4. Patient Care Using
Paper Medical Records

4.1 Project Context: Describing the Current Environment and Systems

After the project is identified, there is a step to look at how the currently organization functions with respect to the project—to look at the current environment and automated systems. Our project to automate the patient medical record in an HMO deals with patient care; thus we are interested in the current environment and automated systems dealing with patient care.

The description of the existing environment and systems can be used to

1. understand the organization with respect to the project area

2. clarify problems that the project can resolve

3. identify other alternative, and perhaps more appropriate, projects which can improve the organization and also fix these problems

4. determine essential business practices and automated systems that should be preserved by the project

5. provide a context to discuss the changed organization that would result from the project

6. provide a baseline against which the changed organization could later be compared.

After the current environment and systems are described, (1) problems with the current environment and systems to be fixed by the project are identified, and (2) business practices and automated systems the project should preserve are identified, thus limiting the scope of the project. This chapter describes patient care in an HMO using paper medical records, problems using paper medical records, and business practices and automated systems an HMO might want to preserve with the project to automate the patient medical record.

4.2 The Players in Patient Care in the HMO

The people who receive care fall into the following non-exclusive categories:

· HMO member: a person who pays a capitation fee--a fixed periodic payment--to an HMO or whose family or employer pays such a fee for the person so the person can receive comprehensive health care from the HMO

· non-HMO member: a person who is not a member of the HMO

· patient: a person who seeks or comes in for care.

· inpatient: a patient who receives care in a hospital.

· outpatient: a patient who receives care outside the hospitals.

The people that provide care in an HMO fall into the following categories:

· outpatient physician: a physician in the outpatient setting

· hospitalist/inpatient physician: a physician in a hospital

· outpatient nurse: a nurse in the outpatient setting

· medical assistant: a healthcare professional who performs a variety of clinical, clerical and administrative duties within a healthcare setting.

· ED triage nurse: a nurse who assesses patients’ medical problems in the emergency department to determine urgency and priority of care to determine which patient is to be seen next

· nurse practitioner: a registered nurse who has completed an advanced training program in primary health care delivery, and may provide primary care for non-emergency patients, usually in an outpatient or community setting

· physician assistant: a practitioner trained in aspects of the practice of medicine who works with or under the supervision of a physician to provide diagnostic and therapeutic care

· inpatient nurse: a nurse in the hospital

· unit assistant: a healthcare professional who performs a variety of clinical, clerical and administrative duties within a unit, or section, of the hospital

· ED physician: a physician in the emergency department

· ED nurse: a nurse in the emergency department

· advice nurse: a nurse who takes patient phone calls and advises the patient on medical conditions according to protocol; the advice nurse informs the patient when self-care is appropriate and when a patient needs to come in and when the patient does not

· appointment clerk: a person who takes member phone calls and who may schedule an appointment

· case manager: a person specifically assigned to oversee the case management of a member of the healthcare organization, where case management is an organized system for delivering health care, which includes assessment and development of a plan of care, coordination of services, referrals and follow-ups

· clinical social worker: a social worker in the clinical care setting who meets with a patient to provide assistance and advice on care, follow-up care, resources, and caregivers

· health care service representative/ombudsman: an ombudsman who an HMO member could call to resolve problems, to learn more about how the HMO functions and to learn more about the benefits provided to the member

· quality manager: a healthcare professional who evaluates the quality of healthcare in the healthcare organization, who is responsible for the generation of reports for accreditation and government agencies

· medical researcher: a healthcare professional who does clinical research such as research into new medications, procedures or best practices for the treatment of various medical conditions

· ancillary department personnel: personnel in a department providing services for patients or services for departments providing direct medical care, including the following: clinical laboratory, x-ray, physical therapy, injection clinic, pharmacy, optical sales and hearing center.

The people who provide care have various types of degrees, licenses and certifications, including the following:

· doctor of medicine (MD): A healthcare practitioner who has completed a doctorate degree in medicine and who has a license within a state to practice medicine as a physician.

· board certified specialist: A physician, nurse, or other healthcare professional who has advanced education and training in a specialty area such as internal medicine, surgery, ophthalmology, etc., each specialty with a qualifying organization which offers qualifying examinations to become “board certified”.

· registered nurse (RN): In the U.S., a person who completed a prescribed course of study from an approved nursing education program and who has passed the National Council Licensure Examination for Registered Nurses (NCLEX-RN) exam.

· nurse practitioner (NP): A registered nurse who has completed an advanced training program in primary health care delivery, and may provide primary care for non-emergency patients, usually in an outpatient or community setting.

· licensed practical nurse (LPN): A nurse who is licensed by a state board of nursing after completing an education program and passing the licensure exam who practices under the supervision of a registered nurse.

4.3 The Workflow of Caregivers in Providing Patient Care

The following describes the activities of people who provide care within an HMO. In general, there are no orientation sessions for new members in most HMOs. Usually, a member’s first encounter with the HMO is when the patient has a medical problem where he needs to see an outpatient physician; thus, we begin with a description of outpatient care in an HMO.

4.3.1 Outpatient Care in the HMO

When a member is sick, he telephones to make an appointment or to talk to an advice nurse. The advice nurse gives advice to the patient on self-care and on whether and when the patient should come in, and also makes appointments.

An appointment is made either with a physician, nurse practitioner or physician assistant, with a first appointment for a problem usually being in a primary care department. Primary care departments are medicine or family practice for adults, pediatrics or family practice for children, and in some HMOs, gynecology for women. The member is appointed to the HMO facility most conveniently located for the patient.

Based upon HMO and facility protocols, members can choose a primary care physician in medicine, pediatrics or family practice to guide the member

s care. Women can also choose a gynecology physician. A member may choose to have a nurse practitioner or physician assistant instead, or decide that he does not want an assigned healthcare provider.

Upon seeing the patient, the primary care physician may refer the patient to a specialist (e.g., dermatologist, urologist, gynecologist, ophthalmologist, etc.) When a primary care physician determines whether the patient sees a specialist, the primary care physician is said to have the role of a “gatekeeper”. (Advice nurses, by protocol, can sometimes book the patient directly with a specialty area physician or nurse practitioner, bypassing the gatekeeping process.)

Urgent care clinics may exist in the HMO for seeing the patient after normal business hours for non-emergency situations.

In general, member visits require appointments, with the visits pre-scheduled through a scheduling system that produces daily schedules for the physicians, nurse practitioners, and physician assistants. Although most urgent care clinics also require appointments, they also have a lot of “drop-in” patients. For minor problems in the outpatient setting, the patient may see a registered nurse rather than a physician, nurse practitioner or physician assistant.

For same day and next day appointments, the patient’s outpatient medical record is ordered at the time of the appointment. For future appointments, the medical record is only ordered by the appointment system the day before; this allows the patient to make an appointment for an earlier date and have the chart available for that appointment. The advice nurse doesn’t have a patient medical record (i.e., chart) available to her in the current environment.

During the patient visit, the physician, nurse practitioner, physician assistant and clinic nurses may add information to the patient chart or produce documentation that is later added to the chart. The clinician orders diagnostic tests (e.g., clinical lab tests, x-rays, etc.), but generally does not get the results until the next day; the patient often goes to another location to have a specimen collected (e.g., a blood test, a urine specimen). The clinician also orders medication that the patient later picks up from the pharmacy. An order is on paper with a copy being put in the patient’s chart.

An outpatient physician may also provide care for the patient when the patient is not in the medical facility. For example,

· informing the patient of diagnostic test results over the telephone

· approving or disapproving phone-in medication refill requests

· providing consultation advice for another caregiver for a patient after the patient seeks advice from an advice nurse or talks to the physician’s nurse.

In these cases, the physician most often first requests and receives the patient’s chart. This may require the physician to have to wait up to half a day, or longer if the patient has an appointment with another physician at that time who happens to have the chart.

Patients who “drop in”, without an appointment, may or may not be seen on the same day. Patients who “drop in” may go through a triage process (for example, run by a registered nurse) to determine if a patient should be seen immediately, should wait to be seen, should go directly to the emergency department, should schedule an appointment for later, or could administer self-care.

4.3.2 Care in the Emergency Department in the HMO

When a patient is faced with an emergency medical problem, he may come into the emergency department on his own or with the assistance of his friends or family. This may happen after receiving advice from an advice nurse or from a physician in urgent care who advises the patient to go the emergency department. Patients may also come in via ambulance to the emergency department.

All “walk-in patients” go through a triage process, controlled by a triage nurse. The patient is assessed. The triage nurse creates a list of patients by what time they came in and by urgency of the medical problem and assigns them to available rooms accordingly.

Patient charts within the facility are ordered from the chart room. If the charts are in an outpatient physician’s office, they may be retrieved from there.

Generally, before a patient is given care, an extensive interview is conducted and an examination is given, recording all relevant health information for the patient on paper, on a History & Physical (H&P) form. The H & P may be started by the triage nurse and continued after the patient is assigned to a room.

Care is then given to the patient. Orders for clinical laboratory tests, diagnostic imaging, or other diagnostic tests are made by a physician or nurse; the patient is usually not discharged until the results come back. Orders for medications are made. The patient is stabilized or procedures are initiated.

The patient is eventually discharged to home, to a hospital, or to an outside medical facility. The patient is given a written set of instructions and follow-up appointments are usually made.

Orders, again, are all on paper. They are included in the patient’s chart, either immediately or later.

The emergency department census identifies the rooms and names of all patients currently in examination rooms in the emergency department. The emergency department census is generally kept on a board and is updated when a new patient is put in a room, when a patient is discharged and the bed is dirty, or when a bed has been cleaned.

4.3.3 Inpatient Care in the HMO

Most often patients either enter the hospital as a walk-in with a pre-scheduled admission (called a pre-admission) or through the emergency department.

The patient goes through an admission process. This use to be done in the admissions office prior to the patient going into the hospital, but is occurring more and more often in the hospital room. A pre-admission would normally be accomplished ahead of the hospital stay during an outpatient visit. Admission and pre-admission is automated with pre-admission information carried over to the admission.

After the patient is moved to a bed in a room in a unit of the hospital (e.g., a medical-surgery unit), the patient is added to the unit census. On admission or pre-admission, the patient is assigned with an admitting physician and attending physician. The patient’s chosen primary care physician may also be involved or, alternatively, a hospitalist may be assigned, a physician who is a specialist in in-patient medicine, who takes responsibility for a patient’s care from the chosen primary care provider during the patient’s entire hospital stay.

Nurses are assigned with patients with consideration of acuity (severity) of the patients’ medical conditions. Upon a nursing shift change, other nurses are assigned.

Copies of the complete patient chart are ordered from various places, including outpatient charts. An inpatient chart for the inpatient stay is created. A summary document is created for the inpatient stay from existing chart documents, that includes physician diagnoses, nursing diagnoses, physician orders, etc., that, because it is a summary of information in the chart, is not saved in the chart; often this a trade-name document called the “Kardex”.

Nurses create extensive documentation during the inpatient stay that is saved in the inpatient chart. The next section describes many of these documents. Physician documentation and orders are also put in the inpatient chart.

Usually, all patient outpatient medications are taken away and medication administration is highly controlled during the hospital stay. Medications the physician orders are recorded, and often outpatient medications are also recorded, on a Medication Administration Record (MAR), which the nurse uses to identify and record the administration of these medications. Medications from the pharmacy for the unit are put on a cart, with the cart being sent to the unit at specified times.

Significant documentation also occurs on discharge, with ordering of medications for the patient when he is discharged and becomes an outpatient; these discharge medications become outpatient medications. The patient is discharged to home or to another medical facility. Outpatient appointments may be scheduled on discharge.

An important document to control inpatient workflow that is not a part of the patient medical record is the inpatient unit census, identifying the names and rooms of all patients in the unit, where a unit is a section of the hospital reserved for a particular purpose (e.g., the intensive care unit or ICU). The unit census is generally kept on a board and is updated when a new patient is put in a room, when a patient has been identified to be discharged, or when a patient is actually discharged.

In the emergency department and then the hospital, information of particular importance are allergies and adverse reactions to medications, and advance directives. Advance directives are written instructions a patient has prepared for medical personnel to inform them of the patient’s wishes for treatments and care when the patient is incapacitated, especially regarding life-sustaining treatment if the patient’s condition becomes irreversible. If the patient is unconscious or otherwise incapacitated, this information may not be available unless recorded in local charts.

4.4 Documents in the Paper Patient Medical Record

The paper patient chart includes the following parts:

· patient demographics information

· patient clinical data

· patient financial data.

The non-financial portions of the chart will be described.

4.4.1 Patient Identifier

A patient identifier is required to select a patient of interest to a caregiver. Currently this is an identifier determined by each healthcare organization.

On August 21, 1997 the U.S. enacted into law the requirement for established standards for health-related commerce [1] to be implemented by the year 2000. This legislation mandates a standard healthcare identifier for each individual, employer, health plan, and health care provider in the U.S. Although this identifier is for financial transactions, there is the potential of a future patient identifier that could be used in patient medical records across healthcare organizations.

4.4.2 Patient Demographics Information

Patient demographics information is information that identifies, locates, or describes a patient. Typical patient demographics information is the following:

· name

· address(es)

· phone number(s)

· sex

· date of birth

· emergency contact information

· race(s) (which is important in some medical decisions)

· religion

· source of payment.

The following additional information is important in the care of the patient:

· contact information for spouse, parent, person with Durable Power of Attorney for Healthcare or guardian

· for a minor, (1) who is legally able to consent to a child’s care, and (2) any special legal constraints, such as a parent who is not allowed to consent to care, who is not allowed to pick up a child from the clinic, or who is not allowed to have access to the child’s medical information [2]

· advance directives.

Of particular importance in California, Texas, and other states bordering Mexico is the following information:

· language preference

· indication of whether or not an interpreter is required.

Some additional demographics information of lesser medical and financial importance is the following:

· marital status

· occupation

· ethnicity

· education

· employment.

4.4.3 Patient Clinical Information

Clinical information in the current paper chart consists of documents of varying types. These documents are likely to vary from organization to organization or even from facility to facility in an organization.

What is presented here are documents found in the current paper charts of a large number of healthcare organizations and is assumed for our HMO. Also presented are basic descriptions of the care processes during which this clinical information is created.

4.4.3.1 Outpatient Clinical Information

The typical outpatient chart includes some or all of the documents listed in figure 4.2 [3].

Figure 4.2 – Outpatient Clinical Documents