King Khalid K University Hospital King Abdulaziz University Hospital Title: CLINICAL DOCUMENTATION Reviewed by: Date: Department: Unit: Policy Number: HWCPP - 005 Issue Date: DEC 2009 Prepared/Revised by: Date: Revision Date Effective Date DEC 2009 Due for Revision on: DEC 2011 Quality Management Department Authorized by: Date: Authorized by: Date: Dr. Farheen Shaikh Policy and Procedure Review Committee Authorized by: Date: Dr. Badr Al Jabri KKUH Medical Director Authorized by: Date: Dr. Abdul Rahman Al Muammar KAUH Medical Director Approved by: Date: Dr. Ayman Abdo Vice Dean for Quality Dr. Abdulaziz Al Saif Vice Dean for Hospitals Prof. Mussaad Al Salman Dean of College 1.0 Conditions: This policy applies to any hospital staff, within KKUH/KAUH, who has privileges to enter data into medical records. 2.0 Purpose: To purpose of this policy is to provide guidelines and instructions to ensure complete and correct medical documentation in a timely manner. In addition, it provides the methods of how these guidelines shall be performed. 3.0 Definitions: 3.1 Legible ability to read a hand-written medical document that can easily be read by someone other than the writer. 3.2 Authorized for data entry the person who is allowed to make an entry into a medical document. 4.0 Policy: 4.1 All medical documents should be legible. 4.2 Documentation should be written/typed in English. Arabic documentation can be used as needed according to hospital policies. 4.3 Only authorized personnel are allowed to make medical documentation. This may include: physicians, nurses, occupational and physical therapists, social workers, health educators, respiratory therapists, clinical dieticians, clinical pharmacists, speech pathologists, and psychologists. 4.4 A complete (hard copy/electronic copy) note of any medical document shall be maintained for every patient who is evaluated or treated as an inpatient, outpatient, or in the emergency department at King Khalid or King Abdulaziz University Hospitals. 4.5 Contents of the medical document should be enable a healthcare provider to: 4.5.1 Identify the patient and his or her medical record number. Page 1 of 9
4.5.2 Review the patient s clinical condition, performed procedures, and future plan. 4.5.3 Provide consultation or assume care through sufficient and detailed information. 4.5.4 Facilitate retrieval of information for purposes of utilization and quality review, patient s transfer, etc. 4.6 Medical documentation shall be considered complete when the required contents are present and authenticated. 5.0 Procedure: 5.1 For the document to be legible: 5.1.1 Personnel authorized to enter data are expected to do their best effort to write clearly to allow others to read their documents. 5.1.2 Abbreviations should be avoided with the exception to the ones detailed in the hospital reference. 5.2 All medical documents must be accurately dated in Gregorian calendar (day/month/year) and timed in 24 hours-clock system (1300 for 0100 pm and 2400 for 12 midnight). The use of Hijra calendar is optional. 5.3 All documents should include the addressograph stamp. Any data entry should be signed legibly with the name. The pager number should also be documented as applicable. The use of stamp containing the name and pager number is preferable. 5.4 No empty spaces are allowed. Spaces should be crossed and signed legibly in the bottom. 5.5 No entry can be obscured or masked by erasure, correcting fluid or other means. In case of erroneous entry, a single line through the entry can be drawn and the word ERROR should be written and then signed. 5.6 Late entries may be made and are placed after the last documentation. It is noted as a late entry with current time and date and reference made to original time and date. Late entries must be made before the end of twenty-four (24) hours after the occurrence. Reasons for late entries must be included. 5.7 An addendum may be added to the record provided that the addendum represents the current date and time, such that the chronology of events is accurate and clearly established. 5.8 The types of medical documents would include but not limited to the following: 5.8.1 Admission note (for physicians and nurses). 5.8.2 Progress note (for physicians and nurses). Page 2 of 9
5.8.3 Physician orders 5.8.4 Consultation note 5.8.5 Emergency department visit note 5.8.6 Surgical/procedure report 5.8.7 Anesthesia 5.8.8 Outpatient clinic note 5.8.9 Transfer not 5.8.10 Discharge summary note 5.8.11 Allied health workers documents 5.8.12 Consent forms 5.9 The contents of each medical document depend on the type of the document: 5.9.1 Admission note should contain: a. Date and time of clinical assessment. b. Presenting complaint c. History of presenting complaint d. Systems review e. Past medical, past surgical, family, social, drug and allergy histories. f. History of birth, development, immunization, and nutrition when relevant (e.g. Pediatric age group). g. Pain assessment h. Social need assessment i. Nutritional assessment j. Physical exam including general assessment, vital signs, and specific organ exam in details. k. Provisional diagnosis and differential diagnosis. l. Proposed Care plan, investigations required and their timings, and consultation. 5.9.2 Progress note should include: Page 3 of 9
a. Date and time of clinical assessment. b. Current subjective complaints of the patient and any change in his/her condition. c. Current objective findings of the patient on examination and investigations. d. Follow-up assessment including response to treatment and future plan. e. Progress note should reflect consultant physician involvement in the patient s care. 5.9.3 Physician orders: a. Date and time of physician orders. b. Orders are written only on the designated order sheet. c. A nurse (in-charge of the patient s care) has to be notified about the order. 5.9.4 Consultation note: Refer to relevant IPP s. 5.9.5 Emergency department visit note: a. Date and time of arrival to the ER. b. Triage time c. If there is any other visit to ER or return to ER within 24 Hours d. Date and time of clinical assessment. e. Adequate history and physical examination. f. Physician orders. g. Laboratory and/or imaging investigations results. h. Repeated assessment of the patient s condition as necessary. i. Nurse s assessment and progress notes. j. Provisional diagnosis and differential diagnosis. k. Proposed plan, investigations required and their timings, and consultations. l. The outcome of the treatment: patient discharged, transferred, admitted. Page 4 of 9
5.9.6 Surgical/procedure documents: a. Pre-operative documentation. a.1 Provisional Diagnosis should be written in the history and physical exam form or in the progress note prior to surgery. b. Planned Surgical procedure should be documented. c. Post-operative Documentation. c.1 Patients clinical assessment should be documented in the progress note. c.2 Future plan/discharge should be documented. d. A typed operative report should be produced in a timely manner brief written operative note should immediately be available in the patient s chart before the patient leaves the operating theater. e. The typed operative report should contain: e.1 Surgery date e.2 Patient s name and medical record number. e.3 The hospital ward that the patient came from. e.4 Consultant s name e.5 Surgeon s name e.6 Assistant s name e.7 Anesthetist name e.8 Type of anesthesia used e.9 Specimen sent to Pathology e.10 Estimated blood loss e.11 Pre-operative diagnosis e.12 Post-operative diagnosis e.13 Surgery performed e.14 Details of the surgery/procedure e.15 Any encountered complications f. Anesthesia Page 5 of 9
d.1 Preoperative anesthesia sheet should be filled out. d.2 Intra-operative monitoring of the patient should be documented. d.3 Post-operative anesthesia assessment and pain management should be documented. 5.9.7 Outpatient clinic note: a. Date of the visit b. Patient s No show should be noted c. Presenting complaint d. History of presenting complaint e. Systems review f. Past medical, past surgical, family, social drug and allergy histories. g. History of birth, development, immunization, and nutrition when relevant (e.g. pediatric age group). h. Physical exam including general assessment, vital signs, and relevant exam in details. i. Provisional diagnosis and differential diagnosis. j. Proposed plan, investigations required and their timings, and consultations requested. 5.9.8 Transfer note: a. Within King Khalid University Hospital and King Abdulaziz University Hospital, a transfer summary report should be provided in the chart. It should include: a.1 Diagnosis and reason for transfer a.2 An update history and physical exam, and relevant investigations. a.3 Future plan b. To an outside institution, the patient should be accompanied with a detailed typed report containing: b.1 Name of receiving institution b.2 Patient name and medical record number b.3 Reason for transfer Page 6 of 9
b.4 Diagnosis and treatment received b.5 Significant history and examination b.6 Results of significant laboratory and radiology investigations b.7 Current medical condition prior to transfer b.8 List of current medications b.9 Future plan b.10 Any precautions during transfer c. If the transfer is an emergency, a handwritten report satisfying the above criteria would be acceptable from outside institution to KKUH/KAUH. c.1 Name of transferring institution c.2 Patient name and medical record number c.3 Reason for transfer c.4 Diagnosis and treatment received c.5 Significant history and examination c.6 Results of significant laboratory and radiology investigations c.7 Current medical condition prior to transfer c.8 List of current medications c.9 Future plan c.10 Any precautions during transfer 5.9.9 Discharge summary a. Should be written at the time of discharge b. No patient should leave the floor without having a hand written discharge summary c. The summary will include c.1 Date of admission and date of discharge c.2 Reason for admission c.3 Diagnosis c.4 Course of treatment Page 7 of 9
c.5 Discharge instruction c.6 Discharge medication and follow up appointment 5.9.10 Discharge Report a. Should be transcribed through the hospital s dictation system. b. If the hospital dictation system is not working, discharge c. Summaries should be written and sent for electronic transcription. d. They should be finished within thirty (30) days of the hospital discharge by a qualified person (consultant or resident), from the treating team. e. Should contain: d.1 Patient name and medical record number d.2 Admission date d.3 Discharge date d.4 Discharge diagnosis d.5 Significant history and examination d.6 Results of significant laboratory and radiological investigations d.7 Hospital course and patient s condition at time of discharge. d.8 List of discharge medications d.9 Future plan(s) d.10 Instructions for discharge and follow-up. d.11 Health education instruction 5.9.11 Do not resuscitate forms (DNR) forms (please refer to relevant HWCPPs) 5.9.12 Death reports (please refer to relevant HWCPP s) 5.9.13 Consent form (please refer to relevant HWCPP s) 5.9.14 In-patients and out-patients drug prescription (please refer to pharmacy HWCPP s). Page 8 of 9
6.0 Reference: Hospital Rules & Regulation, CBAHI Standards. Page 9 of 9