 Hi everyone, my name is Leah and I am your lead course instructor here at Advanced E-Clinical Training and today's lesson is all about clinical documentation. So before we get started, I just wanted to give you a little bit of a disclaimer. Sometimes throughout the lesson, I will interchangeably be using the word charting with documentation or charting with documenting. It is the same thing, but I just wanted to let you know so you weren't confused as we were going through this lesson. So clinical documentation. So really what is clinical documentation? And as you can see here, clinical documentation refers to any written or electronically generated information about a patient describing any type of services or care provided to that patient. So this may include information about the patient's past medical history, their current symptoms or their current complaints, diagnosis, assessment, treatment, medications, as well as any type of testing that's done. So documentation and or charting is intended to create a permanent accurate description of what happened and when it happened. So when it occurred. So why is clinical documentation important? Well, number one, it's a form of communication. So clinical documentation promotes a safe high level of care by facilitating clear communication between the interdisciplinary team members involved in the patient's care. So the interdisciplinary team could include doctors, nurses, nurse practitioners, physicians, assistants, patient care attacks, medical assistants, pharmacists, physical therapy, physical therapists, occupational therapists, social work. So all of these people generally we all work together as an interdisciplinary team to really provide the most comprehensive and best care that we can for that patient. So clinical documentation helps to facilitate that process through communication. Also, it's a legal document and this is very important. So clinical documentation, it is a legal document. So a medical record can be used in any type of legal proceedings. And so when this happens, the documentation is heavily, heavily, heavily scrutinized and criticized to help support in arguments either way. And also know because it is a legal document, if you do document something that didn't happen or that's incorrect, that's falsifying documents. And that is a very, very serious issue. And people have lost their licenses over that. So just keep that in mind. And then lastly reimbursement. And I think, you know, most people don't really typically think about how clinical documentation is important in return, in regard to reimbursement. But the clinical document is a document of service that affects provider funding and reimbursement. So each diagnosis and or treatment that is documented is coded and then translated into a cost for the hospital system or the provider. So different types of clinical documentation methods. So first we have the source oriented and this is the most traditional form of charting or documenting. It is a source oriented record where each medical professional or department documents in different sections of the patient's record or chart. So an example of this would be the admissions department has an admission sheet. The physician has a physician's order sheet. The patient's past medical history is on another sheet. The medications are on another sheet. The patient caretack is documented on another sheet. The medical assistant is documenting on another sheet. So that's kind of an example of the source oriented form of documentation. The advantage of this is that care providers from each discipline can easily locate the forms on which to record their data. And it's easy to trace the information. But a disadvantage of this type of documentation is that the documentation is then scattered throughout the whole record. Moving on to charting by exception, which is another type of clinical documentation method. So charting by exception documents only items, issues, problems that are outside the norm as opposed to the comprehensive note taking. So however, so this type of charting must be based on clearly defined standards of practice and predetermined criteria for assessment and interventions. So this is not, I do not recommend this type of charting for this reason. So limiting documentation can be very risky. And it can be a potential liability if the charting standards are unclear, meaning that how do we know what is outside of the norm? So outside of the norm can be different for each person, each patient, because all of our norms are different. We're not all robots, we're humans. So my norm might be different from somebody else's norms. So how do you know what's outside of the norm and what to chart and what not to chart? So also if staff members use this way of charting kind of as a fair way to chart, that can be a problem. And it can be also extremely difficult to define, like I said, what standard of norms are. So the expectations will be well documented. So again, I do not recommend this type of charting. You don't see this very often anymore. There is an advantage to it that it's less time consuming, allowing the care team to focus on other tasks. But again, I think the disadvantages of this type of charting far outweigh the advantages. An example would be though it would be like generally they use like tools that can set the like checklists and flowcharts because you're not taking that comprehensive note taking, you're just documenting anything outside of the norm, whatever that would be. But again, I don't recommend this and I don't see this very often. So moving on to problem oriented to the problem oriented record and this is again a clinical documentation method. So this type of documentation focuses on problems that patients are having. So each with each problem listed, every member of that interdisciplinary care team can contribute and collaborate on the plan of care. An example of this is the soap note or soap your note. And we've kind of gone through that a little bit and thrill some of the modules in the lesson plan. But an advantage of this type of documentation is that it supports and promotes collaboration among that interdisciplinary team. A disadvantage of this type of documentation is that staff must complete a timely and ongoing assessment of problems and lists. So you are documenting a lot with this type of documentation method. So here's an example of a soap note or a soap your notes for that problem based documentation or the problem based record. So the soap note S, as you can see, this soap is mnemonic for what this type of note looks like but subjective. So this section covers histories such as the past medical history, symptom progression, questions or concerns about, you know, from the patient or their family members. And you move on to the O for objective. This is where you place all those objective findings. So vital signs, labs, exams and observations made during your assessment with them. Then you move on to the assessment. That's where you place your assessment findings, if that is part of your scope of practice. And this is where the medical concern would be. P is for plan. So this is where you would discuss or outline any updates to the patient's care of plan. Interventions, eye for interventions. So this is kind of where you would put what were your actions and interventions like, what did you do for the patient? Did you give them medications? Did you put the bed rail up? Did you place the call light within reach? If E is for evaluation. And this is where you document. So how did your patient responded to those interventions? Did they respond well to the medications? If that's what you gave it, that's within your scope of practice. Did they verbalize their understanding of any education that you provided to them? And then revision. This would be where you would, you know, after your evaluation, if anything needed to be added or changed to your interventions, this is where you would document that. So really, what should be documented? Well, just keep in mind that the most current and up to date information. So this will provide evidence that timely care was provided and appropriate. Clinically appropriate information. So the medical record, like I said, is a tool for continuity of care and communication amongst the healthcare team. So when charting, consider what you would want to know about this patient. If you were assuming care next for them and that you did not know. So this, that's where you would want to put this clinically appropriate information, informed consent discussions or the patient's refusal of care. So you definitely want to include details of refusal for any type of intervention, any type of care. You really want to put in there, you know, that you, with vital signs, you want to take the patient's vital signs, but they, they, they didn't want their vital signs taken at that time. So you didn't do the vital signs, you really want to document, you know, I, you know, patients declined vital signs at this time. And so you definitely want to put that in, in the clinical documentation. And part of this is because there's something in healthcare that we call CYA. And what that stands for is cover your, you know what? So cover your butt. So you, you attempted to provide an intervention, you attempted to do vital signs, you attempted to bathe the patient and they declined. Well, you need to put in the dot, you need to put into the chart that you attempted to do these things, but the patient's declined. Because if you didn't chart it, you didn't do it. So you might not have been able to put the vital signs in because the patient didn't want them, but you have to chart that you attempted to do that. That is very, very important. CYA, always think about that when you're charting and documenting CYA. And if you didn't chart it, you didn't do it. Okay. So moving on, discharge instructions include time and action specific directives, follow up plans, the plans for follow up with the provider, patient complaints and responses. So I include all copies of clinic related correspondence from and to the patients, as well as notes from phone conversations and office discussions, clinically pertinent telephone calls. And this kind of goes with what we just talked about. So you want to include notes regarding any prescription medication requests or instructions about when to seek further medical care, missed appointments and attempts for follow up. This is a big one. So include notes on why the patient missed the appointments and if it ends any other examples of patient non-compliance or failure to follow instructions. And definitely medication, you always want to include allergies and any prior adverse reactions to medications or current contrast media. And I always like to tell my students, you always want to ask about allergies on every patient visit, even if you just saw the patient last week, because you can develop an allergy at any point in your life. So you might not have been allergic to, you know, a penicillin last week and you took penicillin this week and you developed an allergy. So that's always very important to do that. What should we not document? Well, any derogatory or discriminatory remarks. So keep in mind that in some states patients have the right to access both office and hospital medical records and they may review remarks, they might be sensitive and may review remarks as disrespectful or prejudiced. So, and this especially relates to anything, including socioeconomic information. So only document that if it is relevant to that patient's case or care. Arguments and conflicts with the healthcare team is not a place, the clinical documentation chart is not a place to be documenting that. So you want to address these issues through the appropriate chain of command, human resources, but not through the patient's medical record. Subjective statements. So document previous treatment or poor outcomes presented as facts. So use quotation marks to indicate a patient's or family family's impressions, such as this patient acquired a brain injury as a result of a fall. And that's how the patient or their family member understands it and relates that information to you because that is a subjective statement. And so if that is what the family member or the patient said to you, you want to put that in quotation marks. And then any non-patient care information. So you don't want to include the filing of any type of incident reports or referrals or reference to any type of legal issues going on. Just some do's and don'ts of documentation. And we kind of went over these in the last two slides, but obviously you want to be timely with your notes and your charting. You want to chart and document as you're going as it's happening. Because if you have to backtrack and you have to, sometimes you're going to have to backtrack. Sometimes you're going to be very busy and you can't document everything as it's happening, but you really want to try to be as timely with that as possible. And if you do have to backtrack, just make sure you are changing the time to when this happened. So if you took vital signs at 8am, but you didn't get a chance to document them till 10am, make sure you're documenting those vital signs from when you did them. Make sure you provide accurate information. Be clear with your details. You want to make it legible. Now here is something that I really want to go over as far as making it legible. So when we're talking about clinical documentation and clinical charting, now most healthcare systems, most healthcare practices and doctors offices are now using the electronic forms of medical records or the EMR. So making it legible in an electronic form doesn't really make sense, right? But you have to understand that some places, some facilities, some doctors offices are still using paper charts. And so you will be completing all your documentation and charting on paper charts if this is the case. So you want to make it legible. You want to make it so that other people can read it. And also keep in mind that even if your healthcare system or your employer is using an electronic form of a medical record, the medical record can go down. And it has happened to me before while I've been working. And we get the computer stops, the computer stops working, and all the computers crash. And it's a scramble. But what the contingency plans is for that is that they bring in the paper charts and then say you are paper charting. So you always want to make it legible. Also with those electronic medical records, they do have scheduled downtime where they do the any type of upgrades they need to, you know, they they're uploading their security measures, whatever it might be that usually happens like once a month in a hospital. And when that's happening, you're documenting on a paper chart. So make it legible. Provide facts and be objective. You want to make certain that all of your spelling and grammar is correct and only a used approved abbreviations. And then be sure that patient identification is on each page of the chart. So again, with the electronic medical record, that will already happen for you automatically. But just make sure that you are charting in the correct patients chart always, always, always, always. And if you're doing paper charting, you want to make sure that there's the patient identification is on each page of that documentation. So moving on to the don'ts of documentation. Again, we don't want to criticize the patients or make any twist of derogatory remarks. On a paper chart, you do not want to erase or elaborate any incorrect chart entries. So you cannot erase on on a paper chart and you can't write out on a paper chart. You can't scratch it out. So you can't see what's underneath that. And we'll go over that in our next slide. But you want to avoid any gaps in your notes. So you know, should be again, documenting as you go or as closely as to the time that it happened. If you are back charting or back documenting, make sure that you are providing the time that the intervention or the care was provided to the patient or the time that, you know, the incident happened with the patient. Do not use any sarcasm, slurs, humor or profanity. Do not let others document for you. And please, please, please do not document for anybody else either. Again, clinical, the documentation, the clinical document is a legal document. So always keep that in mind. And again, as I said, we were going to talk about how to correct a mistake with your clinical documentation. So first with paper charts, state laws vary on how medical records can be amended, but generally the law does not allow you to erase information so that it cannot be recovered. So for this reason, opaque correction fluid or whiteouts is prohibited in correcting paper records. Instead, if you make a mistake on a paper, on a, on a paper record, it will happen. We all make mistakes. You want to in the incorrect entries in the written medical record should be lined out. So with one line through it, that's it, not scribbled over just one line through it and rewritten the way you want it to be. And then you, so with that mistake, you correct it again with a single line strike through. And then you want to rewrite it how you want to, and then follow that by it clearly initialing and dating your correction with the electronic charts. So first, and you'll know this when you go through any type of training with your employer that if they're using the electronic health record or the EHR, you, they'll confirm with you whether this system allows error correction and they'll determine, you know, what type of process is that they want for the correction. And you'll go through an extensive training with your employer if they're using the electronic health record. And they'll take you through that process, but the system must have the ability to track the corrections or change once the original entry has been entered. And when correcting or making a change to an entry, the original entry should not, should be viewable again. And the current date and time should be entered and the person making the change should be identified and the reason for making the change should be noted. And usually if you're trying to amend something or correct something in electronic chart, you can't even do that without like, it'll prompt you to why are you changing this and you have to either choose from a drop down of reasons or if it's other than you have to provide, you know, your own statement as to why you're trying to change that. So again, with clinical documentation or with charting, you can be using paper charts or you could be using the electronic health record. But either way, the documentation and the charting is very, very similar as, you know, what you're charting and what you should not be charting. And also keep in mind, like I said, CYA, you always want to cover your, you know what, so because this is a legal document, you want to cover yourself that you are doing the most appropriate and high level care for this patient and that you were doing that within your scope of practice. So if you have any questions or concerns or you need any type of clarification, again, you know, you can always email me or schedule office hours with me. But thanks for attending and I will see you all again real soon.