Test Bank Guide to Clinical Documentation 3rd Edition by Debra D Sullivan

Test Bank Guide to Clinical Documentation 3rd Edition by Debra D Sullivan 
Medicolegal Principles of Documentation
LEARNING OUTCOMES
• Discuss medical and legal considerations of documentation.
• Identify groups of people who may access medical records.
• Identify general principles of documentation.
• Discuss medical coding and billing.
• De!ne the terms electronic medical records, meaningful use, and interoperability.
• Identify bene!ts of using electronic medical records.
• Identify challenges and barriers to using electronic medical records.
• Identify components of the Health Insurance Portability and Accountability Act.
• Discuss principles of con!dentiality.
Introduction
You might be asking, “Why a book on documentation?”
Documentation is one of the most important skills a
health-care provider can learn. You might feel tempted
to focus considerably more time and energy on learning
other skills, such as physical examination, suturing, or
pharmacotherapeutics. !ese are essential skills, but
documentation is likewise extremely important. State
licensure laws and regulations, accrediting bodies,
professional organizations, and federal reimbursement
programs all require that health-care providers maintain
a record for each of their patients.
Documentation used to be mostly a memory aid
for the provider—a quick note of his or her thoughts
about a patient’s presentation, a likely diagnosis, maybe
a few words about the treatment plan. Over the past
few decades, however, documentation has become a
more complex task due to changes in medicine and
with patients themselves. Increased complexity in the
medical field is evident by the ever-increasing number
of medications and treatment modalities available to
health-care providers. In addition, patients live longer
with a greater number of comorbid conditions, adding
to the complexity of caring for them and requiring that
complexity in the medical records. !e fact that our society is so litigious certainly adds more weight to clinical
documentation and puts a greater burden on providers
to capture their thoughts and actions for others to read
and interpret years after an episode of care took place.
Dr. Mitchell Cohen wrote about this evolution of
documentation in an article that appeared in Family
Practice Management.* Dr. Cohen explains:
From time to time I’ll stumble upon an old chart in my
office that goes back 40 years. My predecessors charted
office visits on sheets of lined manila card stock, which
would suffice for at least 15 to 20 visits. Clearly, these
charts were only intended for the physicians as a way to
refresh their memory of what happened from one visit to
the next. For example, the documentation for one visit
read simply, “1/20/67: pharyngitis >> penicillin.” "ese
days chart notes are primarily not for the physician or
patient, but for all the others who aren’t in the exam
room and yet feel they have a stake in what takes place
in this once confidential arena. To satisfy coders and
insurers, my documentation for a 99213 sore throat
visit must contain one to three elements of the history
of present illness, a pertinent review of systems, six to
11 elements of the physical exam, and low-complexity
medical decision-making. My malpractice carrier and
my future defense attorney would also like me to explain
my clinical rationale for why the patient has strep throat
and not a retropharyngeal abscess or meningitis. A table
with a McIsaac score calculating the likelihood that this
PART I Foundations of Documentation
Chapter 1

2    |   Guide to Clinical Documentation
Copyright © 2019 by F. A. Davis Company. All rights reserved.
patient does indeed have strep throat might be nice as
well. If I prescribe a weak narcotic for a really nasty
case of strep, the state medical board would be pleased
if I addressed what other medications have been tried
and whether the patient has any history of addiction.
I’ll also need to document that I explained the proper
use of the medications and the need for follow up if the
patient doesn’t get better. When I’m finally done with
my note, it looks like this:
CC: sore throat x 2d
HPI: 17 y/o F with 2d h/o sore throat. Has an associated headache and fever to 1018F. No significant
cough. Patient has noticed some swollen lumps in
neck. Having significant pain despite use of Tylenol,
ibuprofen and salt water gargles.
Social Hx: no h/o substance abuse or addiction.
ROS: denies neck stiffness or back pain, no rash. No
difficulty speaking.
PE: VS: AF, VSS
Gen: alert, pleasant female in NAD
HEENT: NC/AT, PERRLA, EOMI, TM clear b/l,
OP notable for tonsillar enlargement with exudates.
No asymmetry or uvular deviation present.
Neck: + tender anterior cervical adenopathy, no nuchal
rigidity or meningismus.
CV: RRR S1/S2 without murmurs.
C/L: CTAB
Abd: soft, nondistended, nontender, no hepatosplenomegaly.
McIsaac’s score = 4; Rapid strep +
A: streptococcal pharyngitis
P: 1) Pen VK 500 mg po TID x 10 days. Discussed
risks of medication including allergic reaction and
complications of not taking full course of antibiotics
including rheumatic fever and valvular heart disease.
2) hydrocodone elixir q HS to help relieve pain particularly when trying to rest. Has already tried
acetaminophen and NSAID and will continue salt
water gargles. Follow up if no improvement in one
week. Have discussed other potential diagnoses and
reviewed warning signs of retropharyngeal abscess
and meningitis. Patient agrees and understands plan.
Like I said, “pharyngitis >> penicillin.”
(*Used with permission of the American Academy of
Family Physicians)
Medical Considerations
of Documentation
As illustrated in the example, the medical record serves
to document the details of the patient’s complaint and
the medical evaluation and treatment. !e medical
record also serves other purposes and has audiences
other than the patient and the health-care provider; it is
both a medical and a legal document. !e medical record
establishes your credibility as a health-care provider. It
is important to remember that you are creating a record
that other professionals will read; therefore, you should
use professional language and include appropriate
content. Other readers will assume, rightly or wrongly,
that you practice medicine in much the same way that
you document. If your documentation is sloppy, full
of errors, or incomplete, others will assume that is the
way you practice. Conversely, thorough, legible, and
complete documentation will infer that you provide
care in the same way, thus establishing your credibility.
Some excellent providers simply do not have good documentation skills. However, this is the exception rather
than the rule. It is very difficult to persuade those who
read sloppy documentation that the person who wrote
that way can, and did, provide good care.
Up-to-date and complete documentation is an essential
component of quality patient care. !e medical record
is the primary means of communication between members of the health-care team and facilitates continuity
of care and communication among the professionals
involved in a patient’s care. Although many patients
will have a primary care provider who provides most of
their care, patients also may see specialists for specific
problems. Medical records are the vehicle for communication among members of the health-care team,
and the medical record is the common storehouse for
all information about the patient’s care and condition
regardless of who is providing that care.

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