process].

• Name & category of nurse; signature & initials;• Legible, non-erasable, permanent, retrievable;• Patient focused.

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Electronic RecordAsk for an Audit Trail – it is the logical path

linking events sequentially, the chronology of processes, and the names and designations of all who accessed the record.

The audit trail shows who accessed the record and what operations he or she performed.

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ReferencesAmerican Society of Anesthesiologists (October, 2015). Statement on Documentation of

Anesthesia Care. Committee of Origin: Committee on Quality Management and Departmental Administration (QMDA).(Approved by the ASA House of Delegates on October 15, 2003 and last amended on October 28, 2015) http://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/statement-on-documentation-of-anesthesia-care.pdf

College of Physicians and Surgeons of Ontario, (2012), Medical Records, policy statement # 4-12. http://www.cpso.on.ca/CPSO/media/uploadedfiles/policies/policies/policyitems/medical_records.pdf?ext=.pdf

College of Physicians & Surgeons of Ontario, (record keeping)http://www.cpso.on.ca/publications/med_record-keeping2.pdf. (informed consent)

http://www.cpso.on.ca/Policies/consent.htmCollege of Nurses of Ontario (2009). Documentation, revised 2008.

http://www.cno.org/docs/prac/41001_documentation.pdfProvince of Ontario. Regulated Health Professions Act, 1991, S.O. 1991, c. 18. Current:

December 3, 2015. http://www.ontario.ca/laws/statute/91r18

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