Review common pitfalls of medical records and charting, and get resources and strategies to conduct a sufficient and effective medical history interview. To see if …
>> Martin B. Brodsky: Hi, I'm Martin Brodsky.
I'm going to speak to you today
about deriving clinical meaning from medical
chart review.
My financial disclosures are that I'm employed
by Johns Hopkins University.
research is funded by NIH and very specifically
right now NIDCD.
I am receiving
financial compensation from ASHA for this
And I don't have any
nonfinancial disclosures.
The goals for this session are: Explain the
goals for medical chart review; reason
which areas of the medical chart are needed
to inform speech language pathology
diagnosis and treatment goals; and reflect
on and employ at least two pragmatic and
time saving tips to assist with effective
and efficient navigation of the medical setting.
So why complete a medical chart review?
What's the point to it all?
According to
ASHA 2004 in their practice patterns document
they said: Statements that define
generally applicable characteristics of activities
directed toward individual patients or
clients and that address structural requisites
of the practice, processes to be carried out,
and expected outcomes.
Within that section, within the practice patterns
there is a subsection called "consultation."
And in that section it states, and this is
direct quote, "as appropriate to the situation,
the consultant — which is you — gathers
information through observations, interviews,
assessments, or other direct services and
through review of records and materials."
So effectively what it's saying is that at
point you still need to go through the medical
chart whether you want to or not.
This is
the practice pattern that you need to follow.
And to be very honest with you the
information that's in there is definitely
So maybe your first thoughts are, how do I
Where do I begin?
And those
are not simple questions to answer.
In the remaining portions of this presentation,
hope we'll address those in ways that are
directly applicable with your practice.
One of
the other questions that you may be asking
yourself is: Do you need to do a thorough
Does the medical chart review allow you to
do the thorough evaluation?
perhaps the other side of it is, are you doing
it simply because of billing efficiency?
Well, let's explore those a little bit.
So what do you need to know in medical chart
Those are the critical
Those are the things that will help you with
your patient.
One philosophical
approach came from Mark Twain, and he said,
"The secret of getting started is breaking
your complex overwhelming tasks into small
manageable tasks and then starting on the
first one."
Practical advice, right?
We do that every single day.
You even do that right
now by writing goals.
You're writing short-term goals, even before
that you may have
immediate goals, maybe you just want to get
the evaluation done.
After that you do
your short-term goals and you do your long-term
Each of those can be
considered steps on the way to progress for
that patient.
Well, the goals and take
aways from medical chart review are to maintain
compliance and to identify the reason
for the consult, not necessarily what the
patient's complaining of, and that maybe
something completely different.
What I want you to take away from a medical
chart review is to determine the
supporting information for the consult.
What is it about the information that's in
medical chart that says, I need to see the
patient as a speech language pathologist?
Second point, determine the patient's primary
As I said the diagnosis that
you see in the medical chart may be very different
from the actual complaint that the
patient has.
Determine whether and what additional information
is needed before
seeing the patient.
So essentially you're a fact-gatherer.
You're a sleuth.
You're trying
to find out the information that you need
to even make the best choices for which
assessment you use.
And even before you get to that point, which
questions you want
to ask the patient to determine, maybe, or
even fine tune what you do with the patient.
Finally, you want to develop a working hypothesis
for SLP diagnosis and patient
Now I know that's fancy speak with hypothesis,
but all it really means is:
You want to have a best guess as to what you
think this patient is going to look like
when you walk into that room.
That's the feeling that you want when you
first walk away
from that medical chart and on the way to
see that patient.
So what do medical charts provide?
First off and foremost they provide the
medical and therefore legal memory of the
patient's care and historical knowledge of
patient's care.
Basically everything that's done to the patient,
at the patient, for the
patient, with the patient is in that medical
And it is a legal document.
It is
admissible into a court.
So once you put your John Hancock on that
document, it is
admissible and you are responsible for it.
Keep that in mind.
The medical charts also provide results of
completed treatments and testing.
And of course you want that information as
They have plans from all of the
You may know the SOAP notes.
And this is the "P" part of the note.
probably the bottom most part of any given
note in the medical chart, it's what are we
What's coming next?
What's the plan?
And it can be everything from the next
test to patient discharge.
Next point, communication between providers,
the medical chart whether it's
electronic, written, or otherwise is a way
for providers to discuss among themselves,
seemingly in a non-oral communicative way
but verbally through the chart, whatever
everybody's doing.
It's the game plan within the pages and within
the documents
Finally, necessary pieces to assure compliance
with hospital and billing
Basically what that means is that there are
pieces, that are mandated by
federal, state, local governments, even within
your own institution, that says, these are
the parts that keep us legally appropriate,
responsible for the patient, compliant, and
can finally send a bill with some documentation.
So what are the things that are in the medical
chart that may be provided to you
but not necessarily?
And these are the keys.
These are the things that you're looking
for perhaps more so than the ones that are
the givens.
And that is the information to
determine the ideology for each complaint,
meaning, you know what the complaints are
very simply by the diagnosis and what the
patient is saying.
But you may not
necessarily know why this is going on or what
the cause of it is.
That's what you're
interested in.
Decision-making for the need of services,
you're not going to be seeing
something here similar to a geometry proof
in that they're going to be going step by
through their reasoning necessarily.
But you may see, because of X then Y, those
other key points to remember.
Specific concerns related to each consult,
so basically once the consult is over,
the physician or the provider or the clinician
will come back and they'll say, yep, we
believe it's this, but it may be that, and
we need further testing for that.
Those are good
things to know, because those will impact
what you do with the patient.
And then finally the necessary information
but not all the information, as I said to
you before, you may be completely up-to-date
but the reality is, what's in the medical
chart may not be up-to-date as you think it
should be.
Some key areas for review based largely on
the diagnosis for the patient and that
is the admitting medical history.
And that is when a patient comes into the
room, maybe the patient was transferred to
the ICU or the main floor, they'll take a
paragraph, perhaps a few sentences and determine
— or they'll state to you what
exactly it was that happened to the patient
prior to that moment.
They'll review
You'll see consults from various services
among the ones that are probably most
important to speech language pathology are
neurology and neurosurgery,
otolaryngology, head and neck surgery, gastroenterology,
and nutrition or clinical
dietitians may offer something along those
Finally pertinent radiologic evaluations will
be very interesting for you to see,
whether it be the chest film, the upper GI
series, maybe some head shots of a CT scan
or an MRI.
Not to be overlooked, one of the major key
areas are nursing notes, because
while the physicians and other consults may
come in periodically, the nursing notes will
take place absolutely daily and definitely
multiple times within the day, even hourly
depending on the patient and their level of
Other areas of interest in the medical chart
include: Notes from additional
consult services.
So maybe there was a consult service that
I didn't mention on the
previous slide, for example, infectious disease,
maybe the anesthesiologist, maybe a
surgeon, those are important notes depending
on what it is that you need exactly, what
it is that you're looking for, the basis of
why the patient is in the hospital.
Occupational and physical therapy are also
very important notes.
Of course
there are major colleagues in allied health,
but aside from that they will tell you what
kind of transfers the patient can do, whether
they're going to be able to stand up and do
so fairly unaided for a radiologic exam, for
example, the video fluoroscopic swallowing
study, and things of that nature.
So bottom line is they're very important notes,
so don't
discount those either.
Orders, whether they're consults, therapies,
or diets, the orders will give you an
opportunity to see time-based and the focus
of where the physicians are thinking next.
And you'll be able to determine whether the
diet you recommended was indeed ordered,
never mind whether it showed up in the patient's
Labs are very important.
And while new clinicians may not be very familiar
labs, they should get familiar with CBC's,
complete blood counts, an electrolyte panel,
maybe even just very simply some other labs,
urinalysis, blood counts in other forms
and so forth.
So these will give you big clues as to what's
going on with the patient.
keep in mind that those tests are sometimes
They're definitely timed.
And that
your interpretation from those results, are
relative to that time and day.
The medication list is a very important thing
from the standpoint of what you
might be able to expect from the patient.
That is, there are some medications that
directly affect cognition.
There are some medications that may even directly
voice and swallowing.
So you should be aware of those kinds of medications
and plan
Notes from the emergency medical services
or emergency medical team, the
emergency department can be a little bit sketchy
if they're available to you in the first
But they're definitely worthwhile to take
a look at because they'll provide
information that will give you the basis of
what they saw early on in the patient's hospital
And things that may not even be covered in
the histories that are provided by the
first line providers by the time you see the
patient on the floor.
Transfer hospital notes are also very important.
Transfers from the ICU to the
medical ward will typically give a positive
spin because the patient is being downgraded
to a less intense level of care, always good
But the reverse happens as well and
you're going to want to know why that patient
came back to the ICU or went to the ICU
in the first place from the medical wards,
something happened?
Did the patient have
something go on with their heart?
Did they have something go on with the respiratory
Maybe it was an infection that couldn't be
controlled by the floor and they
needed a more intensive treatment.
So those are things that you're going to want
Finally notes from previous in-patient or
out-patient visits.
Again, these can be
hit or miss.
If you're part of a medical record that is
electronic, probably a little bit easier
to get access to those.
But if you're still in a paper record, I wouldn't
count it complete
out, but your chances are not as high to get
those records.
So parsing the medical chart, this looks like
a puzzle doesn't it?
And there are
four pieces to it.
One of the major pieces to it is the actual
review and that's why we're
talking today, the review of the medical chart.
You want the order to see the patient.
you don't have an order in the medical chart,
you cannot see that patient period.
make sure that that order exists.
That it is signed, which is another compliance
and then you can see that patient then you
can go through the medical record.
careful that always needs to be your first
Second step is to take a look at the patient
Who are they?
Where did they come from?
Are they local?
Are they out of state?
Are they out of the
How old are they?
Are they male or female?
Here's one for you, do you
know how to pronounce their name?
Believe it or not that will go a long way
with regard
to patient rapport.
Patient complaints, what is it that the patient
came into the hospital complaining
of and why are you seeing that patient now?
So, those may be wildly different and I'll
give you a simple example.
Patient may have been — come into the emergency
complaining of problems that ultimately ended
up as a urinary tract infection, a UTI, and
suddenly you have a speech pathology consult.
Well, those two don't make sense, do
Somewhere along the lines something happened.
What happened?
When did it
So knowing the patient complaints at the time
that the physicians are ordering
your consult, that's what you want to know.
So the UTI is probably not important, but
I'm guessing that they might be on some antibiotics.
I'm guessing that the UTI may
have caused some cognitive difficulties relative
to the bacterial infection.
And as a
direct result of that, that would be the reason
why you are seeing the patient, not the
Patient medical and social history, you want
to know what happened to the
patient because you've got to know where they're
going from there.
Medical history is
extremely important in terms of have they
been intubated?
What kind of antibiotics
have they been on?
What did they come into the hospital with
and what's new today?
What about their social history?
Were they smokers?
Is the voice that you're hearing
relative to that or did something happen in
the time that they came into the hospital
the voice your hearing is wildly different?
Maybe they're a drug user, maybe they're
recently divorced, all of this goes into social
history, and that will help you understand
the patient.
And knowing that information will not necessarily
build rapport, but it will
keep you from miss-stepping in the clinic
room and asking questions that you probably
want to avoid.
Finally the medical plan, and that's everything
that's in the medical chart.
want to know what's going on with that patient
prior to walking into that room.
you don't want to be surprised with information
and then look like a deer in the
headlights with the patient telling you something
a little bit odd.
So, all of this goes into your medical chart
review, and ultimately it is but one
piece of the puzzle.
And what puzzle are we talking about?
That's the chart
Other pieces include the nursing interview,
the patient interview, and the
clinical assessment all four of those pieces
are what I would refer to as the clinical
presentation, keeping in mind that that chart
review is still one quarter of that
So you're completing a very important part
of this clinical presentation.
So let's talk about proficiency in the medical
chart review.
What does it take to
be proficient?
Well, not to sound a little bit trite but
an expert knows all of the answers,
but that's only if you ask the right questions.
And the reality is that you need to know
what you're looking for in the medical chart
which are your questions and which ones
that you can avoid.
So this is not based on data, but this is
based on years of
experience and talking about clinicians.
I put together this graph.
And on the bottom is
a combination of book knowledge and clinical
On the left side of graph or
the Y axis is the amount of information that
needs to be processed from medical chart
As you can see the first part of the graph
is typically the new clinician, whether
it's the student or the new clinical fellow,
this is the part that has an extremely steep
learning curve.
It's going to take lengthy periods of time
in order to go through the
medical chart in the way that you need to
relative to where is everything?
And in the
way that you need to, relative to the amount
of information that's there and what you
need to be able to process?
On the backside of the curve that's kind of
coming down from the yellow area and
the green area are the more seasoned clinicians,
the more experienced clinicians.
Where not only do they have the knowledge
to be able to parse the information, but
they've spent so much time that they can cut
straight to the chase.
So the learning
curve is considerably lower for them, the
time spent is considerably less than those
starting out.
But keep in mind that this is a process, and
it's not timed in any way.
So it
may take you a month to figure this out in
the facility you're in or it may take a year
figure it out.
And depending on the variety of your case
load your growth will change
relative to that.
Maybe you're quicker with some patients with
some diagnoses and not
others, ones that you're less familiar with.
Bottom line is being patient, and be tolerant,
but you'll ultimately learn those right questions
to ask.
While you're learning the right questions,
the one thing to keep in mind is another
approach, another philosophical approach.
And that's something called Ockham's
What's Ockham's Razor?
Well, I first learned about this from the
"Contact," if you've seen it, and it's very
simply: Among competing hypotheses — there's
that word again — that predict equally well,
the one with the fewest assumptions should
be selected.
Basically that's just fancy talk for the simplest
answer is probably the right
one, cut to the chase, get to the parts that
you need to in a very simple straightforward
You don't need to go digging.
So what about that electronic medical chart?
Is going paperless really more
Sometimes yes, sometimes no, and that depends
on where you are in the
First one is that there are multiple types
of electronic charts.
Some can be
therapy specific, others can be hospital unit
specific, and others can be still service-line
specific, meaning the in-patient versus the
So what are the purposes of the
electronic medical chart?
Of course we want to protect the patient's
So we don't
need paper flying around the hospital.
We don't need things that can be photocopied.
We don't need things that can be taken out
of the medical chart for convenience
because nobody likes writing on 3-ring binders.
So you may lose a page here or there.
Electronic medical records don't do that.
Anything that you start, it is a database,
there's no saving it per se, because it's
automatically saved.
There's a safeguard.
patient safety is protected by everything
that goes in the medical chart, stays in the
medical chart.
Communication of observations and plans, we've
spoken about that a little bit
earlier in this talk, it is the very same
thing as a paper medical chart.
It is a way to
communicate between the providers for that
And it's a good way of doing it.
a pretty quick way of doing it as well.
Because once it goes in, it's immediately
to every other person no matter where they
are in the hospital and sometimes even off
Billing verification, in most cases what's
going to happen is that you're going to
put a medical diagnosis, ICD-9 currently moving
to ICD-10.
You may have other codes
that you put in, but the bottom line is that
by the time that patient is discharged from
hospital, the medical records will be fully
available to the billing department.
And the
billing department is now going to match up
the amount of time that was spent with the
patient, with the patient diagnosis, and ultimately
what you stated in your medical
records, in your treatment and in your diagnostic
All of those need to line up in
order for those folks to do their job.
Finally it is a legal record, once again whether
it's electronic or it's on paper, the
electronic medical record or the medical records
broadly are legal documents.
are things that can be subpoenaed.
These are things that can appear in court's
of law,
for example during malpractice trials, so
be careful.
What you're looking at right here is an example
of a therapy medical record.
Now this particular system called MediLinks,
many of you may be familiar with, is very
typically the medical record system for physical
and occupational therapies as well as
speech language pathologists.
Only those folks typically enter information
into these
Ultimately because these are part of the electronic
medical record, the records
placed here are then transferred electronically
or pulled from this system into other
systems in the hospital.
Once they're pulled into these other systems
in the hospital,
the notes placed here for therapies, certainly
for billing and compliance and other
issues, are then placed in an area where all
providers will have access to them.
providers won't have access to this system.
It's simply an easy somewhat ubiquitous
way for therapists to put their notes in when
the other portions of medical record
systems are not available to us.
A second type of electronic medical record
is the unit specific or hospital unit
specific medical record.
These medical records are often relative to
They may
be related to step down units, maybe they
even got so far as the floor medical wards,
maybe even the in-patient rehab unit.
But the bottom line is that they're unit specific
meaning that everything that you look at within
this medical record is relative to the floor
you're on over the unit you're on.
And that doesn't matter what service you're
whether you're a therapist or you're a physician
or you're a nurse, all of the records will
be put here into one place.
And once you pull up that unit, you'll be
able to see all of
the patients on that unit, and then you'll
be able to go to the specific patient you're
interested in.
So that's a second way of taking a look at
the medical record that's in
some institutions.
A third way of taking a look at the electronic
medical record is the service line.
And that's the in-patient versus the out-patient
medical record.
Now here it gets a little
bit more interesting because sometimes what
happens on the in-patient side is edited.
And you may not necessarily see all of the
details that you normally would in the other
electronic medical records.
So what happens is, when you come into this
record, you'll see some in-patient records,
major records like discharge summaries,
maybe admission notes, things of that nature,
but you're not going to see for example
the flow sheets in an ICU on any given day.
Those will simply not exist in this kind of
medical record.
So you have to be aware of that before you
get into this medical
Now are those medical records still available?
They're just not
You may have to go back to the unit specific
and pull up historical information in
order to get it.
At least that's the way it's working in our
institution, maybe different than
In out-patient medical records I can't think
of an instance where a single
out-patient visit is not captured on this
type of medical record.
Meaning all out-patient
visits will be captured with this kind of
medical record.
So far I haven't seen anything
different and it works quite well.
So again you may want to figure out which
service line
you're interested in, what level of care you're
interested in, and definitely relative to
dates, because that's going to play a big
part in trying to find the medical records
you're interested in.
So let's summarize a little bit.
What have I gone over?
What are the take home
First and foremost, is to remind yourself
that learning is a process.
These are
things that are not going to happen overnight.
They're going to happen through a
period of time and through time things will
become a lot easier, but don't expect it to
happen right this minute.
Medical chart review assessment and treatment
are constantly evolving
processes, so be open to the changes that
occur, especially in the electronic medical
If anything is going to change more than anything
else, it's going to be
software upgrades, so be prepared.
Simple is generally better for everyone and
that includes everything regarding the
medical chart process.
And whether it's the information that you're
gathering or what
you put into the medical record, at the very
least what you want to do is be succinct and
be clear.
Simple is best and I promise you your notes
will be read a whole a lot easier.
So how do you do that in a fairly efficient
First one is to stay focused and
be disciplined.
The big issue here is that it's really tempting
to go off into different areas
of the medical record.
How neat is that that the patient had this?
And how cool is that
that I could learn someone new?
Well, that's not going to help your efficiency.
focused on the things that you need in order
to get out fairly quickly.
You want to do double duty by reviewing and
completing the medical reports at
the same time.
That is, if you're working in an electronic
environment, copy and paste
information from previous notes into your
current notes, no need to get creative here,
that's not the environment.
Simply copy and paste will take you a long
way, and it will
save you a lot of time.
Most computer operating systems allow for
So if you're familiar with
the ways that you can switch between screens
using either operating system or any
operating system, that will save you some
If you're at all able to on larger screens
put up two windows at the same time, that
will save you time instead of one screen
disappearing right behind the other.
So either way, the less clicks, the more efficient
you are.
Finally, here's a great pointer, but it's
going to take you some up-front time, and
that is create yourself some templates and
summaries for standardized tests and things
that you frequently use like goals and hierarchical
If you set those aside,
and make them readily accessible, and whether
it's on the computer that you're on and
using as a therapist, whether it's on the
unit computer and you may have to keep that
some corner of that computer, or maybe it's
just a simple thumb drive, keep those
available to you, because copy and paste,
as I said, is your friend.
You might as well
take the stuff that you had the time to think
about to be able to put them into the medical
I have offered you an appendix that will give
you some idea as to how to
approach these patients and I offer you any
opportunity to E-mail me if you have
questions, I'll be happy to take those as
Thank you so much for attending this presentation,
and I wish you the best of
luck in reviewing the medical chart.

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