clinical documentation - wslhd

CLINICAL DOCUMENTATION Dr Andrew Baker

“She has no rigors or shaking chills, but her husband states she was very hot in bed last night. “

Recording in the Medical Record • Most Frequent Intern Activity • Most Important Intern Activity

“The patient stopped smoking and after a few months started smelling again“

Your Audience

• Medical Colleagues • Other Clinicians • Patient (GIPA) & Family • Clinical Governance • Administrators • Lawyers • Coroner • Medical Records Coders

“Patient has chest pain if she lies on her left side for over a year. “

When to Record

• On admission • Every day • When clinical decisions are taken • When a plan is changed • After a round • After clinical discussion/consult • Esp when decision is made to discharge • When some thing changes

“On the second day the knee was better, and on the third day it disappeared“

What to Write

• Your Name & Designation • Date and time • Reason for Entry • Clinical Findings • Diagnosis • Consultations/Discussions • Actions • Plan • Signature - Do NOT save without signing

"Social history reveals this 1 year old patient does not smoke or drink and is presently unemployed.“

How to Record

• Coherently – normal sentence structure • #NoTwitterTalk • Approved Abbreviations • Accurately & Objective

NB: Imagine this is not just for your benefit, but someone who doesn’t

know the patient, and has to read and make sense of what you write (days or even weeks or years later)

“The patient has been depressed since she began seeing me in 1993”

How to Record

DO NOT USE ALL CAPS BECAUSE IT IS REALLY ANNOYING TO READ AND IT IS A UNIVERSALLY RECOGNISED MEANS OF DENOTING ANGER!!!

HAPPY NEW YEAR TO EVERYONE, INCLUDING THE HATERS AND THE FAKE NEWS MEDIA! 2019 WILL BE A FANTASTIC YEAR FOR THOSE NOT SUFFERING FROM TRUMP DERANGEMENT SYNDROME. JUST CALM DOWN AND ENJOY THE RIDE, GREAT THINGS ARE HAPPENING FOR OUR COUNTRY! 5:08 AM - 1 Jan 2019

"Social history reveals this 1 year old patient does not smoke or drink and is presently unemployed.“

PRIVACY

“The patient refused autopsy.”

PRIVACY

• Patients have a right to expect that their confidential medical information will only be revealed to those members of the treating clinical team who need to know

“The patient refused autopsy.”

PRIVACY

• You cannot access information or divulge information without a legitimate reason

• Confidentiality is upheld by • Legislation • Professional Standards • Code of Conduct

“I saw your patient today, who is still under our car for treatment”

PRIVACY

• Privacy Manual Covers: • Collection • Security • Use • Patient Access

“Both breasts are equal and reactive to light and accommodation.”

Disclosure of Information

• Primary Purpose • Secondary Purpose • Other Laws (eg Vet Affairs) • DOCS • Crimes Act (ie police) • HCCC When in doubt ask the Experts!

“Patient has two teenage children but no other abnormalities” “Discharge status: Alive but without my permission”

How you might come unstuck

• Gossiping with colleagues • Patient Lists • Phone enquiries • GPs • Research / Audits • Facebook • iPhone (esp Photos – there is a policy)

“Rectal examination revealed a normal-size thyroid”

Health Information and Record Service (HIRS)

• Level 1, G Block

(Beneath Emergency) • Department is staffed 24/7 – after hours access by

arrangement

"Patient is to remain plastered for the next 6 to 8 weeks."

Health Information and Record Service • Accessing health care records • Patient confidentiality • Clinical documentation • Police statements / expert certificates • Consent • Sensitive information • Coding

“Patient may shower with nurse”

Medico Legal

Kate Fedrigo • When she calls – JUMP • If external non clinical people ask for info (eg police , solicitors , HCCC

etc) – refer to Kate

“Patient advised to push fluids through his interpreter”

Activity Based Funding What is it?

How does it apply to you

The Language of “Activity”

• Casemix • “literally the mixture of cases” • a system for attempting to compare patients of differing complexity based on

their cost to the system

• ICD – International Classification of Diseases • AR-DRG – Australian refined diagnosis related Groups • NWAU- National Weight Activity Unit • NEP – National Efficient Price

Activity Based Funding

• Admitted and discharged with “chest pain” • Coded as “Chest Pain” - $1870 • Coded as “Unstable Angina” – $2270 • Coded as “Myocardial Infarct”…

Activity Based Funding • Coders can only do their job based on YOUR

documentation • They might notice an elevated Cr, but they can’t

code “renal failure” unless you write it down • The quality of YOUR documentation impacts on the

speed and accuracy of their coding • The accuracy of their coding impacts directly on

Westmead’s funding

Lots of things Affect coding

• Complications & co-morbidities • Even clinically minor ones

(eg hypokalemia, Pressure Ulcer, UTI, Constipation etc) • Procedures • Social History, smokers

Hence - the importance of comprehensive documentation But – Not just about funding. Fundamentally about good

patient care

Complications & Co-morbidities Not just existence, but impact & Onset

What did we do about it? • Actively monitor • Investigate • Institute medication • Vary management Was it Pre-existing?

Activity Based Funding • Issues Lists • Try to document the reason for all actions or variations that

occur in hospital (and if unclear as to the causation express an opinion about likelihood – eg “treated as”)

• Record the presumed diagnosis behind the symptom. • Record the presumed diagnosis behind the abnormal lab

findings • Be particular about abnormal findings that need monitoring

and treatment.

Activity Based Funding • Explain why medication is initiated or varied • Be aware of co-morbidities which often go

unremarked – did they require active monitoring or change of management

• Document any chronic condition which requires a change of treatment (eg diabetes, hypertension etc)

• When in doubt – check each dept has its own checklist

Activity Based Funding

Social History is important! • Record smoking, etOH and drug use • Record living circumstances

Minor Procedures are important • Eg urinary catheterisation

Record incident or injuries in hospital • Eg Falls

New Quality Indicators

• Introduced penalties for hospital complications • Important to identify pre-existing illnesses

ANY QUESTIONS?