The Medical Record - OMS
The Medical Record - OMS
The Medical Record - OMS
Learning Objectives
Key Terms
Drug-related problems
History and physical (H&P)
Problem list
Introduction
As pharmacists continue to increase their involvement in patient care activities,
their ability to navigate the often murky waters of the medical record becomes
even more crucial. Locating vital pieces of information is critical to developing an
appropriate assessment and plan for the individual patient. Additionally, collecting
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this data in a systematic way will permit the pharmacist to then synthesize it and create
acomprehensive list of healthcare needs and considerations for the patient, regardless
of the practice setting.
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Medical History
The medical history, or H&P, includes the following components:
Patient demographics. This section includes the patients name, birth date,
address, phone number, gender, race, and marital status and the name of the
attending physician. This section may also include the patients insurance information, pharmacy name and phone number, and religious preference.
Chief complaint (CC). The chief complaint is the primary reason thepatient
ispresenting for care. Often expressed using the patients own words, it includes
the symptoms the patient is currently experiencing. At times the CC is not
really a complaint at all; the patient may be presenting to thepharmacy
to have a prescription filled or may be coming to the clinic for an annual
physicalexam.
History of present illness (HPI). The history of present illness expands upon
the CC, filling in the details regarding the issue at hand. The HPI is typically
documented in chronological order, describing the patients symptoms in detail
as well as documenting related information regarding previous treatment for
the CC, previous diagnostic test results, and pertinent family and social history.
Additionally, pertinent negative findings are located in the HPI; these include
symptoms the patient is not currently experiencing that provide more information on the case (e.g., a patient presenting with vomiting who notes that he does
not have abdominal discomfort).
Past medical history (PMH). The past medical history includes a list of past
and current medical conditions. Past surgical history (PSH) is often included
within the PMH, as are previous hospitalizations, trauma, and obstetrical
history (for female patients).
Family history (FH). The family history includes descriptions of the age, status (dead or alive), and presence or absence of chronic medical conditions in the
patients parents, siblings, and children.
Social history (SH). This section includes a large amount of information
regarding the patients lifestyle and personal characteristics, including the
patients use of alcohol, tobacco, and illicit drug use, each documented as
type, amount, frequency, and duration of use. The social history also includes
descriptions of the patients dietary habits, exercise routine, and use of caffeine as well as years of education, occupation, marital status, number of
children, sexual practices and preferences, military history, and current
livingconditions.
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Examples of Contents
General
Skin
Head
Eyes
Ears
Nose
Mouth
Throat
Neck
Respiratory system
Shortness of breath, dyspnea, wheezing, cough (dry vs. productive), orthopnea, hemoptysis
Cardiovascular system
Gastrointestinal system
Genitourinary system
Nervous system
Musculoskeletal system
Neuropsychiatric system
Endocrine system
however, the most current and complete results are usually located in a computer
database. Additionally, practitioners H&Ps may include documentation of initial lab
results. However, it is important to view the actual results for oneself, because it is
easy for an error in transcription to occur. Similarly, practitioners may omit some
results from the H&P documentation for the sake of brevity; again, viewing actual
results on a computer system will permit a complete review of data.
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Problem List
The problem list notes, in decreasing order of priority, the issues that require management in the individual patient. The number one need on the list is the working
diagnosis that matches the signs and symptoms with which the patient has presented.
For example, a patient presenting with chest pain who is diagnosed with a ST segment
elevation myocardial infarction will have STEMI listed as the healthcare need of
highest priority on the list. Alternatively, a patient presenting to a community pharmacy with a prescription for an antihypertensive medication for newly diagnosed
hypertension may have initial treatment for HTN as the number one need on the
list. Subsequent healthcare needs or problems are listed in descending order of priority or severity; these typically include chronic medical conditions contained within the
PMH, abuse of substances noted in the social history, drug-related problems identified
with current or past medications, laboratory or diagnostic test abnormalities identified
upon admission, and so on.
Numerous practitioners will document problem lists within the medical record.
For an inpatient, the admitting practitioner, nurse, pharmacist, nutritionist, respiratory therapist, and physical therapist may each have their own prioritized list of needs
within the chart, overlapping in some ways and unique in others. From these, it is
possible to create a comprehensive list that addresses all of the issues at hand. For an
outpatient, the attending practitioner may develop a list at the end of his or her note,
addressing those issues of highest priority. For both inpatients and outpatients, practitioners will often document their plans for each need, including a differential diagnosis, treatments being considered or administered, and a plan for patient education.
Regardless of location, it is important to note that the problem list is dynamic.
It can change from day to day for an inpatient or from visit to visit for an outpatient. This is anticipated because patients diagnoses and individual characteristics can
change quickly, especially in the acute setting. Later in this chapter we will review
how to develop a comprehensive problem list that includes drug-related problems.
Clinical Notes
The inpatient paper chart often gets thick with the many types of clinical notes written by the numerous practitioners caring for the patient. The resident and attending
physician will write daily progress notes that document an updated and abbreviated
H&P, problem list, and plan. Other specialists (e.g., cardiologist, gastroenterologist)
will also document their findings in daily progress notes following their initial consultation notes. For example, a patient with a history of atrial fibrillation and coronary
artery disease may have a cardiologist following his case; the impressions of this specialist are communicated to the patient care team via daily progress notes focusing on
the patients cardiac issues.
Nurses maintain their own clinical notes within the computer system or on a bedside chart. Often these include documentation of vital signs, pain assessments, patient
activities (e.g., out of bed to chair, bathroom visits), and quantity of fluid a patient
ingests and excretes (e.g., ins and outs). Additionally, if there is a change in care, such
as movement from the intensive care unit (ICU) to the general medical floor, transfer
notes are written by the physicians and nurses to smooth the transition between care
teams. Similarly, if a practitioner is no longer going to care for a patient, for example,
due to a vacation or time away from the hospital, he or she will write an off-service
note to assist the successor practitioner in the transition of care. All of these notes
areuseful summaries of the diagnostic methods used and treatment provided prior to
the occurrence of the transfer.
Lastly, a discharge summary provides a snapshot of the patients hospital course,
including a healthcare needs list and treatments provided, as well as a plan for future
follow-up and a list of discharge medications. This is combined with discharge paperwork from the nursing and pharmacy staff that includes educational information provided to the patient, such as medication leaflets and postdischarge instructions (e.g.,
wound care directions, date of follow-up appointment with primary care physician).
Outpatient medical records typically include notes from all office visits. Additionally, any clinical notes from hospitalizations are often copied and placed in the paper
chart or are scanned and placed in the electronic medical record to permit continuity
of care.
Treatment Notes
Treatment notes are utilized most frequently in the inpatient setting. Treatment notes
include medication orders, medication administration records (MARs), documentation of surgical procedures, and documentation of services such as radiation therapy,
physical therapy, occupational therapy, respiratory therapy, and nutrition. All of these
areas of the chart are important to review, because each provides details regarding
the execution of the patients treatment plan. Medication orders can be transcribed
bythe practitioner onto a paper order form; these can then be faxed, scanned, or copied
and sent to the pharmacy for processing and filling. Alternatively, the practitioner may
enter the medication orders directly into the computer system using computerized
prescriber order entry (CPOE, discussed below); the orders are then reviewed and
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processed by the pharmacist. The orders section of the chart may also contain orders
from other practitioners, including physical and occupational therapists, respiratory
therapists, and nutritionists. Rationale for these orders can be found in the treatment
notes section for each of these practitioners. This provides insight as to the patients
entire problem list, because these practitioners play important roles in managing various healthcare needs on the individual patients list.
Medication administration by nurses and other practitioners (e.g., respiratory
therapists, physical therapists) is documented via MARs. These can be paper-based
or electronic (eMAR) and permit one to view the dates and times of all medications
administered to the patient as well as documentation of missing or refused doses.
electronic laboratory result data is shown in Figure 2.2. It is important to note that
although an institution may utilize an electronic system, not all of the data available
in that institution may be recorded electronically; data that are only recorded in
paper format despite the presence of an electronic system should be identified.
In addition to maintaining the patients permanent record, inpatient systems may
record medications as they are administered to the patient, thereby maintaining an
interactive patient eMAR. Figure 2.3 presents a screenshot of a sample eMAR. In the
outpatient setting, similar technologies can facilitate sharing of patient and electronic
transfers of medication prescription requests. For example, prescription requests,
along with supportive data, may be transferred electronically to a pharmacy. Limitations to implementation of such software in healthcare institutions tend to include
cost, workflow support, training, and organizational factors.5 Paper-based records
should offer the same data recorded as the electronic medical record.
Patients are permitted to receive copies of their medical records, but the procedures for this must be set forth by the healthcare institution in accordance with state
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and federal law. Typically, patients can review their medical record in the medical
records department of the institution or receive results of laboratory and diagnostic
testing from their physician.3
Pharmacists can follow a number of steps to prevent improper disclosure of medical information, thereby preventing legal consequences and fines:
Providers should keep clipboards and folders containing patient information
with them at all times and/or in a secure area (e.g., in a locked file in the pharmacy department).
Providers should follow the institutions policies for retaining and discarding
health information. This may involve storage of information in locked cabinets
and shredding materials when they are no longer needed.
Providers should sign off of the computer system when they are finished using
it. Applications with patient information should never be left open, even if the
provider just gets up for a minute to answer a phone or to use the restroom.
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Data collection methods may vary between pharmacists or clinical sites; however,
they share the common goal of allowing a consistent review of a single patient or
multiple patients at once. This approach usually involves the use of a paper-based or
electronic form that has enough space to include all of the relevant material that the
pharmacist may need to collect. These forms are often developed or tailored to meet
the needs of a specific pharmacist with a designated set of patient care responsibilities
and may be formatted to mirror the order in which the pharmacist will either collect
or interpret the data.
The benefits of a systematic approach are numerous. First, it allows the pharmacist to routinely organize information pertinent to the pharmaceutical care of the
patient in a consistent manner. Second, systematic data collection allows the pharmacist to maintain a process during which potential drug-related problems may be
evaluated. Third, this approach allows for ease of patient care pass-off should the
pharmacist transfer care of a patient to another pharmacist. Additionally, the pharmacists collected data may become a resource for reporting on patient care during
rounds, facilitating discussion with other healthcare practitioners, or documenting
clinical interventions.
Age:
Weight:
Height:
Allergies:
Chief complaint:
History of present illness:
Past medical history:
Social history:
Family history:
Home medication and
dose:
Route:
Frequency:
Frequency:
Indication:
Physical exam:
ROS:
Laboratory data and serum concentrations:
Current medication
and dose:
Problem list:
Route:
Patient plan:
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Datacollection forms are heavily influenced by the manner in which the pharmacist is
likely to assess the patient; therefore, the format and data vary based on the type of practice setting or provider service. Several factors may play a guiding role in the decision to
use a particular type of data collection form, including the clinical setting (e.g., inpatient
or outpatient), the role of the patient care team (e.g., primary team or consult service),
or the specific task presented to the pharmacist (e.g., assessment ofafocused problem or
a generalized workup of the patient). Regardless of the nuances among data collection
forms, applying a systematic method of data collection from apatients medical record
is key to ensuring consistency in the approach, assessment, and plan for each patient.
Pharmacy-Related Components
of the Patient Medical Record
A critical skill for the efficient pharmacist is to review the data with several key
harmacy-related aspects in mind; this will permit concise data collection while providing
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the pharmacist with adequate information to develop recommendations to optimize
pharmacotherapy. Depending upon the patient care responsibilities of the individual
pharmacist, the pertinent pharmacy-related components of a patients chart may vary.
For example, an infectious diseases clinical pharmacist may dive right into the chart to
seek out antibiotic orders and laboratory data for serum drug concentrations and renal
function assessments, whereas a cardiology pharmacy specialist may initially search for
blood pressure values from the physical examination in order to assess the effectiveness of
a patients antihypertensive drug regimen. Regardless of specialty or focus, several general
pharmacy-related components are contained within each portion of the medical record.
Medical History
The medical history (H&P) is a key area for identifying drug-related problems, which
will be discussed at length in the final section of this chapter. Thus, the majority of
information contained within the H&P is valuable in developing an assessment and
plan for interventions to optimize pharmacotherapy. The pharmacist may find data
lacking in some areas, which will require clarification via additional patient interviewing. For example, a patients chart may indicate an allergy to penicillin, but the specific
reaction not be identified. The pharmacist can then question the patient to obtain and
document this important piece of information. Similarly, components of the medication history may not be complete. For example, the H&P may note a medication list
without doses or frequency of administration. The pharmacist can question the patient
and even contact the patients pharmacy to obtain this information for documentation
in the chart and on the pharmacists data collection form.
Additionally, physical findings may be germane to assessing the patients response
to medications that are either missing or not documented in the chart. These require
the pharmacist to perform the appropriate assessment technique to obtain and document the finding. For example, the physical examination of a patient who presents
to the hospital with nausea and vomiting resulting from phenytoin toxicity should
note the presence or absence of nystagmus, a finding associated with supratherapeutic serum concentrations of the drug. If this information is not found in the medical
record, the pharmacist should perform the appropriate assessment (in this case, the
Htest to assess for nystagmus) and document the finding accordingly.
Throughout the H&P, the pharmacist can identify pertinent positive and negative components that are key to the development of an assessment and plan. This
becomes especially important when gathering data from the HPI, ROS, and PE. The
importance of pertinent positives can be easily rationalized, while pertinent negatives
are not so obvious. For example, if the family history of a 39-year-old man presenting
to the emergency department with a myocardial infarction indicates no family history
of coronary artery disease, it is a pertinent negative fact to note on the data collection form, because it might be expected that someone in the patients family would
have preexisting cardiac disease. Another example would be a patient presenting with
pneumonia who has no shortness of breath (SOB). The pharmacist should document
no SOB in the ROS of this patient, because it is a pertinent finding for this patient.
A large majority of the H&P is relevant to the pharmacists data collection.
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Missing Details
Details are often missed during the documentation of the PMH. For example,
apatient who is HIV positive should have the year of diagnosis and the most recent
viral load and CD4 T-cell counts listed. The chart of a patient with diabetes, for
example, should have the type of diabetes documented (i.e., type 1 or type 2) as well
as any associated complications (e.g., diabetic retinopathy, neuropathy, nephropathy).
If these clarifying details are missing, they can often be located in other areas of the
chart, including H&Ps from previous admissions or visits, previous lab studies, and
even from interviewing the patient.
Conflicting Information
Conflicting information may become an issue when multiple practitioners perform
H&Ps on the same patient. For example, the PE performed by the medical student may note that the patients breath sounds are clear to auscultation bilaterally,
whereas the resident physician has documented rales and rhonchi in the left lower
lobe of the lung. Clarification of conflicting information may require reviewing further information in the chart in addition to speaking with the team of practitioners
taking care of the patient. Additionally, the pharmacist may interview the patient
and perform a physical assessment of the patient to determine a resolution for the
conflicting information.
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adifferent medical floor or a medical library, will permit review of electronic information in a timely manner. It may also be helpful to perform reviews of medical records
at off hours on the patient care floor, such as very early or late times of the day or
during resident physicians mandatory conferences, because the demand for charts and
computers is often lower at these times. Once gathered on a data collection sheet, the
pharmacist can synthesize all of the key pieces of information in the medical chart to
develop a comprehensive healthcare needs list.
Disease States
Often referred to as medical problems, the disease states a patient has should be included
in the healthcare needs list. These are often derived from acute diagnoses, as in the
case of a patient in the hospital setting, and from the PMH. Practitioners such as physicians, physician assistants, and nurse practitioners are the primary caregivers who
diagnose and document these disease states in the medical record. Examples of disease
states include hypertension, hyperlipidemia, otitis media, andCAP.
Drug-Related Problems
Drug-related problems (DRPs) are events or issues surrounding drug therapy
that actually or may potentially interfere with a patients ability to receive an optimal therapeutic outcome.6 DRPs are separate entities from a patients specific disease
state. Inpractice, the pharmacist can help determine the presence of actual or potential DRPs. Any observed DRPs should be added to the patients healthcare needs list
and ultimately serve as the foundation for the pharmacists assessment of the patient.
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Preventive Measures
Healthcare professionals additionally take action to prevent illness. This often takes
the form of health maintenance actions, such as administration of routine immunizations (e.g., influenza, pneumococcal), and patient education, such as smoking cessation
counseling. Also included in this category are prophylactic measures against acute illness, including deep vein thrombosis prophylaxis and stress ulcer prophylaxis, each of
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Case Study
Consider the following case study and the pharmacists development of an appropriate
problem list.
CC: I am so dizzy and confused!
HPI: ZZ, a 40-year-old man, is brought to the emergency department by his wife on a December
morning. ZZ complains of increasing dizziness, lethargy, and confusion over the past 3 days. He
also describes diplopia for the past day. ZZs wife notes that ZZ can barely walk in a straight line.
PMH: Seizure d/o x 15 years, HTN
FH: NC
SH: Does not smoke, no ETOH use, lives at home with wife, works in construction operating a
bulldozer
ALL: PCN (hives)
Meds PTA: Phenytoin 300 mg PO 3 times daily; HCTZ 25 mg PO daily; ibuprofen 800 mg
PO6 times daily as needed for headaches
ROS: + for dizziness, confusion, lethargy, diplopia, nausea; for vomiting, diarrhea
PE:
VS: 110/70, 98.5, 99, 14, 67 inches tall, 60 kg
HEENT: PERRLA, + nystagmus, MMM
Neck: Supple, no JVD, no LAD
Lungs: CTA bilaterally
Heart: S1S2, no m/r/g
Abd: NTND, + BS
Neuro: + Romberg, A&O x 1, CN assessment not performed due to patients inability to follow
directions
Rectal: Deferred
LAB: Na 138; K 3.7; Cl 100; CO2 25; BUN 10; SCr 1.1; Glu 94; AST 19; ALT 20; Tbili 1.0;
albumin 4.0; phenytoin 35 mg/L; CBC: pending
Chapter Summary
Problem List
Type of Problem
Drug-related problem
(adverse drug reaction/wrong
dosage)
Seizure disorder
Disease state
Hypertension
Disease state
Influenza immunization
Preventative measure
Based on the pertinent information from the H&P and reviewing the information
closely for DRPs using the method described in Table 2.4, the pharmacist caring for
ZZ has developed a problem list documented in order of priority from most clinically
significant to less clinically significant (Table 2.5).
Chapter Summary
Although it is easy to become overwhelmed by the voluminous amount of information available in the patients medical record, it is important to gain perspective on the
components of the medical record, whether it is available electronically, on paper, or
both. It is important to develop a strategy for collecting data and identifying the pieces
of information that are critical to the creation of a problem list. Additionally, the stepwise approach to developing a problem list that includes the drug-related problems
presented in this chapter will allow you to efficiently prioritize the issues that impact
your patient. This can then be taken to the next level through provision of pharmacotherapeutic recommendations to the prescriber in order to optimize drug therapy
and outcomes.
Take-Home Messages
It is critical to develop a systematic approach to gathering and documenting
patient information from written and electronic medical records. Becoming
comfortable with a consistent data review format will assist in efficient data
gathering.
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As you become more and more familiar with the key pharmacy-related components of the medical history and physical examination, you will find it easier to
navigate the chart to obtain the information you need.
Be sure to follow an organized method for identifying each of your patients
problems. Utilizing the steps to recognize drug-related problems will allow
you to easily identify issues that should be noted on your patients problem list, in addition to their medical problems and potential preventative
measures.
Review Questions
1. What are some challenges that arise when searching for information in the
medical record?
2. What is the difference between clinical notes and treatment notes?
3. What are some ways that information can be systematically collected from
a patients medical record for the purposes of developing an assessment
andplan?
4. What are key pieces of information that should be gathered from the H&P in
order to identify drug-related problems?
5. What are some ways in which drug-related problems are utilized to create a
pharmacist-driven problem list?
References
1. Jones RM. Health and medication history. In: Jones RM, Rospond RM. Patient assessment in
pharmacy practice. 2nd ed. Philadelphia; Lippincott Williams & Wilkins; 2008;2638.
2. LeBlond RF, DeGowin RL, Brown DD. History taking and the medical record. In: LeBlond
RF, DeGowin RL, Brown DD. DeGowins diagnostic examination. 9th ed. New York: McGrawHill; 2009;15133.
3. Barker BN. Security and privacy considerations in pharmacy informatics. In: Fox BI, Thrower
MR, Felkey BG. Building core competencies in pharmacy informatics. Washington DC: American
Pharmacists Association; 2010;423442.
4. Thrower MR. Computerized provider order entry. In: Fox BI, Thrower MR, Felkey BG.
Building core competencies in pharmacy informatics. Washington DC: American Pharmacists
Association; 2010;183197.
5. Nicoll CD, Pignone M, Lu CM. Diagnostic testing and medical decision making. In: McPheeSJ,
Papadakis MA. CURRENT medical diagnosis and treatment 2011. New York: McGraw-Hill
Medical; 2011. Available at: AccessMedicine.com/CMDT. Accessed January, 2013.
6. Strand LM, Morley PC, Cipolle RP, et al. Drug-related problems and their structure and function. DICP, Ann Pharmacother. 1990;24:10931097.
References
7. Rovers JP. Identifying drug therapy problems. In: Rovers JP, Currie JD. A practical guide to
pharmaceutical care: A clinical skills primer. 3rd ed. Washington DC: American Pharmacists
Association; 2007;2345.
8. Cipolle RJ, Strand LM, Morley PC. Drug therapy problems. In: Cipolle RJ, Strand LM,
Morley PC. Pharmaceutical care practice: The clinicians guide. 2nd ed. New York: McGraw-Hill;
2004;171198.
9. Kane MP, Briceland LL, Hamilton RA. Solving drug-related problems. US Pharm. 1995;20:5574.
10. Jones RM. Patient assessment and the pharmacists role in patient care. In: Jones RM, Rospond
RM. Patient assessment in pharmacy practice. 2nd ed. Philadelphia: Lippincott Williams & Wilkins;
2008;211.
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