PHM113 Patient Records and Documentation PDF

PHM113 *Patient Records and Documentation* **Learning Objectives** 1. Recognize the principles of privacy, security, and confidentiality. 2. Understand and apply the concepts of Circle of Care. 3. Distinguish common formats for clinical documentation and structures for recording and comm...

PHM113 *Patient Records and Documentation* **Learning Objectives** 1. Recognize the principles of privacy, security, and confidentiality. 2. Understand and apply the concepts of Circle of Care. 3. Distinguish common formats for clinical documentation and structures for recording and communicating clinical data. E.g. print and digital charts. 4. Describe principles and elements of good documentation in patients' health records. 5. Recognize features and requirements of documentation in various practice settings. 6. Employ commonly used formats for documentation notes. 7. Identify the components of the aEHR and explain its purpose. 8. Navigate the aEHR to retrieve or required health information. **Examples of Patient Health Records provided by Medical Institutions** - MyChart - My Health Record - myUHN **Personal Health Information** - Recorded information about an identifiable individual related to their physical or mental health, and the provision of care to the individual, including their provider. - Contrast from contact information; data related to identifying an individual (e.g. date of birth, gender, marital status, photo, phone numbers). - Patient records can include appointment schedules, prescriptions, audio counseling, CT or MRI digital images, lab or imaging reports, photographs of a wound, electronic or paper chart records. **Privacy, Security and Confidentiality** - Privacy: The right for individuals to determine when, how and what extent they share information. Right to be free from intrusion and interruption? - Security: Systems and processes which preserve the confidentiality, integrity, and availability of personal health information. - Confidentiality: Principle that information is not made available or disclosed to unauthorized individuals. Contributes to maintaining privacy (but insufficient alone). **PHI MUST be kept secure**. - It is the obligation of an organization AND the responsibility of an individual. - There's a lot you can do with data and PHI. It can be: - Collected (Recorded) - Stored - Used - Accessed - Transferred - Managed - Disclosed - Disposed **Security is achieved by:** - Implementing policies and procedures based on legislation and ethical principles. - Managing operations related to access and disclosure of PHI. - Careful planning, designing, and maintaining technology solutions. - Implementing safeguards (physical, technical, administrative). - Managing physical space during provision of care, to ensure privacy. - Trust that each healthcare provider is a good custodian of information. **Why is confidentiality important?** - Encourages information sharing by patients, they feel assured and safe to do so. - Helps ensure efficiency and effectiveness of the entire health care system (when we have the information willingly shared) - Breaches in confidentiality are harmful to patients. - Important for the protection of health care workers (from penalties). - The "Need to Know" rule: Always ask yourself, "Is it necessary that I access this confidential patient information to carry out my job duties?" **Circumstances of Disclosure** - For immediate health and safety of an individual (emergency care) - Disclosure to police when there is threat of a patient harming themselves or others. - Public health surveillance (i.e. communicable disease). - Reporting child or elder abuse as required by law. - In response, to a subpoena or court order. - Disclosure to authorized researchers. **Legislation** - Office of the "Privacy Commissioner" is responsible for oversight. - PHI is described in laws across Canada, but varies by province. - Provincial legislation always takes precedence. - PIPEDA = Personal Information Protection and Electronic Documents Act = Federal - Applies to information federally regulated in the private sector (e.g. telecom banks, airlines). - PHIPA = Personal Health Information Protection Act = Provincial - Applies to public hospitals including labs, pharmacies and diagnostic services. **Personal Health Information Protection Act (PHIPA) Ontario, 2004** - Act applies ONLY to personal health information that is collected, used, and disclosed by health information custodians. - Protects the confidentiality of PHI in the delivery of health care. - PHIPA establishes rules for electronic health records and practices to protect PHI against theft, loss and unauthorized access. - Patients have the right to request access to, and correct their PHI. - Individuals have the right to file a complaint with the Privacy Commissioner Office if their information has been improperly disclosed. - \*\* Hospitals are also governed by FIPPA (Freedom of Information and Protection of Privacy Act) for providing information under control of the hospital to public. **Expressed vs. Implied Consent** - Expressed consent: Voluntary agreement with what is being done or proposed that is unequivocal and does not require any inferring from the patient. - Given either verbally, or in writing, to a custodian to collect, use or disclose PHI. - E.g. informed consent, research, and medical procedures. - Implied Consent: Voluntary agreement with what is being done or proposed that can be reasonably determined through the actions or inactions of the person. - In Ontario, implied consent is valid within the circle of care. - Example: A person presents for care -- this is implied that they give their consent. **Circle of Care** - "Include the individuals and activities related to the care and treatment of a patient" - Not officially defined in the legislation. - Refers to health information custodians' ability to rely upon implied consent to collect, use or disclose personal health information for the purpose of delivery of health care. - Six conditions are described in order for implied consent to be assumed (See Circle of Care document assigned reading from the Office of the Information and Privacy Commissioner for Ontario) **Breaches of Confidentiality** - Conversational violations. - Paper record violations. - Electronic record violations. - Other: Using social media, portable device storage, taking photo and accidentally including a patient in the background, sending messages about patient care that are unencrypted. **Consequences** - Sanctions from the employer, regulatory body, school. - Legal - Financial (fines) **Code of Ethics -- Ontario College of Pharmacists** - Standard 2.9 (under non-maleficence) - Take every reasonable precaution to protect patient confidentiality by preventing unauthorized or accidental disclosure of confidential patient information. - Standard 3.6 (under Respect for Persons/Justice) - Respect the patient's right to privacy and do not disclose confidential information without the consent of the patient, unless authorized by law. - Standard 4.7 (under Accountability/Fidelity) Members maintain confidentiality in creating storing, accessing, transferring, and disposing of records they maintain and control. **Documentation** - Documentation occurs in all healthcare settings and becomes part of the patient's permanent health record - Institutions (e.g. hospitals, long term care, special outpatient) - Private offices and clinics, pharmacies. - Documentation is a professional requirement by the College. - Key element of every health profession's standard of practice and one of the most basic professional responsibilities. **Documenting in Pharmacy Practice** **Why document?** - Shows accountability and responsibility for your actions. - Demonstrates your role as medication expert along with your professional judgement. - Supports interprofessional collaboration, and intraprofessional delivery of care, for enhanced continuity of care (e.g. patient handover). - Prevents duplication of work - Legal protection/liability (if you didn't document, what happened?) **When to Document** - Every patient encounters. - Providing patient education - Medication histories and discrepancies - Recommendations. - Discussions with other HCPS. - Monitoring and follow ups. - ALWAYS, when in doubt, document. **Documentation** **Guidelines** - Factual (accurate) - Complete - Current (timely) - Organized - Documentation should also be concise and clear. You shouldn't have to write a novel to document. - Avoid extraneous information that does not support the focus. - Be specific (avoid vague language) - Avoid use of harsh, negative, or judgmental tones. Aim for neutral wording. Your documentation is being read by others, sometimes including the patient! - E.g. "Poor historian" or "patient refused" or "the team should" - Avoid abbreviations, especially those that are not agreed upon by the organization E.g. DI **The Patient Record -- Types of Notes** - The history and physical note documents the patient's history and a plan for addressing the issues that led to the healthcare encounter. - Often an admission to hospital or health care facility (Often titled "Admission Note" - Consult notes that are used for a specialize documenting their assessment and recommendations for the patient. Often titled "letter" and can be copied to relevant parties in the circle of care, e.g. family physician, referring physician. - Progress Notes are used by a variety of health providers to record patient progress through patient care activities, findings, assessments, recommendations, and interventions. - Pharmacists, physicians, nurses, physiotherapists, dieticians etc. **The Patient Record** - Medication Administration Record (MAR) -- Where medications administered to the patient are recorded. - All regularly scheduled and as needed (PRN) medications are listed with the dose, frequency, start/stop dates and other instructions. - MARs can be paper or Electronic = eMAR. Which can be linked to barcoding technology OR nurse signs off on computer. **Components of History & Physical Admission Note** - CC = Chief Complaint (The reason they sought care) - HPI = History of presenting illness (reports the story of how they presented, and the symptoms experienced leading to the visit) - PMHx -- Past medical history (conditions) - Meds = List current meds and past (e.g. past chemo, notable treatment courses). - Allergies/Intolerance = List allergies to medications or other substances, and the reaction/severity if known "NKDA" - Fam, SocHx Family history, social (alcohol, smoking, drugs), occupational history (work exposures) - ROS, Physical: Review of Systems, Physical Exam. Including head to toe assessment including vitals, respiratory, CV. - Labs, DI: Pertinent lab values and diagnostic imaging findings. - Ax: Assessment, usually where you will find the diagnosis. - P (Plan) Actions to be carried out, and next steps. **Standard Documentation Formats** - Some institutions have their own policies for expected documentation (including format) - SOAP = subjective findings, objective findings, assessment, plan. - FARM = Findings, assessment, recommendations, monitoring. - DAP and D-DAP: Drug-related problem, data, assessment, plan. - SBAR = situation, background, assessment, recommendations. - F-DAR = focus, data, assessment, response. Focus charting on a specific concern. **A closer look at SOAP notes** - Developed in the 1970s and commonly adopted by pharmacists and other HCPs. - Subjective Information: Obtained from the patient or caregiver, not directly measured, or observed by the writer. E.g. patient describes their rash as itchy and red. - Objective = observed or measured information. E.g. blood pressure, temperature, labs, your description of rash as "3cm round erythematous patch" - Assessment: Provide the drug related problem + evaluation with alternatives (may also be report on progress of a previous 'A') - Plan: Proposed actions/decision. **Clinical Documentation in Community Pharmacy Records** - Documentation may exist in the PPMs in the patient's profile in Notes. - Documentation may be scanned into the patient's file as a document. - Hard copies of prescriptions may be scanned into the system and paper Rx may be retained with counselling notes or assessment notes by the pharmacist written. - Medication reviews (MedsCheck) - Other professional Services - Vaccinations - Minor Ailment Records - Adapting or Renewing Prescriptions **Academic Health Record (aEHR)** - Recall: An electronic health record is the digital version of the lifetime health history of the patient. - Shares health information across the continuum of care from providers. - Including medications, reports, diagnostic imaging.  1. Patient Profile Contains Demographics, Allergies, and History - Patient history includes conditions, medications, social history, surgical, family history, and immunizations. 2. Care team allows you to see the professions involved in the patient's care + add their community pharmacy. 3. Past appointments history also available to see. 4. Patient Chart -- Allows you to view all the details of the patient's current visit + progress - Admitting diagnosis - Vital Signs, labs, fluids - Assessment across body systems - Medication orders (this is what populates the mecdication list in section 1. Patient profile) - Upcoming requisitions and referrals. - Interprofessional Care Plan - Discharge Summary -- essentially a summary of what happened at the clinic appt. - Here is where you will find the progress notes! From all the visits from the various disciplines who saw the patient. **Reports and Documents** - Allows you to view consult letters, laboratory reports, OR/anesthesia reports, and medical imaging, from all visits.  **External Resources** - There is a built in link to the e-CPS