A doctor’s touch vs documentation and fitting things into boxes on computer screens

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Writing narratives in paper based medical records is the usual way the team of healthcare professionals taking care of the patient – doctors and nurses largely record in the medical record to tell a story about what is happening to the patient and what occurred in the course of care. Such narratives are considered to be essential for communication between members of  healthcare professionals.

Following the advent of the Electronic Medical Record (EMR) / Electronic Health Record (EHR), doctors and nurses find the loss of space in the patient record to write narratives. The freedom of being able to describe something in a doctor’s or nurse’s own words is now replaced by structured drop-down menus, a prominent feature of EMRs / EHRs.

I like to share an essay, “Checking Boxes” about the frustrations and misgivings of a primary-care doctor who makes house calls in and around Tuscaloosa, Alabama, United States of America. Read this essay here.

The notion is that many caring doctors and nurses still wish to spend their time speaking and caring for patients rather than been overwhelmed with computer documentation and fitting things into boxes on computer screens.

References:

Regina, H 2013, Checking Boxes, 18 October 2013, Pulse–voices from the heart of medicine, viewed 27 Nov 2013, <http://www.pulsemagazine.org/archive/stories/310-checking-boxes>

JCI Standard MCI.4 – accuracy and timeliness of information in the hospital through effective communication

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shutterstock_100750468

My intention in bringing this post to a Health Information Management (HIM) / Medical Records (MR) practitioners reader specifically and to all other readers in general, is to understand the dynamics of communication and your role in managing patient-specific information in a hospital setting when the leaders of the hospital agree to an essential condition  whereby effective communication must prevail among and between professional groups; structural units, such as departments; between professional and non-professional groups; between health professionals and management; between health professionals and families; and with outside organisations.

In making this agreement for effective communication throughout the hospital setting, I agree the stipulations that this issue is primarily a leadership function of the hospital’s leaders. This agreement is stipulated in the Joint Commission International (JCI) Standard MCI.4 which states that “Communication is effective throughout the organization”, especially so if you are practising in a hospital accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.

The reader as a leader of a structural unit setting and relevant service needs to be aware of the following conditions in this agreement for effective communication:

  1. for patient care to appear seamless, processes must be in place for communicating relevant information in an accurate and timely manner throughout one’s structural unit, such as the HIM / MR department and between other structural units in the hospital; this is to ensure that the processes are designed and implemented to support continuity and coordination of care as patients move through the hospital from admission to discharge or transfer, several departments and services and many different health care practitioners may be involved in providing care; for example from emergency services to inpatient admission
  2. the hospital defines the patient-specific information, example patient’s weight and other physiological information available from the medical record, required for an effective review process and is facilitated by a record (profile) i.e via medication administration records (MAR) or medication list, also to be found within a medical record for all medication administered to a patient except emergency medications and those administered as part of a procedure; the medical record folder is updated after a review of a patient receiving medications, example the folder is tagged with an alert sticker for allergies or sensitivity; this review also facilitates the medication reconciliation process across the continuum of care and the process continues upon discharge and transfer of the patient, and the complete list of patient medications is shared with the next provider of patient care
  3. effective communication occurs in the hospital among the hospital’s programs ranging from the emergency services, inpatient admission, diagnostic services and treatment services, surgical and non-surgical treatment services and outpatient care programs for seamless care
  4. since patients frequently require follow-up care to meet on-going health needs or to achieve their health goals, there is a plan by the hospital’s leaders with the leaders of other health care organisations in its community for effective communication to occur between the leaders of these other health care organisations in its community during referrals; the plan establishes contact with known resources i.e. the patient’s home community and identified specific individuals and agencies that are most associated with the hospital’s services and patient population in order that they help support continuing health promotion and disease prevention education
  5. there are policies and procedures developed to support and to promote patient and family participation in care processes to ensure that continuity and coordination are evident to the patient; effective communication thus occurs with patients and families in these circumstances:
    1. patients and families are involved in care decisions by effective communication thus occurs with patients and families when (i) they understand how and when they will be told of planned care and treatment(s), (ii) understand their right to participate in care decisions to the extent they wish and learn about how to participate in care decisions
    2. inpatients and outpatients who leave against medical advice when patients, or those making decisions on their behalf, may decide not to proceed with the planned care or treatment or to continue care or treatment after it has been initiated guided by a process for the management and follow-up of such cases
    3. effective communication thus occurs with patients and families when those who provide education encourage patients and their families to ask questions and to speak up as active participants
    4. effective communication occurs with patients and families when indicated, planning for referral and/or discharge begins early in the care process ie. soon after admission as inpatients and, when appropriate, includes the family
    5. effective communication occurs with patients and families when patients are reassessed to plan for continued treatment or discharge
    6. effective communication occurs with patients and families such that symptoms and complications are prevented to the extent reasonably possible during the care of the dying patient
  6. and finally. the reader as a leader must not only set the parameters of effective communication but also serve as role models with effective communication of the hospital’s mission and appropriate policies, plans, and goals to all staff.

I acknowledge the role of effective communication and its pervasiveness in creating, gathering and sharing health information in meeting challenges and improving health care outcomes. In this post, I think I have achieved to address some pertinent issues relevant to effective communication when implementing the requirements of the JCI Standard MCI.4 specifically and also delving into the issues of effective communication in general.

References:

  1. Dale, EB & Daena, JG (eds.) 2009, Communicating to manage health and illness, Routledge, London, UK
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
  4. Sheila, P & Sandra, H (eds.) 2007, Health communication Theory and practice, Open University Press, McGraw-Hill Education, England, UK

Duty of confidentiality

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During a High Court proceeding in Kuala Lumpur, Malaysia the presiding Judicial Commissioner proclaimed that the bedrock of society’s belief would be shattered.if the medical profession do not uphold a patient’s information safe from unauthorised disclosure. This was reported on 31 October 2013 in the local English daily newspaper, The Star.

In his judgement he called upon medical professionals and hospitals to take the duty of confidentiality very seriously since they had a duty to ensure patients’ medical information were safeguarded and not disseminated in any unauthorised manner.

In passing sentence, the court then ordered a director of the Medical Centre and two others to pay RM400,000 to a community leader for revealing his psychiatric medical records. The plaintiff claimed that the documents were circulated to the residents of his community to humiliate him and which implied he was a lunatic, of unsound mind and unfit to hold positions in the NGOs. He sued for costs and other relief deemed fit by the court for negligence and failure on the part of the Medical Centre to safeguard his personal documents, and the defendants for exemplary and punitive damages – to me it is clear that the defendants’ wilful acts were malicious and wanton.

Nevertheless, I  find It is not clear from the daily’s article how the medical records landed in the hands of the two defendants who had distributed documents containing the personal particulars and medical records of the plaintiff’s treatment to other residents of the community as well as when they started to tell the residents that the documents showed that the plaintiff was a lunatic.

The moral of the story is to quote from Hillary Clinton, “In almost every profession – whether it’s law or journalism, finance or medicine or academia or running a small business – people rely on confidential communications to do their jobs. We count on the space of trust that confidentiality provides. When someone breaches that trust, we are all worse off for it.”

References:

  1. Nation, The Star Online, ‘Four pay price for revealing medical records’, viewed 31 October 2013 <http://www.thestar.com.my/News/Nation/2013/10/31/Four-pay-price-for-revealing-records-Community-leaders-medical-documents-were-distributed-to-residen.aspx>

End-of-life issues, what you need to document in the medical record

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Image credit : National Institutes of Health, USA

Image credit : National Institutes of Health, USA

Assessment findings guide the care and services to be provided by all the patient’s health care practitioners, including the doctor and/or nurse. The findings are then normally documented in the patient’s medical record.

Likewise, reassessment by a doctor are also documented in the patient’s medical record. I had posted about the need to document reassessment into the patient’s medical record as defined in organisation policies and procedures for thirteen (13) situations in the post Reassessment of all patients and results are always entered in their medical records (this link will open in a new tab of your current browser window), the thirteenth situation been when dying patients and their families are assessed and reassessed according to their individualised needs by evaluating and managing their symptoms and preventing complications to the extent reasonably possible in the care of these dying patient to optimize his or her comfort and dignity.

When patients are at the end of life, these dying patients including their families or indeed anyone else actually connected with the patient are then assessed and reassessed to identify the patients’ and families’ needs, i.e end-of-life issues. Assessments and reassessment are carried out to evaluate the patient’s condition such as symptoms of nausea and respiratory distress and to identify factors that seem to alleviate or exacerbate the physical symptoms, the patient’s current symptom management and the patient’s response.

Thus the medical record of a dying patient should contain documentation on symptoms like nausea and respiratory distress and whatever factors that are alleviating or exacerbating these physical symptoms.

Also to be found in the medical record of a dying patient will be documentation on assessments on both the patient’s and family’s individualised needs including evaluations to record the following :

  1. spirituality – it would be much more difficult to anticipate the spiritual needs of a patient and family from a culture unfamiliar to you, so better understand what is the patient’s and the surrounding family members’ dominant religion and views regarding the meaning and purpose of life and, as appropriate, any involvement to a religious group and what are their spiritual concerns or needs, such as despair, suffering, guilt, or forgiveness, thus the need to work within the patient’s and the patient’s family cultural belief system by hearing the patient and his or her family and the patient’s daily experiences; culturally based care i.e transcultural nursing according to Madeleine Leininger who was a nursing theorist, nursing professor and developer of the concept of transcultural nursing, contributes to healing (health), well-being, and helping patients who face dying or death
  2. their psychosocial status, such as family relationships, the adequacy of the home environment if care is provided there, coping mechanisms
  3. the patient’s and family’s reactions to illness since the patient will experience significant loss as a result of the health alteration when recovery from illness is incomplete; as a result many people (patient and/or family) may direct that anger towards health-care personnel because they have no control over the situation already as the loss begins to sink in but when finally, the patient and family come to terms with the loss, they will begin making plans for the future
  4. the need for support or respite services with the challenges of caring for the dying by the caregiver(s)
  5. the patient’s need or request from the patient’s family for, an alternative setting or level of care
  6. any survivor risk factors, such as family coping mechanisms and the potential for pathological grief reaction

The above documentation requirements in a medical record of a dying patient are required more so if you as a Health Information Management (HIM) / Medical Records (MR) practitioner manage such medical records in a hospital which is already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, when your hospital will need to fully comply with the JCI Standard AOP.1.9 which states that “Dying patients and their families are assessed and reassessed according to their individualized needs.” The three (3) Measurable Elements of Standard AOP.1.9 will be measured through the Medical Record Review Tool (MMRT).

Medical records documentation of dying patients is not just to comply with an accreditation body like the JCI.  The filing of the medical record about end-of-life concerns about the amount of information which might be submitted within the medical record which will then be subject to scrutiny irrespective of whether that scrutiny included any authorised investigatory agency. Although a doctor may believe  that he or she may not have done nothing wrong, he or she will fear the process of investigation of deaths (Stephen 2012), under a death reporting system.

As a diversion to end-of-life issues, medical records of a not-dying patient, Hilly Boscher from the Netherlands is worthy of mention when in the Chabot case (Stephen 2012), a psychiatrist named Chabot helped this patient to die who was NOT terminally ill i.e NOT a dying patient. In this case, she (Hilly) had been suffering from grief as a result of losing both of her children. Dr Chabot diagnosis was :  ‘an adjustment disorder consisting of a depressed mood, without psychotic signs, in the context of a complicated bereavement process’. Hilly had refused all anti-depressants and bereavement counselling. However, Chabot was not convicted by the Dutch Supreme Court on the ground that (Stephen 2012 p.288) “there was no requirement that suffering is terminal or physical”.  My point is, seven (7) other psychiatrists had examined her medical records and had agreed with Chabot’s diagnosis, so do you agree that there is the greater need for greater detail in medical records documentation in the case of a dying patient?

References:

  1. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  2. Joint Commission International, 2010, Hospital Survey Process Guide (HSPG), 4th edn, JCI, USA
  3. Stephen, WS 2012, End-of-Life Decisions in Medical Care Principles and Policies for 
  4. Regulating the Dying Process, Cambridge University Press, Cambridge, United Kingdom
  5. Pamela, MS & Linda, N 2010, Communication for nurses : how to prevent harmful events and promote patient safety, F. A. Davis Company, Philadelphia, PA, USA

WHO-FIC Network Annual Meeting 2013 – Beijing, People’s Republic of China

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A Health Information Management (HIM) / Medical Records (MR) practitioner reader of this website-blog will surely be familiar and knowledgeable of The International Classification of Diseases (ICD) that covers death and disease, two main parameters of health and the health system.

Perhaps many  HIM / MR practitioners may still not know that the ICD is one other reference classification which belongs to the World Health Organization Family of International Classifications (WHO-FIC)  Likewise, ICF (the International Classification of Functioning and Disability) and ICHI (International Classification of Health Interventions) are also reference classifications which belong to the WHO-FIC.

I think it is appropriate for any HIM / MR practitioner to be aware of developments of WHO classifications such as the ICD.  In this post, I like to share in this post of what is already available at the WHO website about the 2013 Annual Meeting of the International Network of WHO-FIC Collaborating Centres (WHO-FIC 2013) which will be held at the Empark Grand Hotel, in Beijing, China, from 12 to 18 October 2013. This year’s theme is: “Universal Health Coverage: Information and Innovation”. The reader can view detailed information about the meeting venue, accommodation and registration available on the meeting website at this link (this link will open in a new tab of your current browser window).

Since participation to this meeting is by invitation only, I like to suggest – since HIM / MR practitioner readers will already be familiar with ICD-10 but need to be aware of the ICD-11 revision, to focus and follow the progress and developments in ICD-10 and ICD-11 to be presented when the WHO-FIC Council meets in Beijing soon to review progress in relation to the strategic work plan of the WHO-FIC network and plan for the future. Please click on these links below (each of these links will open in a new tab of your current browser window) to know and learn the progress and developments in ICD-10 and ICD-11 :

progress and developments in ICD-10

progress and developments in ICD-11

References:

  1. WHO-FIC Network Annual Meeting 2013 – Beijing, People’s Republic of China, Classifications, The World Health Organisation (WHO), viewed 3 October 2013, <http://apps.who.int/classifications/network/meeting2013/en/>
  2. WHO-FIC Network Annual Meeting 2013, 2013 WHO-FIC Network, The World Health Organisation (WHO), viewed 3 October 2013, <http://www.whofic2013.org/register/toFrontPage.do>