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

Document	Description
History and Physical	The patient's initial medical examination and evaluation data. This document includes the following: chief complaint (CC), history of present illness (HPI), past medical history (PMH), family history (FH), social history (SH) and marital history, review of systems (ROS),
	physical exam (PE), assessment, diagnosis (Dx), impression, rule out (R/O), plan, prognosis (Px).
Progress notes	Documentation for a follow-up visit. The physician's objective findings concerning improvement or aggravation of the condition, any change in treatment or medication, and the patient's own report about the condition.
Physician's orders	A record of a physician's medical orders.
X-rays, other diagnostic images, EKGs, etc.
Diagnostic findings	Diagnostic and laboratory data--for example, hematology, pathology, radiology, and X-ray test results and transcriptions.
Correspondence / E-mail	Letters and E-mail conveying clinical information on the patient.
Phone messages	Phone messages conveying clinical information on the patient.
Consent forms	A patient's or patient's guardian's consent for treatment, special procedures or to release information.
Consultation reports	An opinion about the patient's condition by a practitioner other than the primary care physician.

A patient calls in for an appointment or an appointment was made after a previous visit. The patient comes in at the time of the appointment; alternatively, a patient “walks in” and may be seen.

Either after the patient is escorted to a room or just prior, a nurse takes the patient’s vital signs and puts this information either on the physical examination part of the history and physical form or on a separate vital sign record. If not already in the examination room, the patient is escorted to the room.

Figure 4.3 identifies a classical data collection and interpretation strategy known as the hypothetico-deductive approach [4], followed by many physicians and nurse practitioners within the examination room (and which is applicable both for the outpatient and inpatient setting). This physician or nurse practitioner records examination information on history and physical (H&P), progress notes and associated documents.

As a first step in this process, the patient’s identity (ID) is verified and the chief complaint (CC) is recorded [5]. Information given by the patient is recorded under the heading subjective. A history of present illness (HPI) is recorded that would include the following: (1) the symptoms that are troubling the patient, (2) when the symptoms first occurred, (3) the patient’s opinions as to the cause of the illness, (4) remedies the patient may have tried, including any medication treatment. From this information the caregiver forms some initial hypotheses on the diagnosis; the set of active hypotheses are referred to as the differential diagnosis, a set of possible diagnoses.

The caregiver asks further questions of the patient, including information about past medical history (PMH), past illnesses and treatments administered, past operations, accidents, injuries, congenital problems and allergies; family history (FH), health information about other family members, especially genetic disorders; and social history (SH) if applicable, information related to the patient’s eating, drinking, smoking habits and occupation. The caregiver then reviews each body system with the patient (e.g., respiratory system) and records it as a review of systems (ROS).

In order to refine the hypotheses on the diagnosis, the caregiver exams the patient and may order diagnostic tests. The caregiver’s examination of the patient is recorded under the heading objective. Previously recorded vital signs might be included in this section. Results of the examination are recorded under the heading physical exam (PE), with findings usually separated out by each body area; the physical exam may later include laboratory, X-ray and other diagnostic results that come back on medical reports for various diagnostic findings, laboratory reports, X-ray reports, etc.

From the subjective and objective findings, including diagnostic test results, the caregiver makes a best determination of diagnosis (Dx), the name of the condition from which the patient is suffering, which is recorded under the heading assessment.

The plan or treatment section lists a treatment for the patient, which may include the following:

· medications and dosages

· instructions given to the patient

· any recommendations for hospitalization or surgery

· any special tests that need to be performed.

The caregiver’s prognosis (Px), the caregiver’s opinion of what the outcome of the illness will be (e.g., “fair”, “good”, “poor” or “guarded”).

In reality, this data collection and interpretation process for outpatients usually extends beyond the single outpatient visit. The physician or nurse practitioner orders but does not wait for diagnostic test results before forming a preliminary diagnosis. Treatment is determined on this preliminary diagnosis, usually involving a medication program. When the caregiver receives back the diagnostic test results, the caregiver determines whether or not to modify the diagnosis. If the diagnosis needs to be modified, the patient may be called by the physician, the nurse practitioner or his nurse with modified treatment instructions, or the patient may be called to arrange a return visit.

During this process, the caregiver may request an evaluation of the patient from clinical specialists for additional diagnoses and treatment recommendations. This may result in a referral letter to the clinical specialist with a consultation report being returned from the clinical specialist.

The patient may remain in treatment for a long time over many visits (e.g., chemotherapy for cancer, or treatment for diabetes or other chronic condition). The patient may return many times with a cycle of observation, with possible changing of the diagnosis or treatment.

In the outpatient setting, some HMOs have advice nurses who answer patient phone calls and follow protocols based upon patient symptoms. Through a triage process, the advice nurse might have the patient (1) seek an emergency evaluation by coming in within a short period to the Emergency Department or the physician’s office, (2) come in to see a physician within 24 hours, (3) make a future appointment with a physician, (4) attend a health education class or (5) follow self management. The advice nurse might describe care steps the patient should follow.

In some situations, the advice nurse may request advice of a physician regarding a patient. She might make a phone call to the physician or leave a phone message or send an e-mail message. The phone message or e-mail message could optionally be put in the chart. At the same time as the phone message or e-mail, any paper chart could be ordered, sending it to the physician. Upon receiving the physician’s advice, the advice nurse would later call back the patient or alternatively, the physician or a nurse could call back the patient.

An appointment clerk in an HMO makes appointments following protocols. An appointment could be made for a patient upon the patient calling in or made for the patient after the patient’s visit to schedule a follow-up appointment. Upon protocol, a patient calling in could be transferred to advice nurse.

An important document to control outpatient workflow that is not a part of the patient medical record is the outpatient schedule. Schedules are for a particular physician, nurse, room or piece of equipment identifying by time all patients scheduled to see that person, room or piece of equipment (i.e., and thus identifying all patients who have an appointment with the person or object). There is generally one schedule for each date the person works or the object is used. Schedules might also identify who shows up for an appointment and who does not, who cancels, and who didn’t have an appointment but will be seen. The outpatient schedule for a person or object is thus a very important workflow document for outpatient clinics.

4.4.3.2 Inpatient Clinical Information

The typical inpatient chart includes some or all of the documents listed in figure 4.4 [3] and is assumed in our HMO. The inpatient care process involves admitting and caring for the patient, and may include the admissions department personnel, physicians, nurses, and unit assistants; see figure 4.5.

Figure 4.4 – Inpatient Clinical Documents

Document	Description
Face sheet	Information identifying the patient, including name, admission date, address and birth date, emergency contact and closest relative, allergies, admitting diagnosis and attending physician.
Medical history and physical examination	The patient's initial medical examination and assessment data completed by the physician.
Initial nursing assessment form	Initial assessment.
Physician's orders	A record of a physician's medical orders.
Problem or nursing diagnosis list	List of nursing diagnoses.
Nursing plan of care	Plans for patient care.
Graphic sheet	A type of flow sheet showing graphic recording of the patient's temperature, pulse rate, blood pressure, and possibly daily weight.
Other flow sheets	Abbreviated progress notes, recording dates, times, changes in the patient's condition.
Medication administration record (MAR)	A recording of each medication the patient receives, including name, dosage, route, site, and date and time of administration.
Physician's progress notes	Physician's observations, notes on the patient's progress, and treatment data.
Nurses' progress notes	Patient care information, interventions, and patient's responses.
Consultation sheets	Reports of evaluations made by physicians and others called in for opinions and treatment recommendations.
Health care team records	Notes from other departments, including physical therapy and respiratory therapy.
X-rays, other diagnostic images, EKGs, etc.
Diagnostic findings	Diagnostic and laboratory data--for example, hematology, pathology, radiology, and X-ray test results and transcriptions.
Consent forms	A patient's or patient's guardian's consent for treatment, special procedures or to release information.
Incident report	Information about a reportable event.
Advance directives	A legal, written document that specifies patient preferences regarding future health care or specifies another person to make medical decisions in the event that the patient is unable to do so.
Discharge plan and summary	A brief review of the patient's hospital stay and plans for care after discharge.

Admission to the hospital could be a result of a discharge from the emergency department (ED) or could be an “elective admission” pre-planned during a previous outpatient visit. Admission could take place in an admitting department, in the patient’s room, or in the ED. Information for an elective admission could be entered ahead of time as a “pre-admission”; the pre-admission information would enable the admission to be completed quickly because most of the admission information would already have been collected and would allow diagnostic testing done prior to the admission to be identified as part of the hospital stay.

As a result of admission to the hospital, a face sheet is created, which includes the name, address, birth date, contact and other patient demographics information, and may include admitting diagnosis, admitting physician, attending physician, unit, room and bed location and assigned diagnostic related group. Other information may include patient allergies and an advance directive (instructions from a patient at admission informing medical personnel of the patient’s wishes for treatments and care when the patient is incapacitated). The face sheet is usually put on the outside of the newly created or an existing paper inpatient chart.

The hypothetico-deductive approach described earlier for physicians in the outpatient process and shown in figure 4.3 is also applicable to inpatient care. The physician’s role in inpatient care shown in figure 4.5, to “(determine) diagnosis” possibly with the help of “diagnostic tests”, to “(determine) treatment”, to “observe results”, and to “refine (a) hypothesis” is the equivalent of the same steps in the outpatient process shown in figure 4.3. In fact, the first iteration of this inpatient care process usually occurs in the outpatient patient setting, either in the ED immediately before the patient is admitted from the ED or during an outpatient visit occurring some time before a planned patient admission. During this ED or outpatient visit the admitting diagnosis, admitting physician, and often the attending physician, are determined. In the ED an H&P is produced that gathers as much of a history of past illnesses and conditions and of family history as possible as well as information on the current problem.

Once the patient is in the hospital, the physician re-examines the patient and may order diagnostic tests (X-rays, EKGs, etc.) receiving back diagnostic findings, possibly revising the diagnosis as a result. A treatment plan is determined, which may include orders for medications, radiation treatment, physical therapy, respiratory therapy, etc. Results of the treatment plan and patient care are observed, with possible further revisions of diagnosis or treatment. As in the outpatient setting, this information is recorded on the H&P and physician progress notes. The physician may ask for consultation advice from specialists requesting treatment recommendations, with the results of these consultations being put on consultation sheets.

Other steps in the diagram depicting the inpatient care process in figure 4.5 describe care activities of nurses and ancillary departments. The first step in the nursing process, occurring shortly after admission, is assessment. Assessment is the collection of a database of clinical information on the patient that may later be used in development of the nursing care plan. Upon admission, a nurse makes the initial nursing assessment. This usually includes the admitting diagnosis, a review of major body systems, medications taken, allergies, information on height and weight and other drug calculation information, psychosocial factors such as fears, anxieties, and support systems, potential for injury and self-care deficits, need for education of patient and family members to support care after discharge, and other needed post discharge information. The assessment is updated as necessary during the patient’s stay.

From the assessment, a nurse identifies a list of patient problems that can be resolved, diminished, or changed through nursing intervention and management, creating a problem or nursing diagnosis list. For each problem, a description of the problem is given, the probable cause is stated, and the signs and symptoms identifying that problem are stated. Based upon the nursing diagnoses, the nurse develops outcomes, or goals, for each diagnosis, that provide a mechanism for evaluating the patient’s progress.

Note that a nursing diagnosis differs significantly from a medical diagnosis. A nursing diagnosis is any condition that relates to the patient’s well being that can be resolved by patient care intervention. Examples are “impaired skin integrity related to prolonged bed rest” or “ineffective breathing patterns”.

The nurse then develops a nursing plan of care that identifies prescribed nursing interventions for the various diagnoses required for achievement of the expected outcomes, where interventions are care activities to achieve or measure progress toward the outcomes. Note that recent trends have been to move away from detailed nursing care plans, and instead provide a basic plan of nursing care, which provides more flexibility in providing care.

Another trend is movement toward multidisciplinary care planning [6]. Such a care plan may include physicians, ancillary department personnel, and other caregivers in the care plan, in addition to nurses. The multidisciplinary care plan may also include care activities outside the inpatient stay, possibly including diagnostic tests before admission and follow-up care after discharge, such as outpatient visits, and later care at sub-acute and skilled nursing facilities (SNFs). A case manager may be assigned to track follow-up care when it is likely to be of high risk or expensive; a clinical social worker may provide assistance for lower risk cases. A clinical pathway, a structured document to identify care activities and caregiver workflow needed to care for a patient, is one technique for multidisciplinary care planning.

Despite recent trends to move away from detailed nurse care planning for patients, there is the potential of making generation and maintenance of a complete and personalized nursing care plan for an inpatient stay much easier by computerization now that a standardized set of nursing diagnoses, interventions and outcomes have been developed [7]. These standards have been developed in conjunction with the University of Iowa and include NANDA nursing diagnoses, NIC nursing intervention classifications and NOC nursing outcomes classifications [7]. A nurse can select from the list of diagnoses, select applicable interventions and outcomes, producing the complete, personalized nursing care plan.

A number of documents are associated with implementation of the physician treatment plan and of his or her medication and orders, and with implementation of the nursing and other care plans. The physician’s medication orders, which often include the patient current outpatient medications, are transferred over to a medication administration record; upon administration of a medication the nurse records the date and time on medication administration record. Notes on therapy ordered by the physician with the orders implemented by ancillary departments are recorded on health care team records (e.g., radiation treatment, physical therapy, and respiratory therapy). Nurses document the interventions used to meet the patient’s needs, which may include the type of intervention, the time of care and the identity of the nurse administering care; documenting of interventions is primarily accomplished using flow sheets. One type of intervention for insuring that a patient performs normal day to day functions, such as eating, bathing, tooth brushing and grooming; this is referred to as activities of daily living.

Nurses’ progress notes are used to record the patient’s status and to track changes in the patient’s condition. These progress notes describe in chronological order pertinent nursing observations, patient responses to interventions, progress toward expected outcomes, and need for reassessment.

Nursing and physician observations provide information for re-assessment of the patient and revision of diagnoses, treatments and care plans.

Although the nursing assessment identifies increased chances for incidents such as the patient falling, and possibly breaking bones, and the care plan may identify interventions to prevent these incidents, reportable incidents do occur. These are reported in incident reports.

For each nursing shift, the identity of the nurses caring for a patient changes. Because nursing care for a patient must continue as if there was no change in shift, it is important that there is significant communication about the patient and his care between the nurses on the different shifts. Two documents that are not part of the patient’s chart that assist in this process, are the shift report and Kardex. The shift report for a patient is created to provide information on a patient for the following shift.

A Kardex is a trade-name for a card-filing system that allows quick reference to the particular need of an inpatient for certain aspects of nursing care [8]. It is a type of document that this book calls an “inpatient clinical summary”.

An “inpatient clinical summary” is a summarization document to quickly identify the current status of the patient, which, for example, might include the following:

· the patient’s name, age, sex, marital status and religion

· medical diagnoses, usually by priority

· nursing diagnoses, usually by priority

· current physician orders for medications, treatments, diet, IV’s, diagnostic tests, procedures, etc.

· consultations

· results of diagnostic tests and procedures

· permitted activities, functional limitations, assistance needed, and safety precautions

· care plan.

All information in an Inpatient Clinical comes from other documents in the patient’s chart and thus does not become part of the chart.

Planning for discharge begins at the time of initial assessment and continues up to the time of discharge. Information is put on a discharge plan and summary document and may include the following information:

· family at home or other care support

· financial resources

· home environment, including barriers

· history of present illness

· history of compliance

· transportation availability

· impediments to self-care.

The discharge summary part of the document is usually completed immediately after discharge and may include

· all relevant diagnoses

· all operative procedures

· instructions specifying medications, level of physical activity, diet, follow-up care, and patient and family teaching.

An important document to control inpatient workflow is the unit census. It is a list of all patients in rooms in a hospital unit that identifies each patient in the unit, the patient’s room location and the nurses and physicians assigned to care for the patient.

4.4.3.3 Emergency Department Clinical Information

The emergency department (ED) is considered to be an outpatient department, but functions somewhat differently from non-ED outpatient clinics.

The patient either “walks in” or comes in by ambulance. The walk-in patient goes through a triage process whereas the patient who comes in by ambulance is usually immediately escorted by the triage nurse to a room.

Figure 4.6 lists documents used in an ED.

Figure 4.6 – Possible Emergency Department Clinical Documents

Document	Description
Triage documentation	This document, which may be a part of another document such as the Nursing flow sheet, records information which determines how to triage the patient. Information may include mode of arrival, acuity, chief complaint, medications, allergies, nursing actions at triage.
Medical history and physical examination	The patient's initial medical examination and evaluation data. This document includes the following: chief complaint (CC), history of present illness (HPI), past medical history (PMH), family history (FH), social history
	(SH) and marital history, review of systems (ROS), physical exam (PE), assessment, diagnosis (Dx), impression, rule out (R/O), plan, prognosis (Px).
Progress notes	The physician's objective findings about improvement or stabilization of the condition.
Nursing flow sheet	Abbreviated progress notes, recording times, treatments, medications and diagnostic tests given, changes in the patient's condition, including vital signs.
Physician's orders	A record of a physician's medical orders.
X-rays, other diagnostic images, EKGs, etc.
Diagnostic findings	Diagnostic and laboratory data--for example, hematology, pathology, radiology, and X-ray test results and transcriptions.
Emergency Room discharge instruction sheet	Lists discharge instructions for diet, treatments, medications, activities and follow-up visits.
Follow-up after discharge	Documentation of calls to patients following discharge from the ED.

The triage nurse examines and interviews the patient for information useful for triaging the patient and may provide care to the patient. Examples of information recorded are the following:

· mode of arrival

· priority

· chief complaint

· medications

· allergies

· nursing actions at triage.

The triage process may result in the patient

· waiting in the waiting room and later being escorted to an exam room in the ED

· being immediately escorted to an exam room in the ED

· being escorted to an outpatient clinic, outside the ED

· being told to come back to an outpatient clinic at a later date or time.

A nurse, physician or medical assistant may order the patient’s chart. After being escorted to an exam room, the patient waits in the room for the nurse or physician. The nurse takes vital signs and may initiate diagnostic tests by protocol.

The physician comes into the exam room and follows a data collection and interpretation process as shown in figure 4.3 and described in section 4.4.3.1. The principal difference from the standard outpatient clinic visit is that the patient usually stays in the room while diagnostic tests are done and perhaps while diagnoses and treatments are refined. This process is recorded on an H&P.

The physician and nurse may visit the patient a number of times, with the physician recording additional progress note information for the H&P and the nurse recording changes on a nursing flow sheet.

The H&P also is used to gather as much of a history of past illnesses and conditions and family history as is possible.

After a patient has been stabilized and is ready to be discharged or admitted to the hospital, the physician and nurse complete the documentation and the patient is discharged from the ER. The patient may be discharged to

· home

· the hospital (and thus admitted)

· some other place, such as a skilled nursing facility (SNF).

For those patients discharged to home or sometimes to other places, the patient is given a discharge instruction sheet, possibly identifying instructions for diet, treatments, medications, activities and follow-up visits. This sheet is important in documenting fulfillment of the professional responsibility to provide discharge instructions and to shift the responsibility for following these instructions to the patient.

In some cases, a call is made to the patient after discharge to evaluate his status. This call may be documented.

Important documents to control emergency department workflow that are not a part of the patient medical record are two lists of patients: (1) the triage list, the patients waiting to be triaged, and (2) the emergency department census, the patients in emergency department rooms.

Other than patients who come in by ambulance, all patients who come into the emergency department are seen the triage nurse. The triage list is used by a triage nurse to list patients who have been seen by a triage nurse, listing the time the patient came in and the time he was seen by the triage nurse, and the priority of care determined by how ill the patient is. The times and priority of care is used to identify which patient should be seen next. Once the patient is escorted to a room, the patient is put on the emergency department census along with the physician(s) and nurse(s) caring for the patient.

4.4.3.4 Other Categories of Clinical Information

Documentation is used in many other situations, including the following:

· home health care: skilled nursing and related care supplied to a patient at home

· skilled nursing facilities (SNF): an establishment with a nursing staff that bridges the gap between hospital and home for elderly patients who need skilled nursing care or rehabilitation services.

· hospice care: care specifically given to terminally ill patients—generally those with six months or less to live

· advice nurse and physician telephone calls: calls by a patient seeking advice or by a physician to a patient.

Further, there may be specialized documentation for many situations, including the following:

· oncology, chemotherapy

· psychiatry

· critical care

· respiratory therapy

· injection clinic

· obstetrical areas

· surgery.

4.5 Purposes of a Patient Medical Record

The purposes of the patient medical record are the following: (1) to record information from the patient, (2) to record the caregiver’s findings and treatments, (3) to communicate information to later caregivers who see the patient and to communicate information to the patient, (4) to coordinate caregivers and organize their activities in the care to the patient, (5) to serve as a formal, in particular legal and financial, record of care, and (6) to provide information for public health, epidemiological studies, and clinical research.

4.5.1 Caregivers’ Record of Information from the Patient

A caregiver records the patient’s health complaints. The caregiver asks the patient questions about these complaints and makes observations (e.g., listens to breathe sounds), recording the patient interview and the observations. The patient may be asked about the patient’s current medications, allergies, and family history. The caregiver records information from clinical instruments (e.g., vital signs). Results from caregiver orders provide further input (e.g., from clinical laboratory tests, from analyses of diagnostic imaging and other procedures).

The initial medical examination is recorded in a History and Physical document (H&P). Subsequent encounters result in recording notes of the patient’s progress in Progress Notes. An examination or assessment by a consulting physician may be recorded on a Consultation Report. Information given by the patient is recorded in the subjective section of the H&P, Progress Note or Consultation Report, while a record of the clinician’s examination of the patient and of results from diagnostic tests are recorded in the objective section [5].

4.5.2 Caregivers’ Findings and Treatments

After talking to and observing the patient, possibly consulting with other caregivers and receiving the results back from tests, a caregiver will make and record an assessment of the patient’s condition and problems that is the clinician’s interpretation of the subjective and objective findings and includes the diagnosis and identifies any further tests that are needed. The assessment is recorded in the assessment section of the H&P, Progress Note or Consultation Report.

A caregiver then creates a treatment plan including orders for medications to be given to the patient, instructions to the patient and nurses, and recommendations for hospitalization or surgery. Procedures, therapies and diagnostic tests that were ordered as part of the treatment or care plan are recorded, and the results of these are recorded. The treatment plan is recorded in the plan section.

Later, a caregiver may establish and record a prognosis, the doctor’s opinion of what the outcome of the illness will be.

4.5.3 Communication to Later Caregivers and with the Patient

Prior to and during a patient’s visit, a caregiver needs to find clinical information on the patient recorded from previous visits. This enables the clinician to

· quickly evaluate the patient’s overall health based upon past visits, social and family history

· identify what took place during any selected previous visit, especially the most recent ones (e.g., the treatments, test results, medications taken)

· find previous recorded diagnoses or problems to assist in current evaluations

· find previous patient complaints and information on previous observations to compare against present ones

· determine all current medications taken

· identify allergies, drug reactions, and immunizations.

4.5.4 Coordinating and Organizing Caregivers in the Care of the Patient

Coordination of care is essential for quality and effective medical care for the patient and for a team approach to patient care. Currently, coordination of caregivers is most common in the inpatient, rather than outpatient, setting. With the shifting of procedures from the inpatient to the outpatient setting and the large number of outpatient physicians who see the patient in managed care settings such as HMOs, caregiver coordination in the outpatient setting is becoming increasingly important. The patient chart is the primary vehicle for communication between caregivers and this coordination between caregivers.

“Demand management” also involves coordination of caregivers. Demand management [9] is an approach used in HMOs to instruct patients in self-care or to insure patients are seen by the appropriate and most cost-effective caregivers. For example, an advice nurse might tell one patient that he need not come in, that self-care is appropriate, while telling a another patient that his condition requires him to come in immediately to the emergency department and another patient that an appointment will be made for him with an urgent care clinic. Again, the patient chart is important in this process. Demand management in an HMO is described in more detail in section 4.6.

4.5.5 Creating a Formal Record of Patient Care

A formal record of patient care is required by law. Additionally, a formal record of care is required to record services so patients, the government or insurance companies can properly be charged for these services. A formal record of care is also required as the source for various forms of internal and external reports to be sent to the patient’s employee, for example for workmen’s compensation claims, and to government and industry regulatory agencies, to evaluate care within a healthcare organization.

If the patient sues a caregiver for malpractice, information to disprove the case must be found in the patient chart or other sources. Ideally, the total of information would be found in the patient chart.

The most efficient way to determine charges to the patient, to the patient’s insurance company, or to the government for Medicare or Medicaid is to derive charges, where possible, directly from the patient care information in the patient chart. Charges, for example, can be derived from lab orders completed, medications recorded as given, supplies used, etc., and either manual or automated diagnoses and procedures reported in the chart.

Information for government review (e.g., OSHA), for health care report cards for HMOs (The Health Plan Employer Data and Information Set, HEDIS, for HMOs [10,11]) and for accreditation agencies (e.g., the Joint Committee on Accreditation of Healthcare Organizations, JCAHO, and the Health Care Financing Administration, HCFA, the federal agency that administers Medicare, Medicaid and Child Health Insurance programs) must be available in the patient charts and other internal sources. Information for determining organizational budgets and making other organizational management decisions comes from the charts and other sources. When there are quality concerns about a physician, the parts of patient records created by the physician may be reviewed as part of an independent staff peer review.

4.5.6 Information for Public Health and Clinical Research

The patient medical record provides information for public health purposes, supporting community efforts to identify and prevent disease and to control communicable diseases. For example, a patient may come in because of food poisoning after having eaten at a number of different restaurants. A physician or epidemiologist could search for other patients with the same medical problem by looking through charts and contact those patients to determine where they had eaten and what they ate, so the restaurant where the problem occurred can be determined.

The patient medical record also provides information for clinical research, including research on safety and “efficacy” of treatment plans, procedures and drugs, where “efficacy” means the ability to produce the desired results. Various patient attributes also recorded in the chart must be taken into account during this clinical research, including the patients’ current health, previous and current diagnoses, age, gender and current medications.

Important for clinical studies is picking appropriately targeted patient populations for a clinical research project. For example, for clinical tests of a particular drug, it is desirable to test the drug on a patient with the targeted disease who is otherwise healthy, does not have other diseases with similar symptoms to the targeted disease, and does not take other drugs that could make it difficult to determine the effect of the drug being tested. Patient charts provide information to select patients who are appropriate for these clinical research studies.

4.6 Special Characteristics of Patient Care within an HMO

Physicians have been increasingly banding together into “managed care” organizations to decrease costs. Such “managed care” organizations charge patients not for each service performed, but a certain amount per month independent of the services performed; this payment approach is referred to as “capitation”. The primary types of managed care organizations are Preferred Provider Organizations or PPOs (where a healthcare organization contracts caregivers) and Health Maintenance Organizations or HMOs (where a healthcare organization primarily uses caregivers who only work in the HMO and work primarily in HMO facilities).

Because of fixed payment for care, physicians in managed care organizations care about providing cost-effective patient care. For example, as compared to physicians in the fee for service setting, HMO physicians are less likely to order unnecessary diagnostic tests or expensive medications and less likely to perform non-cost-effective procedures.

In an HMO, one major way of cutting costs is referred to as demand management [9], a system to provide a patient with the most cost-effective care for the patient’s medical complaint, by instructing a patient in self-care, by “triaging” the patient to the most cost-effective caregiver, and by coordinating the caregivers giving the care to the patient.

Demand management might include the following:

· advice nurse: a nurse who accepts patient phone calls and advises the patient on medical care according to protocol; she advises the patient on when self-care is appropriate and when a patient needs to come in; if a patient needs to come in, she advises the patient on whether it is more appropriate for the patient to come in immediately to the emergency department, see a caregiver the same or next day (which is usually less costly than an emergency department visit), or come in at a later date

· gatekeeper: a primary care physician, usually in Internal Medicine, Pediatrics or Gynecology, who must be seen first before the patient is allowed to see more costly specialists

· personal care physician: a physician who serves as the primary caregiver for assigned patients and who is responsible for coordinating the care of these patients, especially in the outpatient setting

· non-physician primary caregiver: a nurse practitioner and physician assistant, supervised by a physician, who serves in the place of a physician as the primary caregiver for a patient

· hospitalist [12]: a physician who is a specialist in in-patient medicine, who takes responsibility for a patient’s care during the patient’s entire hospital stay, and then returns responsibility to the primary caregiver when the patient leaves the hospital

· case manager: a healthcare professional who determines the most effective and least costly treatment programs and organizations for a patient who has a high cost and high risk disease and who insures that the patient receives that care

· utilization manager: a healthcare professional who determines a patient’s eligibility and coverage for benefits (e.g., for durable medical equipment or for care in outside specialty facilities)

· “disease management” caregiver or consultant: a healthcare professional or consultant who provides care, advice, data or software for a particular disease area such as diabetes, cancer, coronary artery disease or asthma, with care given for the condition being measured against established treatment guidelines for the condition. (Whereas case management focuses on the sickest patients, disease management targets individuals at the earliest stages of known high-cost conditions [13].)

Another part of demand management are wellness programs that attempt to decrease demand for health care services by screening patients for certain diseases or conditions and providing care before the disease or condition becomes costly to treat. Areas where wellness programs may be effective include the following: sigmoidoscopy (looking at the lower large intestine) or colonoscopy (looking at the whole large intestine) to screen for colon cancer, smoking cession programs to encourage members to stop smoking (and perhaps providing alternative means for weight control at the same time), and breast exams and mammography to screen for breast cancer.

Patient education is an important part of demand management. A patient with a chronic disease, such as diabetes or asthma, could be educated about when self-care is appropriate and when it is absolutely necessary to come in to be seen. A new mother could be educated about childhood diseases and conditions and likewise could be told when at-home care for a child by the parent is appropriate and when it is not.

Figure 4.7 summarizes the way HMOs save money as compared to fee for service organizations.

Figure 4.7 – Cost Savings for Managed Care Over Fee for Service

Number	Cost Savings	Assisted by Software Systems
1	More efficient use of caregivers, because if one caregiver is not available then another caregiver in the same healthcare organization can see the patient	scheduling and workflow systems
2	A larger number of patients per physician	patient clinical systems; scheduling and workflow systems
3	Nurse practitioners, physician assistants or registered nurses may see patients in place of physicians	scheduling system
4	Prescription of lower cost medications, either generic medications or those in the HMO drug formulary, or recommendation of over-the-counter medications (which most HMOs do not cover)	patient clinical systems
5	Greater chance of continuity of care because of greater chance of sharing of the patient's clinical information between caregivers in the same healthcare organization who see the patient than by caregivers in different healthcare organizations	patient clinical systems
6	Because HMOs are more organized than fee for service organizations, computer systems, which make information more quickly available to caregivers and replace costly and time consuming paperwork, are more common in HMOs.	all systems
7	Because of capitation, greater incentives to keep patients healthy, especially through preventive healthcare and patient education	patient clinical systems; scheduling systems
8	Because of capitation, use of alternative delivery systems such as home, hospice and skilled nursing facilities instead care in hospitals	patient clinical systems; financial systems
9	Because of capitation, outpatient surgeries sometimes replace more costly inpatient surgeries and inpatient stays	patient clinical systems; scheduling and workflow systems
10	Because of capitation, lesser use of costly procedures and diagnostic tests and lesser use of expensive specialists	patient clinical systems
11	Because of capitation, lesser use of purely defensive medicine, where the patient is given a large number of diagnostic tests to aid in the initial diagnosis and to protect against lawsuits	patient clinical systems
12	Efficient sharing of costly technology, where, for example, a CT scanner is used by physicians from all facilities in the healthcare organization	scheduling and workflow systems
13	Demand management techniques (see section 3.6) such as advice nurses who advise patients on when self care is appropriate and when the patient should come in, and primary care physicians who serve as “gatekeepers” to determine if patients indeed need to see	patient clinical systems; scheduling and workflow systems
	costly specialists. Drop in outpatients may be triaged.
14	Lesser chance of unnecessary repeated tests or of need for multiple complete health histories because of sharing of clinical information between caregivers in the same healthcare organization	patient clinical systems
15	Buying items in bulk, for example, medications.	financial systems
16	Other efficiencies of scale including efficient collection of payments from employers (capitated payments), the government (e.g., Medicare payments) and insurance companies; efficient payment to drug and other	financial systems
	external companies; and lower cost malpractice insurance because of having its own lawyers and sharing of liability among HMO caregivers.
17	Attempts to substitute arbitration via the PPO or HMO contract to protect against costly malpractice suits	patient clinical systems
18	Telephone calls may substitute for outpatient visits, where applicable	patient clinical systems, financial systems
19	Least costly, most beneficial insurance reimbursements selected (e.g., care consistent with insurance company or Medicare payments or best insurance taken where both husband and wife have family coverage)