Section D　Writing

Health Record or Medical Records

The evolution of health records parallels advancements in medicine.The first incorporated hospital in the United States，Pennsylvania Hospital，was established in 1752.Benjamin Franklin served as the secretary for the hospital and recorded each patient's name，address，disorder，date of admission，and date of discharge.Massachusetts General Hospital in Boston has the distinction of having a complete medical record on each patient since 1821.

Today，technology affects all aspects of health care，and the health record is no exception.Hospitals and practitioners are moving from a paper-based record to an electronic health record.Whether paper-based or electronic，the health record is the link connecting all of health care.The health record is a valuable tool used by all entities involved in providing patient care，including practitioners，hospital，patient and family，and third-party payers.

In some settings，the health record is called the medical record，but the more updated term is health record.In this section we will provide an overview of the purpose，maintenance，and content of the health record.

1.Overview of the Health Record

The health record，whether paper-based or in electronic format，should contain sufficient information to justify the patient's diagnosis，treatment，and services rendered.Documentation in the record should explain the patient's progress including the response to therapy，medication or care rendered.Health records play the following roles in supporting the health-care industry.

· Serve as a communication tool that facilitates ongoing care and treatment of the patient.

· Justify reimbursement for hospitals and other health-care practitioners.

· Serve as legal document describing the health-care provided.

· Serve as a resource for research and education.

· Support clinical decision making.

· Provide information for evaluating the quality of care provided.

· Serve as a source of data for outcomes research.

2.Maintaining a Health Record

Health records are kept in one of three formats：paper format，electronic format，or a combination of both formats，known as a hybrid health record.Health records are maintained by all entities that provide health care to patients.Physicians，dentists，chiropractors，podiatrists，optometrists，nurses，physical therapists，occupational therapists，hospitals，urgent care centers，rehabilitation centers，skilled nursing facilities，residential facilities，emergency care facilities，home health-care agencies，behavioral health facilities，and correctional facilities are required to maintain a health record for each patient.Documentation requirements and the type of record maintained vary according to the type of facility and provider.Documented medical information links all aspects of the healthcare delivery system； so，all health-care providers must document information to meet the needs of the patient and to comply with the laws and regulatory standards.

Maintaining a health record for patient encounters and documenting the care provided are mandatory.Over the decades，health-care has become increasingly complex resulting in the need to have documentation that is accurate，timely，and legible.Regulatory agencies such as the Joint Commission，the Commission on Accreditation of Rehabilitation Facilities （CARF），the Accreditation Association for Ambulatory health-care （AAAHC），the American Osteopathic Association （AOA），the National Committee on Quality Assurance （NCQA），and the American Accreditation health-care Commission （AAHC） are just a few of the accrediting agencies that have standards for health records and documentation.Attaining accreditation signifies that the institution has made a commitment to having high standards for performance improvement and quality improvement.

The federal government became more involved in health care in 1965 with the establishment of the Social Security Act，of which Medicare was a component.Medicare is a health insurance program for persons over the age of 65，persons under the age of 65 with certain disabilities，and individuals with end-stage renal disease requiring dialysis or a kidney transplant.Standards for health record content and documentation for federal patients are established by the Centers for Medicare & Medicaid Services （CMS），a division of the federal Department of Health and Human Services.

The health record must contain information to justify admission and continued hospitalization or outpatient ambulatory care，support the diagnosis，and describe patient's progress and response to medications/treatment and service.

Periodic reviews of health records by the state survey agency occur to ensure compliance with Medicare Conditions of Participation.Failure to demonstrate compliance could negatively impact reimbursement the provider and the health-care facility.

States also have specific documentation requirements as part of their licensure process.These regulations usually are under the direction of the state Department of Health.Failure to comply with the regulations could result in closure of the health-care facility.

3.Ensuring Quality Documentation in the Health Record

The therapist providing the care is responsible for making high-quality entries into the patient's health record.These entries must be timely，legible，and authenticated in accordance with the rules and regulations specified by the institutions in which the therapist works.Therapists will need to adhere to the documentation guidelines for their own profession.The following are documentation guidelines that all health-care providers should follow.

（1） All entries in the health record must be dated and signed with your name and professional designation to identify the author of the entry.

（2） Entries in the health record by graduates pending licensure or students in a physical therapy or physical therapist assistant program must be authenticated by a licensed physical therapist or physical therapist assistant when allowed by law.

（3） Entries in the health record cannot be erased or deleted.Corrections in a paper record are made by drawing one line through the error，leaving the incorrect material legible.The error should be initialed and dated so that it is obvious that it is a corrected mistake.If using an electronic health record system，use the appropriate procedure for indicating that a change was made without deletion in the original health record.The specific procedure for this will vary depending on the electronic health record program you are utilizing at your facility.

（4） All entries in the paper health record should always be made in black ink.Colors such as red，green，purple，and pink do not copy or scan well.

（5） Blank spaces should not be left in any documentation.Record an “X” in the blank area to prevent the insertion of additional information that would be out of date or out of sequence.

（6） All blanks on consent forms should be completed.

4.Location Information in the Paper Health Record

The health record is a repository of data.Locating information in the paper record can be challenging.This section provides an overview of the contents of the patient's health record to assist the therapist in pinpointing meaningful information.

The health record contains two types of data：administrative and clinical.Regulatory agencies or professional organizations do not mandate a specific form.Form design is the discretion of the health-care organization or health-care provider if working in private practice.

（1） Administrative Section

Administrative data include the patient's demographic information，such as name，address，date of birth，next of kin，payment source，billing or accounting number，and patient identification number，which is also called a health record number.

Demographic information is collected at the time of registration and recorded on a face sheet or top sheet of the health record.Facilities using a computer-based admission and discharge system will print out the demographic information on the face sheet or top sheet if the record is in a paper format.

At least two different pieces of demographic information must appear on each page of a patient's health record （paper format）：the patient's name and the record number.Therapists should verify that they are making entries in the correct health record prior to making the entry.

Consent to release information，acknowledgment of patient rights，HIPAA acknowledgment，advance directives，consent to special procedures，property and valuables lists，and birth and death certificates are all considered administrative content.

（2） Clinical Section

Clinical content includes information related to the patient's condition，treatment，and progress.Clinical data make up most of the health record.Therapist must know each of the components of the clinical portion of the health record to be able to find the information needed for patient care.

（3） Health History

The health history and review of systems is the basis for formulating the provisional diagnosis and establishing a treatment plan.Contents of the history are somewhat subjective，since much of the information is provided by the patient or the patient's representative.Components of the health history include the following.

Chief complaint （CC）：Stated in the patient's own words and explains why the patient is seeking treatment.Example：“My throat hurts.”

History of present illness （HPI）：Describes the duration，location，clinical signs and reason （cause） for the current condition，if known.

History of past illness：Documents any relevant childhood illness，previous surgeries，injuries，or illnesses that might have a bearing on the current condition.Allergies and drug sensitivities are also documented in the history of past illness.

Social history：Addresses habits，living conditions，occupation，material status，psychosocial needs，alcohol consumption，drug use，and tobacco use.

Family History：Documents conditions considered genetic or conditions of family members that might have relevance to the case such as diabetes，cardiovascular disease，or cancer.

Review of system （ROS）：Asks questions that derive information that the patient might not have provided.All systems in the body are inventoried.Information in this section is not to be confused with the results of the physical examination as performed by the medical practitioner.

（4） Physical Examination

The physical examination provides objective data on the patient's condition.All body systems are included in the physical examination.There should be information in the record that addresses all the body systems with special emphasis on the areas that are pertinent to the Chief Complaint and the Review of systems.A clinical impression and course of action，based on the medical history and physical examination，conclude the history and physical.The therapist will find the history and physical examination beneficial in obtaining sufficient information to assist in patient care.

（5） Interdisciplinary Care Plan

The Interdisciplinary Care Plan lays the foundation for the care provided to the patient.Each profession associated with the patient contributes to the Interdisciplinary Care Plan，which includes an assessment of the patient，statement of desired goals for the patient，strategies on attaining the goals，and a periodic assessment of progress made toward achieving at scheduled intervals and revised as needed.

（6） Physician or Practitioner Orders

The Joint Commission defines a licensed independent practitioner as “any individual permitted by law and by the organization to provide care，treatment，and services without direction or supervision”.As a therapist，it is important to determine your level of authority in writing orders by checking the facility's policies and procedures，as well as the bylaws，rules，regulation of the medical staff and state law.

Orders communicate the type of treatment and diagnostic procedure（s） the practitioner wants for the patient to carry out the care plan.Orders can be verbal or written.Verbal orders must be authenticated in accordance with state and federal regulation； bylaws，rules，and regulations of the medical staff； and regulatory agencies.Use of standing orders is discouraged because not all of the actions on the standing order may be medically necessary for the patient.

（7） Progress notes and patient/client management notes

Notes are interval statements that relate to observations about the patient's progress and response to treatment from the perspective of the professional.Although the frequency of a patient's treatment may vary，a note is required for every treatment attempt and for treatments that are provided.For every treatment provided，documentation should include what was done including frequency，intensity，and duration as appropriate，equipment used or provided，changes in the treatment plan，reaction to the treatment，and communication with the patient/family or other health-care providers.

In addition to dating and authenticating your progress/re-evaluation note，some facilities require that you provide a start and stop time documenting when you were with the patient.This will be important when billing for services rendered to the patient.Remember：Write your professional credentials after your signature.

（8） Consultation

A consultation report contains an opinion about a patient's condition by a practitioner other than the attending physician.It is important for the consultant to document his or her opinion based on a review of the patient record，examination of the patient，and conference with the attending physician.Consultants address their specialty area only.

（9） Discharge Summary and Clinical Resume

For patients who have a health record available from a previous admission，the discharge summary or clinical resume summarizes the patient's course in the hospital or other care setting.This is a great place to find significant finding from examinations，laboratory tests，procedures，and therapies，along with how the patient responded.The patient's condition on discharge，physical activity，diet，medications，and follow-up care are included in the discharge summary.

Pertinent information can be found elsewhere in the health record including the operative report，pathology report，nursing notes，medication administration record，laboratory reports，radiology and imaging reports，radiation therapy，and notes from therapists such as speech-language pathology，occupational therapy，physical therapy，respiratory therapy，and dietetics.

Remember，the health record is a communication tool.Although abbreviations，acronyms，and symbols save time when documenting，they can be misinterpreted by others，placing the patient at risk.If your facility has an approved abbreviation list，be sure to use only those abbreviations exactly as they appear in the approved list.The Joint commission has a list of abbreviations that are not to be used in the health record.The list can be accessed at jointcommission.org.

5.The Electronic Health Record

Health-care facilities are transitioning from a paper record to one that is computerbased，or electronic.Two terms used interchangeably are electronic medical record （EMR） and electronic health record （EHR）.Even though the terms sound the same，there is a difference.The EMR came on the scene first.It made sense to use EMR because healthcare was computerizing the “medical” aspect of patient care for the primary purpose of diagnosis and treatment.

The EHR supports patient care by capturing data to support the overall “health”of the patient-mind，body，and spirit.It is a repository for all the patient data collected from components of the electronic systems，such as computerized physician order entry，laboratory，pharmacy，radiology，imaging，admissions，and transcription.The EHR provides the caregivers，the patient，and others with access to patient-specific information or information on a group of patients for research purposes.At this point，it is fair to say that health care is somewhere between EMR and EHR.The EHR for the United States will take about another 10 to 15 years.We have a lot of catching up to do with the rest of the world！

6.Summary

Information contained in the health record links all of health care.The value of the health record to the care providers and institution is only as good as the documentation in the record.Therapists must take the initiative to follow the documentation guidelines specified in the rules and regulations where they work and to make timely entries in the health record.The EMR/EHR is being implemented throughout the health-care industry.

Exercise for health record

1.What kinds of roles do health records play in supporting the health-care industry？

2.What kinds of documentation guidelines should all health-care providers follow？