Charting and Documentation

What is documenting?

  • Process of recording information about a patient in the medical record.

  • Performed by all caregivers who are directly involved with the care of the patient.

  • Information must be complete and as accurate as possible.

  • Some guidelines are:

    • Check the name on the patient record before making an entry to ensure you have the correct record.

    • If the patient is in front of you, perform patient verification with at least 2 identifiers.

    • Document information accurately, using clear and concise phrases.

    • Spell correctly.

    • Document immediately after performing a procedure.

    • NEVER document for someone else.


The Patient Intake Interview

  • Interacting with the patient

    • Put patient at ease 

    • Guide conversation

    • Keep on track

    • Obtains the most information 

    • Explain terms or concepts

    • Remain professional

    • Not be embarrassed or uncomfortable by answers

  • Approaching sensitive topics

    • Environment private and free from distractions

    • Use casual direct eye contact without staring

    • Pose questions in matter-of-fact tone

    • Adopt nonjudgmental demeanor

    • Use “normalize” technique when appropriate (letting patients know that others have shared similar experiences and that their response or symptoms are not uncommon or wrong)


Patient Information Forms

  • Demographic data form

    • Name and address

    • Home, work, cell telephone numbers

    • Date of birth

    • Social Security number

    • Insurance information

    • Emergency contact person

    • Release of information signature

  • Medical history form

    • Present health history, including why patient being seen

    • Past health history, personal and family

    • Social history including marital status, sexual orientation, occupation, smoking status, drug use.

    • Military service dates and assignment

    • Body systems review/questionnaire

    • Medications currently taken (OTC and prescription)

    • Provider’s review of system (ROS)


The Medical Health History

  • Personal data from demographic form

  • Chief complaint

  • Present illness

    • Medications

    • Allergies

    • Other providers or alternative therapy practitioners being seen

  • Medical history

  • Family history

  • Social and occupational history

  • Review of systems by physician or provider


Patient Information Forms

  • Privacy information form

    • Since 2004, HIPAA limited circumstances in which individuals’ PHI can be used or disclosed

    • Civil penalties for failure to comply

  • Release of information form

    • Sent to former providers to obtain past medical records

    • In some cases, can be used to allow sharing of information with family member

  • Financial information form 

    • Financial policy of practice

    • Billing

    • Insurance billing

    • Co-payment billing

    • Finance Charges


Patient Health Questionnaire PHQ-2

  • The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past two weeks. 

  • The purpose of the PHQ-2 is to screen for depression in a “first-step” approach.

  • It includes the first two items of the PHQ-9 (multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression)

Generalized Anxiety Disorder GAD 7

  • The Generalized Anxiety Disorder 7 is a self-reported questionnaire for screening and severity measuring of generalized anxiety disorder. The GAD-7 is normally used in outpatient and primary care settings for referral to a psychiatrist pending outcome

The Medical Health History

  • SOAP/SOAPER

    • S = Subjective data; patient’s complaint in his or her own words

    • O = Objective, observable, measurable findings

    • A = Assessment, probable diagnosis based on subjective and objective factors   

    • P = Plan for treatment, medications, instructions, return visit information

    • E = Education for patient

    • R = Response of patient to education and care given

  • CHEDDAR

    • C = Chief complaint, presenting problems, subjective information

    • H = History

    • Social and physical of presenting problem; contributing data

    • E = Examination, body systems review

    • D = Details of problem(s) and complaint(s)

    • D = Drugs and dosages; list of current medications, dosages, frequency

    • A = Assessment; diagnostic evaluation, further testing, medications

    • R = Return visit, if applicable

  • Chief Complaint (CC)

    • Specifies and identifies reason that patient is seeking care (symptoms)  

    • Foundation for the more detailed information obtained later on

    • Noted in as few words as possible; should be concise, brief and it can be direct quote from patient

    • The duration of the symptom should be included

    • Subjective complaint: known by patient but cannot be seen or measured by provider 

    • MA should avoid using names of diseases or diagnostic terms

    • Use open ended questions to obtain information from the patient. IE: What seems to be the problem? How can we help you today? What can we do for you today? What brings you in today?


Subjective vs. Objective 

  • Subjective: what the patient reports based on feelings, opinions, or emotions.

  • Objective: what you can observe based on facts and evidence.

  • Which one is subjective? Which one is objective?

    • A. Stomach pain

    • B. Elevated blood pressure

    • C. Nausea

    • D. Weight: 175 lb


The Medical Health History

  • Chief Complain (CC) - Symptom Characteristics:

    • Location

    • Radiation

    • Quality

    • Severity

    • Associated symptoms

    • Aggravating factors

    • Alleviating factors

    • Setting and timing

(interactive portion is on progress note)


Activities that Need to be Documented

  • Procedures

    •  Vital signs, weight, height, visual acuity, and ear irrigations.

    •  Should be documented immediately after they are performed.

    •  The following should be included:

      • Date and time

      • Type of procedure

      • Outcome

      • Patient reaction

  • Administration of Medication

    • Important responsibility of the MA

    • Information should include:

      • Date and time

      • Medication name

      • Medication lot number (if required)

      • Dosage given

      • Route of administration (for parenteral medications)

      • Injection site

      • Observations or patient reactions

  • Specimen Collection

    • Pap smears, wound cultures, nasal swabs.

    • Each time a specimen is collected from a patient the following should be documented:

      • Date and time

      • Type of specimen

      • Area of the body from which the specimen was obtained

  • Diagnostic Procedures and Laboratory Tests

    • All diagnostic procedures and laboratory tests ordered should be documented in the medical

    • record, this protects the provider legally.

    • If the patient declines or doesn’t complete the order it is documented in the chart.

    • The following information should be included:

      • Date and time

      • Type of procedure or test ordered

      • The scheduling date (if you made the appointment)

      • Location of the procedure or test (where is being performed)

  • Laboratory Test Results

    • Results should be document whether instructions from the provider were passed along to the

    • patient or results from a test performed in office are being entered

  • Patient Instructions

    • All instructions regarding medical care (IE: wound care, cast care, suture care) given to the patient

    • should be documented in the chart.

    • If instruction sheet is given, the patient should sign a form indicating that he/she has read and

    • understands the instructions. The form should also be signed by the MA and it should be

    • scanned or filed in the patient’s file. This protects the provider legally.

    • Other areas where the MA is responsible to document are: telephone calls, medication refills,

    • changes in medication or dosage by the provider.