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Record Documentation (record + documentation)

Distribution by Scientific Domains
Medical Sciences100%

Kinds of Record Documentation

  • medical record documentation
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    Selected Abstracts

    Emergency Medicine Resident Documentation: Results of the 1999 American Board of Emergency Medicine In-Training Examination Survey

    ACADEMIC EMERGENCY MEDICINE, Issue 10 2000
    John Howell MD
    Abstract. Objectives: To assess how emergency medicine (EM) residents perform medical record documentation, and how well they comply with Health Care Financing Administration (HCFA) Medicare charting guidelines. In addition, the study investigated their abilities and confidence with billing and coding of patient care visits and procedures performed in the emergency department (ED). Finally, the study assessed their exposure to both online faculty instruction and formal didactic experience with this component of their curriculum. Methods: A survey was conducted consisting of closed-ended questions investigating medical record documentation in the ED. The survey was distributed to all EM residents, EM,internal medicine, and EM,pediatrics residents taking the 1999 American Board of Emergency Medicine (ABEM) In-Training examination. Five EM residents and the Society for Academic Emergency Medicine (SAEM) board of directors prevalidated the survey. Summary statistics were calculated and resident levels were compared for each question using either chi-square or Fisher's exact test. Alpha was 0.05 for all comparisons. Results: Completed surveys were returned from 88.5% of the respondents. A small minority of the residents code their own charts (6%). Patient encounters are most frequently documented on free-form handwritten charts (38%), and a total of 76% of the respondents reported using handwritten forms as a portion of the patient's final chart. Twenty-nine percent reported delays of more than 30 minutes to access medical record information for a patient evaluated in their ED within the previous 72 hours. Twenty-five percent "never" record their supervising faculty's involvement in patient care, and another 25% record that information "1-25%" of the time. Seventy-nine percent are "never" or "rarely" requested by their faculty to clarify or add to medical records for billing purposes. Only 4% of the EM residents were "extremely confident" in their ability to perform billing and coding, and more than 80% reported not knowing the physician charges for services or procedures performed in the ED. Conclusions: The handwritten chart is the most widely used method of patient care documentation, either entirely or as a component of a templated chart. Most EM residents do not document their faculty's participation in the care of patients. This could lead to overestimation of faculty noncompliance with HCFA billing guidelines. Emergency medicine residents are not confident in their knowledge of medical record documentation and coding procedures, nor of charges for services rendered in the ED. [source]

    Factors Associated with Physician Interventions to Address Adolescent Smoking

    HEALTH SERVICES RESEARCH, Issue 3 2004
    Tammy H. Sims
    Objective. To determine the percent of adolescent Medicaid patients with medical record documentation about tobacco use status and cessation assistance; and factors associated with providers documenting and intervening with adolescent smokers. Data Source. Secondary analysis of data collected in 1999 from medical records of Wisconsin Medicaid health maintenance organization (HMO) recipients 11 to 21 years old. Study Design. Random reviews and data collection were related to visits from January 1997 to January 1999. Data collected included patient demographics, provider type, number of visits, and whether smoking status and cessation interventions were documented. Data Extraction Methods. Medical charts were reviewed and a database was created using a data abstraction tool developed and approved by a committee to address tobacco use in Medicaid managed care participants. Principal Findings. Among adolescents seen by a physician from 1997 to 1999, tobacco use status was documented in 55 percent of patient charts. Most often tobacco use status was documented on history and physical or prenatal forms. Of identified adolescent smokers, 50 percent were advised to quit, 42 percent assisted, and 16 percent followed for smoking cessation. Pregnant patients were more likely to have tobacco use documented than nonpregnant patients (OR=10.8, 95 percent CI=4.9 to 24). The odds of documentation increased 21 percent for every one-year increase in patient age. Conclusions. Providers miss opportunities to intervene with adolescents who may be using tobacco. Medical record prompts, similar to the tobacco use question on prenatal forms and the tobacco use vital sign stamp, are essential for reminding providers to consistently document and address tobacco use among adolescents. [source]

    Physician Recognition of Cognitive Impairment: Evaluating the Need for Improvement

    JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2004
    Joshua Chodosh MD
    Objectives: To assess physician recognition of dementia and cognitive impairment, compare recognition with documentation, and identify physician and patient factors associated with recognition. Design: Survey of physicians and review of medical records. Setting: Health maintenance organization in southern California. Participants: Seven hundred twenty-nine physicians who provided care for women participating in a cohort study of memory (Women's Memory Study). Measurements: Percentage of patients with dementia or cognitive impairment (using the Telephone Interview of Cognitive Status supplemented by the Telephone Dementia Questionnaire) recognized by physicians. Relationship between physician recognition and patient characteristics and physician demographics, practice characteristics, training, knowledge, and attitudes about dementia. Results: Physicians (n=365) correctly identified 81% of patients with dementia and 44% of patients with cognitive impairment without definite dementia. Medical records documented cognitive impairment in 83% of patients with dementia and 26% of patients with cognitive impairment without definite dementia. In a multivariable model, physicians with geriatric credentials (defined as geriatric fellowship experience and/or the certificate of added qualifications) recognized cognitive impairment more often than did those without (risk ratio (RR)=1.56, 95% confidence interval (CI)=1.04,1.66). Physicians were more likely to recognize cognitive impairment in patients with a history of depression treatment (RR=1.3, 95% CI=1.03,1.45) or stroke (RR=1.37, 95% CI=1.04,1.45) and less likely to recognize impairment in patients with cognitive impairment without definite dementia than in those with dementia (RR=0.46, 95% CI=0.23,0.72) and in patients with a prior hospitalization for myocardial infarction (RR=0.37, 95% CI=0.09,0.88) or cancer (RR=0.49, 95% CI=0.18,0.90). Conclusion: Medical record documentation reflects physician recognition of dementia, yet physicians are aware of, but have not documented, many patients with milder cognitive impairment. Physicians are unaware of cognitive impairment in more than 40% of their cognitively impaired patients. Additional geriatrics training may promote recognition, but systems solutions are needed to improve recognition critical to provision of emerging therapies for early dementia. [source]

    Evaluation of documentation in potential abusive head injury of infants in a Paediatric Emergency Department

    ACTA PAEDIATRICA, Issue 5 2009
    Björn Tingberg
    Abstract Aim: The aim is to evaluate medical record documentation regarding potential abusive head injury (AHI) in infants presenting to a Paediatric Emergency Department (ED) with certain primary complaints known to be associated with AHI. Methods: A database search was performed to find all medical records over a period of one year relating to those children who had one AHI-related primary complaint and who had had a CT head-scan performed in conjunction with admission. Each medical record was reviewed, in order to assess whether potential abuse had been investigated and documented. Each CT-scan image was re-evaluated for missed indications of potential injuries attributable to AHI. Results: Forty-seven such medical records were found. Of these, 87% showed the diagnosis to be head injuries. The largest group of children was in the age group 0,3 months (38%). Of the children admitted to the Paediatric ED due to a head injury, 54% had a history deemed to raise suspicions of abuse but only five of them had had a documented investigation of child abuse. The re-evaluation of the CT-scans showed no missed cases. Conclusion: In this study we found that among children with known risk factors for AHI, only a few had documentation regarding potential child abuse. The use of a standardized protocol could be helpful in the important work to help staff discover potential AHI. [source]