chapter 10

1Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 10Chapter 10

Recording Skills: The Basis for Recording Skills: The Basis for Data Collection, Organization, Data Collection, Organization,

Assessment Skills, and Treatment Assessment Skills, and Treatment PlansPlans


Types of Patient RecordsTypes of Patient Records

Traditional chartTraditional chart Problem-oriented medical record (POMR)Problem-oriented medical record (POMR) Computer documentationComputer documentation


Traditional ChartTraditional Chart

Also called Also called block chart block chart or or source-oriented source-oriented recordrecord

Divided into distinct areas or blocksDivided into distinct areas or blocks Emphasis placed on specific informationEmphasis placed on specific information


Traditional Chart (Cont’d)Traditional Chart (Cont’d)

Typical blocks include:Typical blocks include: Admission sheetAdmission sheet Physician's order sheetPhysician's order sheet Progress notesProgress notes History and physical examination dataHistory and physical examination data Medication sheetMedication sheet Respiratory care sheetRespiratory care sheet Nurses’ admission informationNurses’ admission information Nursing care plansNursing care plans


Problem-Oriented Medical RecordProblem-Oriented Medical Record(POMR)(POMR)

1.1. Systematically gather clinical dataSystematically gather clinical data2.2. Formulate an assessmentFormulate an assessment3.3. Develop an appropriate treatment planDevelop an appropriate treatment plan


SOAP— SOAP— Most Common POMRMost Common POMR

S:S: Subjective informationSubjective informationO:O: Objective informationObjective informationA:A: Assessment (cause of subjectiveAssessment (cause of subjective

and objective data)and objective data)P:P: Plan (treatment selection)Plan (treatment selection)


SOAPSOAP

S:S: Subjective information presented by the Subjective information presented by the patient. For example:patient. For example: ““I coughed hard all night long.”I coughed hard all night long.” ““My chest feels very tight.”My chest feels very tight.” ““I feel very short of breath.”I feel very short of breath.”


SOAP (Cont’d)SOAP (Cont’d)

O:O: Objective information that can be measured, Objective information that can be measured, factually described, or obtained from other factually described, or obtained from other professional reports or test results. Includes professional reports or test results. Includes the following:the following:

Heart rateHeart rate Respiratory rateRespiratory rate Blood pressureBlood pressure TemperatureTemperature Breath soundsBreath sounds Cough effortCough effort



A:A: Professional conclusion about the cause of Professional conclusion about the cause of the subjective and objective data. For the subjective and objective data. For example:example: The assessment of The assessment of bronchospasmbronchospasm can be can be

concluded from concluded from wheezeswheezes.. Or, acute Or, acute ventilatory failure with moderate ventilatory failure with moderate

hypoxemia hypoxemia can be inferred from the following can be inferred from the following ABGs:ABGs:• pH: 7.18pH: 7.18• PaCOPaCO22: 80 mm Hg: 80 mm Hg

• HCOHCO33: 29 mEq/L: 29 mEq/L

• PaOPaO22: 54 mm Hg: 54 mm Hg



P:P: Plan is the therapeutic procedure(s) selected Plan is the therapeutic procedure(s) selected to remedy the cause identified in the to remedy the cause identified in the assessment. For example:assessment. For example:

An assessment of bronchial smooth muscle An assessment of bronchial smooth muscle constriction justifies the administration of a constriction justifies the administration of a bronchodilatorbronchodilator

The assessment of acute ventilatory failure The assessment of acute ventilatory failure justifies mechanical ventilationjustifies mechanical ventilation


SOAPIERSOAPIERExtended SOAP model with the added “IER”Extended SOAP model with the added “IER”

I: Implementation—the actual administration I: Implementation—the actual administration of the specific therapy planof the specific therapy plan

E: Evaluation—collection of measurable data E: Evaluation—collection of measurable data regarding the effectiveness of the planregarding the effectiveness of the plan

R: Revision—refers to any changes that may R: Revision—refers to any changes that may be made to the original plan in response to be made to the original plan in response to the evaluationthe evaluation


SOAP Case ExampleSOAP Case Example

A A 26-year-old man26-year-old man arrived in the emergency arrived in the emergency room with a room with a severe asthmatic episodesevere asthmatic episode. On . On observation, his arms were fixed to the bed observation, his arms were fixed to the bed rails, he was using his rails, he was using his accessory muscles of accessory muscles of inspirationinspiration, and he was using , and he was using pursed-lip pursed-lip breathingbreathing. The patient stated that . The patient stated that “it feels like “it feels like someone is standing on my chest. I just can’t someone is standing on my chest. I just can’t seem to take a deep breath.”seem to take a deep breath.”


SOAP Case Example (Cont’d)SOAP Case Example (Cont’d)

His His heart rateheart rate was was 111 beats per minute111 beats per minute and and his his blood pressure was 170/110blood pressure was 170/110. His . His respiratory raterespiratory rate was was 28 and shallow28 and shallow. . Hyperresonant notesHyperresonant notes were produced on were produced on percussion. percussion. Auscultation Auscultation revealed revealed expiratory expiratory wheezingwheezing and and rhonchi bilaterallyrhonchi bilaterally. His . His chest x-chest x-rayray revealed a revealed a severely depressed severely depressed diaphragmdiaphragm and and alveolar hyperinflationalveolar hyperinflation. .


SOAP Case Example (Cont’d)SOAP Case Example (Cont’d)

His His peak expiratory flowpeak expiratory flow was was 165 L/min165 L/min. Even though . Even though his his cough effortcough effort was was weakweak, he produced a , he produced a large large amount of thick white secretionsamount of thick white secretions. His . His arterial blood arterial blood gasesgases showed a showed a pH of 7.27pH of 7.27, a , a PaCOPaCO22 of 62 of 62, and an , and an

HCOHCO33 of 25 of 25, and a , and a PaOPaO22 of 49 of 49 (on room air) (see (on room air) (see

Figure 10-1).Figure 10-1).


SOAP Case ExampleSOAP Case Example


General InformationGeneral Information

Age: 26Age: 26 Sex: maleSex: male Admitting diagnosis: asthmaAdmitting diagnosis: asthma


Admitting Diagnosis: Asthma.Admitting Diagnosis: Asthma.


SUBJECTIVESUBJECTIVE

““It feels like someone is standing on my chest.”It feels like someone is standing on my chest.”

““I just can’t seem to take a deep breath.” I just can’t seem to take a deep breath.”


OBJECTIVE OBJECTIVE RR 28RR 28 HR 111HR 111 BP 170/110BP 170/110


Use of accessory musclesUse of accessory muscles Pursed-lip breathingPursed-lip breathing HyperresonantHyperresonant Expiratory wheezing and rhonchi (bilateral)Expiratory wheezing and rhonchi (bilateral) X-ray exam: Severely depressed diaphragmX-ray exam: Severely depressed diaphragm PEFR: 165PEFR: 165 Weak coughWeak cough Large amount of thick white secretionsLarge amount of thick white secretions pH 7.27, PaCOpH 7.27, PaCO22 62, HCO 62, HCO33 25, PaO 25, PaO22 49 49

OBJECTIVE OBJECTIVE


Use of accessory musclesUse of accessory muscles

Pursed-lip breathingPursed-lip breathing

HyperresonantHyperresonant

Exp. wheezing Exp. wheezing

RhonchiRhonchi

X-ray film: Severely depressed diaphragmX-ray film: Severely depressed diaphragm

PEFR: 165PEFR: 165

Weak coughWeak cough

Lg. amt thick and white sec.Lg. amt thick and white sec.

pH 7.27, PaCOpH 7.27, PaCO22 62, HCO 62, HCO33 25, PaO 25, PaO22 49 49

BronchospasmBronchospasm

Lg. airway sec..

Poor ability to mobilize thick secretions

Acute ventilatory failureand severe hypoxemia

Respiratory distress

OBJECTIVEOBJECTIVE ASSESSMENTASSESSMENT


Oxygen TxOxygen Tx

ASSESSMENT ASSESSMENT PlanPlan

Acute ventilatory failure andAcute ventilatory failure andsevere hypoxemiasevere hypoxemia

Respiratory distressRespiratory distress

BronchospasmBronchospasm Bronchodilator TxBronchodilator Tx

Mechanical vent. TxMechanical vent. Tx

Lg airway secretionsLg airway secretions

Poor ability to mobilize Poor ability to mobilize thick secretionsthick secretions

Bronchial hygiene TxBronchial hygiene Tx


Figure 10-1. Figure 10-1. Completed predesigned SOAP form.Completed predesigned SOAP form.


Figure 10-1: Figure 10-1: Abbreviated FormAbbreviated Form

S:S: “It feels like someone is standing on my chest. I “It feels like someone is standing on my chest. I can’t take a deep breath.”can’t take a deep breath.”

O:O: Use of acc. mus. of insp.; HR 111, BP 170/110, RR Use of acc. mus. of insp.; HR 111, BP 170/110, RR 28 and shallow, pursed-lip; hyperresonance; exp. 28 and shallow, pursed-lip; hyperresonance; exp. whz; diaph. and hyperinfl.; PEFR 165; wk. cough; whz; diaph. and hyperinfl.; PEFR 165; wk. cough; lg. amt. thick/white sec.; pH 7.27, PaCOlg. amt. thick/white sec.; pH 7.27, PaCO22 62, HCO 62, HCO33

25, PaO25, PaO22 49 49

A:A: Bronchospasm; hyperinflation; poor ability to mob. Bronchospasm; hyperinflation; poor ability to mob. tk. sec.; acute vent. fail. with severe hypox.tk. sec.; acute vent. fail. with severe hypox.

P:P: Bronchodilator Tx/pro.; CPT and PD/pro., Bronchodilator Tx/pro.; CPT and PD/pro., mucolytic/pro., mech. vent/pro.; ABG 30 minmucolytic/pro., mech. vent/pro.; ABG 30 min


Figure 10-2 A, Figure 10-2 A, Respiratory care protocol guide. Respiratory care protocol guide.


Figure 10-2 B, Figure 10-2 B, Respiratory care protocol guide.Respiratory care protocol guide.


Computer DocumentationComputer Documentation

So-called:So-called: Electronic medical recordsElectronic medical records Electronic health recordsElectronic health records Computer-based personal recordsComputer-based personal records Electronic patient medical chartsElectronic patient medical charts


Health Insurance Portability and Health Insurance Portability and Accountability Act (HIPAA)Accountability Act (HIPAA)

Both the health-care provider and a Both the health-care provider and a representative of the insurance company representative of the insurance company must explain to the patient how they plan to must explain to the patient how they plan to disclose any medical records.disclose any medical records.

Patients may request copies of all their Patients may request copies of all their medical information and make appropriate medical information and make appropriate changes to it. Patients may also ask for a changes to it. Patients may also ask for a history of any unusual disclosures.history of any unusual disclosures.


Health Insurance Portability and Health Insurance Portability and Accountability Act (HIPAA) (Cont’d)Accountability Act (HIPAA) (Cont’d)

The patient must give formal consent should The patient must give formal consent should anyone want to share any health information.anyone want to share any health information.

The patient’s health information is to be used The patient’s health information is to be used only for health purposes. Without the patient’s only for health purposes. Without the patient’s consent, medical records cannot be used by: consent, medical records cannot be used by: 1.1. A bank to determine whether to give the patient a A bank to determine whether to give the patient a

loanloan2.2. A potential employer to determine whether to hire A potential employer to determine whether to hire

the patientthe patient


Health Insurance Portability and Health Insurance Portability and Accountability Act (HIPAA) (Cont’d)Accountability Act (HIPAA) (Cont’d)

When the patient’s health information is When the patient’s health information is disclosed, only the minimum necessary disclosed, only the minimum necessary amount of information should be released.amount of information should be released.

A patient’s psychotherapy records get an A patient’s psychotherapy records get an extra level of protection.extra level of protection.

The patient has the right to complain to HHS The patient has the right to complain to HHS about violations of HIPAA rules.about violations of HIPAA rules.

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