chapter 1 the medical chart

8/10/2019 Chapter 1 the Medical Chart

1/8

CHAPTER 1

BrianT Harel, BrettA Steinberg,

an dPeter . Snyder

h Medical Chart

ffi ient Information

atheringStrategiesand

Proper ChartNoting

The medical chart is a repository of clinically an d research-

oriented information regardingan individual patient. Thus,a

patient s medical historyandresponsivenesstovarious clinical

interventions (i.e., pharmacological, surgical, psychological,re-

habilitative),

aswellasdata that may beused in retrospective

clinical research studies,arecontained withinthechart. Having

this informationin asingle, standard format means thatit may

serve as a

vehicle

of

communication among

all

health care pro-

viders, documenting

and

coordinating,

in a

systematic

and

inte-

grated

manner,

all

care administered

to an

individual patient.

Without this vehicleofcommunication, the multidisciplinary

approachtopatient carein ahospital setting wouldbeimpossi-

ble. Becauseo fthis, themedical chart also servesas arecordof

care

should

any

liability issues arise. With regard

to

psychiatric

issuessuch assuicide,fo rexample, themedical chart wouldb e

checked to ensure

that

proper assessment and precautionary

procedures were followed. Morespecific

to

neuropsychologists,

themedical chart servestodocument theinformation thatled

to any

diagnosis

we

might offer, should concerns regarding

an

evaluation arise.

Another aspect

of

liability involves

the

privacy

and

security

of

a

patient s medical chart.

On

April

14,

2003,

the

privacy

rule

of the Health Insurance PortabilityandAccountabilityA ct

(HIPAA),

which

was

signed into

law in

August 1996, became


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10 Harel Steinberg and Snyder

active (U.S. Department of Health and Human Services,O ffice

of

Civil Rights, 2003). Th egeneral goals of this legislation are

to protect previously ill Americans who change jobs or resi-

dencesfromlosing their

health

insurance and to provide stan-

dards for the electronic transmission of medical information.

Th e second aspect of this legislation has direct relevance for

both

the

privacy

and the

securityofelectronically stored med ical

information. Although a thorough discussion of HIPAA is be-

yond

the

scope

of

this chapter, there

are two

general points

that

are

directly relevant

to our

profession.

The first is

that

HIPAA regulations allow patients greater accessto, and knowl-

edge

of,

their

own

medicalrecords.

It is

worth

notingthat

psy-

chotherapy notesare nowconsidered protected health informa-

tion

and are more difficult for the patient to gainaccessto. The

second isthatthe implementation ofHIPAArequires psycholo-

giststo receive additional trainingto be incompliance withthe

privacy rule.

The

increased emphasis

on

maintaining privacy

an d confidentiality, while at the same time allowing for in-

creased

patient access

to

their

own

records, meansthatclinicians

need

to be

verycareful

in

bothwriting

and

protecting

the

secu-

rity of their patient records.

Despite the changes

that

are taking place as a resultof

technological advances

in the

storage

and

transmission

o f

medi-

cal data,and thecritical importancethatthemedical chart plays

in

coordinating

an d

documenting

al l

facets

of

patientcare,there

are

relativelyfewsourcesofinformationthatdescribethe basics

ofproperchartreviewand

chart

notingforneuropsychologists

who practice in a hospital setting.

I THE

C H A R T R E V IE W

Experienced neuropsychologists, like other hospital-based

health care specialists, have developed efficient strategies

for

obtaining information from

the

medical chartthat

i s

pertinent

to

their evaluations.

The fact thatthe

chart

is a

repository

of

information from medical staff across a variety of disciplines

(e.g.,

neurologists, surgeons, physical and occupational thera-

pists [PT/OT],and nurses) requires that the neuropsychologist

have

a

working knowledge

of the

language

and

techniques used

in

other areas

of

health care.

We are not

suggestingthat neu-

ropsychologists beexpertsinotherfields, but ratherthat they

be capable of conversing with patients' medical care providers

and that they have some understanding of the strategiesand

techniques used

in

other disciplines (e.g., neurologic diagnosis,

patient management techniques, and strategies for providing


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TheMedical Chart 11

day-to-day patient care).At thesame time, however, neuropsy-

chologists should

be

aware

of the

limits

of

their professional

competencies and thus be wary of Interpreting data outside of

their areas of expertise.

When reviewingthemedical chart,it isalso important to

keepgeneral clinical issues in mind, such as psychosocial and

environmental factors,sothattreatment recommendations will

be optimally

effective.

To do this, neuropsychologists mustbe

skilled

at behavioral and

psychological

assessment and

intervention.

Although it may not be necessary to review all of the sec-

tionsof the medical chart, it isimportant to be awareof the

various contents should

the

need arise

to find

specific data.

The following is meant to orient neuropsychologists to a few

ofthe most applicable sections of a typical chart by providing

brief descriptions of the pertinent information contained in

each section.Not allmedical settings willuse thesame format,

however. (It is worthwhile to

note

that charts arefullof medical

abbreviationsandacronyms.TheAppendixat thebackofthis

textprovides a listing of themore

common

abbreviations, and

most hospitals publish their

own

lists

of

abbreviations that

are

approved for use in medical charting at that institution.)

A

Sectionsof the

Chart

1.

Referral

Information/History

a nd

Physical (H P)

contains

referral

history, admission history, and results of physi-

cal examination.

2. AdmissionDatacontains general consent form, initial

assessments and evaluations, social work intake/

psychosocial consult.

3.

P h a r m a c y

contains pharmacy orders.

4. T r ea t m en t contains admission protocol, treatmentor-

ders,

physician order sheet.

5. Progress

Notescontains problem list, progress notes

for

al l

disciplines.

6. Consul ta t ions-Medical contains consultation records

for

physician, physiatry, psychiatry, neurology,

psychology.

7.

Evaluat ions/Assessments

contains audiology, OT/PT

evaluations, pressure sore flowsheet, social work

evaluations.

8. Advance Directivescontains power of attorney and pro-

bate papers.

9.

Chemis try/Hematology/Urinalys is /Stool

contains labs.


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12

Harel

Steinberg and

Snyder

10. Microbiology

contains labs.

11 . X-Raycontains cardiac rhythm sheet, echocardiogram,

electrocardiogram (EKG), electromyography

(EMG),

modified barium swallow results, sleep study, x-ray,

and neuroimaging data.

12. Care Plan/Critical Path contains individual treatment

plan (IIP),

patient

care plan, and behavior manage-

ment plans(BMPs).

B Stepsfor

Reviewing

the Chart

As

the previous section indicates, the medical chart stores data

that can be used to develop a conceptual framework within

which the neuropsychological assessment results can be inter-

preted.

Fo r

example, review

of the

chart might reveal informa-

tion regarding psychoactive medications that could be influ-

encing test performance or

affecting

the patient's symptoms in

away that might not otherwise be readily apparen t. Therefore,

we

offer

several suggested steps to more efficiently direct the

neuropsychologist's review of the chart:

1. Clarifythereferralquestion. This will help to guide the

review

of the

medical chart

in an

organized

and

efficient

manner.

If, for

example,

a

patient

is

referred

for

evalua-

tion

following a stroke, the neuroimaging and PT/OT

notes m ay yield informa tion rega rding the arterial terri-

tory

and

functional consequences, respectively,

of the

vascular

event.

2. Read

through

theinitialhistory and physical examina-

tion (H&P), which generally contains the following

components (for

a

more detailed review,

see

Blu-

menfeld,

2002):

a.

Chief complaint

(CC)contains presenting complaint

along with brief pertinent background data.

b. Historyo f

present

illness H P I ) contains complete history

of

current illness that brought patient to hospital.

c. Past

medical

history P M H ) contains information

about prior medical and surgical problems.

d.

Review of systems

R O S ) contains brief review of

medical systems (e.g., head, eyes, neurologic,

and

OB/GYN).

e. Family history

F H x )

containsalistofimmediate rela-

tives

and any family

illnesses.

Social

a nd

environmenta l

history S o c H x ) contains

in-

formation

about work history, family relationships,

an d

so on.


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The

Medical hart 13

g.

Medications a nd

allergies

contains lists

of

current med-

ications aswellasallergies.

h. Physical e x amcontains information about generalap-

pearance, vital signs (temperature, pulse, blood pres-

sure,

an d respiratory rate),

HEENT

(head, eyes, ears,

nose,

and

throat), neck, back

and

spine, lymph

nodes, breasts, lungs, heart, abdomen, extremities,

nervous system, reproductive system,and skin.

i. Resul ts of l ab studies contains data from diagnostic

tests (e.g.,bloodwork, tissue biopsy, and radiologi-

ca ltests).

j. ssessmenta n dplancontains brief summary along

with diagnosisand suggested interventions.

3. Review reports pertaining to relevant neuroimaging

studies (computed tomography [CT], magnetic reso-

nance imaging

[MRI],

singlephotonemission computed

tomography [SPECT], position emission tomography

[PET],

and cerebral angiography).

Also,

read any avail-

able electroencephalography (EEG)

or

neurosurgical

re-

ports availablein the chart.

4. Reviewlaboratory datafo rabnormallyhighor lowcriti-

ca l

blood orurine test values,fo rliver function tests,a s

well as forpositive resultsofdrug screen tests. (Chapter3

ofthisbook provides

a

review

of how

such important

laboratory studies shouldbereadandinterpretedby the

neuropsychologist.)

5. Review current medications and dosages as well as

whether the patient recently has been taken off or

started

on a

medication that might have

a

negative

impact

on

neuropsychological functioning.

6.

Review prior consultation reports

from

the medicine,

neurology, radiology, neurosurgery, psychiatry, and

physiatry services.

In

particular,

it may beusefulto

focus

on the initial and most recent reportsso as to havea

sense of current functioning aswell as progress made

to date. (Chapter 2 of this book provides a reviewo f

the organization andwritingof standard neurological

consultation andprogress notes.Inaddition, references

are

included

at the end of the

present chapter.)

7. Review progress notes from other relevant disciplines,

such as nursing, nutrition, social work, and OT/PT.

These notes

are

useful

because they

may

provide

a

fairly

detailed description of the

patient's

behavioronadmis-

sion, levelofcooperation with hospital

staff,

arousability

and alertness, aswellas any socially inappropriate or


6/8

14 Harel Steinberg and

Snyder

potentially hazardous behaviors. When possible,

it is

also

useful

to

brieflyinterview

the

nursingstaff prior

to

th e examination.

8. Note the schedule of appointments, as this is likely to

influencethe p atient's ability toperformoptimally dur-

ing

neuropsychological testing.

Fo r

example, several

hoursof FTwill likelyaffect apatient's pe rformanceon

testingthat occurs immediately afterward.

II THE P R O G R E S SNOTE

Th e

progress note serves

as a

more im med iately accessible sum-

mary of the most salient points of the evaluation. Ultimately,

aprogressnoteshould give the reader (e.g., attendin g p hysician)

sufficient

in formation regardingth e implicationso f theevalua-

tionsothat

appropriate care

can be

provided. Because

the

prog-

ress

note

functions

as a

briefsummary

of the

neuropsychological

evaluation, it should be written as soon

after

the evaluation

takes

place

as is

reasonably possible. (For maximum usefulness

in patient care and in disputes about liability, notes should

include the dates and times that they were written.) Although

we

discuss the general types of information that should be in-

cluded in the progressnote, each facility has its own tradition

an d culture fo rwriting progress notes.

Initially, we clearly state the reason for the evaluation,

including

the

referral source

an d

question.

In

much

the

same

wa ythat

thereferralquestion directs the review of the medical

chart, the referral question should direct the way the

note

i s

written (e.g., the language used and

specific

issues addressed).

Behavioral

observations an d judgments about the validityof

the

results

arethen

presented.

We

typically highligh t

the

salient

test findings by addressing each func tional domain with a one-

or

two-sentence summary

of

performance.

( To

keep this brief,

it is impo rtant tofocuson neurocognitive domains rather

than

on individual test scores. We may, however, include IQ scores

to

provide

a

quantitative frame

of

reference

for the

reader's

interpretation of other findings.) Inaddition to the neuropsy-

chological test report data, we include da ta regarding psycholog-

ical

functioning (e.g., risk

of

harm

to

self

or

others, level

of

arousal,

level of cooperation during examination, and mood

and

affect).This

is

followed

by a

briefsummary

of our

diagnostic

impressions and the implications of the results as they relate

to the

originalreferralquestion.

Ifit is

appropriate,

the

prognosis

can

also

be

discussed

in

terms

o f

time sinceinjury

or

onset

of

the

disease, treatment progress,efficacy

of

medication(s),

and


7/8

The Medical Chart

15

what

is

currently known about

the

condition. Furthermore,

recommendations that can be readily implemented and are of

an imm ediate n atur e are included. F inally, as a courtesy, we

like

to

thank

the referral

source

for the

opportunity

to

participate

in the

patient's

care.

Once

a

progress note

is

written,

it

immediately becomes

part

ofthat

patient's medical record.

It is

important

to

remember

that

this record

is

regarded

as a

legal document

an dthat

once

information isenteredintothe record, itbecomespermanent.

Forthis reason, if an error is made while writin g (e.g., a misspell-

ing or an

incorrect drug name),

it

should

not

simply

be

scratched

out or covered with correction fluid (e.g., White-Out). Instead,

the error should be crossed out, the correct word should be

printed above

or

next

to it, and the

writer's initials should

be

signed

in the

same place.

I f an

error

is

discovered

after an

entry

is

completethena newentry shouldb eenteredintotherecord.

This new entry should

identify

the date, time, and nature of

the

error

that

was

discovered;

it

should provide

the

correct

infor-

mation;

and a

note should

be

placed

at the

location

of the

old,

erroneousnoteindicating

that

anerror wasfound andwhen

the

revision

was

added. Finally,

it is

worthnoting that neatly

written progress notes

are

more likely

to be useful and to be

appreciated

by

colleagues.

III

THE

FUTURE

OF MEDICAL

R E C O R D S

Although the electronic storage and transmission of medical

charts has engendered concerns regarding privacy and security

(as

isapparentby the enactment ofHIPAA),italsooffers consid-

erablepossibility. As records become electronic docum ents, sev-

eral potential

benefits

may

improve patient care.

The first is

that information will become accessible more quickly and be

available to a

greater number

of

health care professionals.

In

addition, search engines will allow for a more interactive experi-

ence between the medical staff and the medical chart. For in-

stance, algorithms designed

to

seek

out and

compare

informa-

tion within the chart willbe ableto offer suggestions as to

what type of antidepressant should be used based on informa-

tion

about

th e

patient's current medications, sleep

an d

eating

habits, response to a similar

class

of drugs taken in the past,

diagnoses,and so on. Inresponseto the advancement in com-

puter technology, for example, Rollman et al. (2001) evaluated

the

utility

of

providing screening

and feedback for the

initial

management of

major

depression to pri mary care physicians via

electronic medical records. Rollman

et al.

found that electronic


8/8

16 Harel Steinberg andSnyder

notification of the

depression diagnosis

canaffect the

primary

care provider's

initial

management

of

major

depression

(p .

197). That

is,

when provided with such electronic

notifica-

tion,

the

primary care providers were found

to

respond more

rapidly and to manage their patients closely

from

that

point

forward.O f

course,

future research

will

be

needed

to

determine

to

what extent this will improve clinical outcomes.

IV

CONCLUSION

This

chapter provides

a

basic overview

of how to

thoroughly

reviewinpatientmedical charts

and how to

responsibly convey

clinical

impressions

an d

recommendations through

effective

chart noting.

BIBLIOGRAPHY

Blumenfeld, H.

(2002).

Neuroana tomy through

clinical cases.Sun-

derland, MA: Sinauer Associates.

Rollman,B . L.,

Hanusa,

B. H.,

Gilbert,

T., Lowe, H. J.,

Kapoor,

W. N., &

Schulberg,

H. C.

(2001).

The

electronic medical

record:

A

randomized trial

of its

impact

on

primary care

physicians' initial management

ofmajor

depression.

Archives

o f Internal Medicine,

161 189-197.

U.S.

Department

of

Health

and

Human Services,Office

for

Civil

Rights. (2003).

Medical

privacy:

National s tandards

to

protect

the privacy of personal health

information. Retrieved

April 11,

2003,

from

http://www.hhs.gov/ocr/hipaa/

chapter 1 the medical chart

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