Chart Review Lecture

Introduction

• Speaker: Martin Brodowski

• Employment: Johns Hopkins University

• Funding: NIH, specifically in IDCD

• Financial Disclosures: Receiving compensation from ASHA for this presentation; no non-financial disclosures.

Goals for the Session

• Explain the goals for medical chart review.

• Identify areas of the medical chart that inform speech language pathology (SLP) diagnosis and treatment goals.

• Present at least two pragmatic and time-saving tips for navigating the medical setting.

Importance of Medical Chart Review

• Purpose of Medical Chart Review:

  • According to ASHA 2004 practice patterns document, activities directed toward patients must address:

  • Structural requisites of the practice.

  • Processes to be carried out.

  • Expected outcomes.

  • A subsection called consultation emphasizes the need to gather information through observations, assessments, and records review.

  • The necessity of reviewing medical charts is emphasized as a vital part of the practice.

Beginning the Medical Chart Review

• Key Questions:

  • How do I begin?

  • Where do I start?

• Philosophical Approach: Mark Twain's quote underscores the importance of breaking complex tasks into manageable steps, similar to writing goals before proceeding to evaluations.

Goals and Takeaways from Medical Chart Review

• Main Goals:

  1. Maintain compliance and identify the reason for the consultation.

  2. Determine the patient's primary complaint—understanding that diagnoses may differ from complaints.

  3. Identify additional information needed before meeting the patient for effective assessment.

  4. Develop a working hypothesis for SLP diagnosis and patient presentation.

What Medical Charts Provide

• Legal and Medical Memory:

  • Medical charts serve as a legal document outlining all care associated with the patient, admissible in court.

• Treatment and Testing Results:

  • Record of completed treatments and tests, providing essential information for assessments.

• Plans from Providers:

  • Includes details on follow-up actions, tests needed, patient discharge plans, etc.

• Provider Communication:

  • Facilitates communication among healthcare providers through documented notes, whether electronic or paper.

• Compliance Procedures:

  • Ensures adherence to healthcare regulations at various governmental and institutional levels.

Critical Information for Review

• Key Elements to Look For:

  • Etiology for each complaint: understanding why the patient is experiencing those symptoms.

  • Decision-making rationale for the need for services.

  • Specific concerns about each consultation.

  • Necessary information that may not be fully present in the chart.

• Medical History Areas to Review:

  • Admitting medical history: What occurred prior to the patient's admission.

  • Consults from important services: Neurology, surgery, gastroenterology, nutrition, etc.

  • Pertinent radiologic evaluations.

  • Nursing notes: Provides frequent updates on patient status and care.

  • Notes from other consult services: Occupational therapy, physical therapy, and emergency services documentation.

  • Orders of consults, therapies, and diets: Essential insights into ongoing assessments.

  • Laboratory results: Familiarity with blood counts, electrolyte panels, etc. provides clues to patient conditions.

  • Medication history: Understanding how medications may affect cognition, voice, and swallowing abilities.

  • Transfer records: Insight into patients' previous and current care levels.

  • Previous visit notes: Historical data on patient care and assessments.

Parsing the Medical Chart

• Four Pieces of Medical Chart Review:

  1. Review of the Medical Chart: Ensures an existing signed order for patient consultation.

  2. Patient Demographics: Key patient information including age, sex, background, and pronunciation of the name for rapport building.

  3. Patient Complaints: Understanding the reasons for consultation beyond the primary complaint.

  4. Medical and Social History: Essential for tailoring assessment and treatment to the individual patient context.

Proficiency in Medical Chart Review

• What to Know for Proficient Review:

  • Importance of asking the right questions to extract needed information from charts.

  • Learning curve differences: New clinicians have a steep learning curve while experienced clinicians can navigate charts more efficiently.

  • Recognizing Occam's Razor: Simplest explanations are often preferred—avoid unnecessary complexities.

Electronic Medical Records (EMRs)

• Benefits of EMRs:

  • Enhance patient safety by preventing data loss.

  • Improve provider communication through accessible and timely documentation.

  • Support billing verification, ensuring treatments match diagnoses and documentation.

  • Maintain legal integrity, as documents are admissible in court.

• Types of EMRs:

  1. Therapy Medical Record Systems: Specifically designed for SLPs, OT, PT, and allow for quick access to therapy notes.

  2. Unit-Specific Medical Records: Overall unit records relevant to holds at specific hospital locations (ICU, general wards).

  3. Service Line Medical Records: Inpatient and outpatient records, which may differ in the detail of information presented.

Summary of Key Takeaways

• Learning is a gradual process—patience is key.

• Be open to evolving practices, particularly in electronic record keeping.

• Strive for simplicity in documentation for greater clarity and utility.

• Efficiency Tips:

  • Stay focused on relevant data.

  • Use copy and paste options effectively to save time.

  • Utilize multitasking to streamline the review process.

  • Create templates and summaries for frequent assessments and treatments.

Conclusion

• Encourages personal outreach for questions and further inquiries.

• Wishes success in conducting medical chart reviews.