Medical Record Format

Medical record format refers to the organisation of forms within the medical record. Medical records have been kept in a variety of ways since the beginning of modern medicine. Physicians in the 1880s kept all their patients’ records in a personal leather-bound ledger. In 1907, this was replaced by patient-based records. Documentation can take many forms, including: source-oriented medical records, narrative charting, problem-source-oriented medical records, progress notes, focus charting, charting by exception (CBE), graphs, photographs, videotapes, audio tapes, drawings and physical specimens (International Federation of Health Information Management Association, 2012, Quinn and Gordon, 2010). Each rehabilitation service may have its own method of maintaining patient records. These documentation systems can be implemented using traditional paper forms or electronic medical records. The next sections of this part of the

literature review will discuss the most commonly used documentation formats in detail. These will include: source-oriented medical records, narrative charting, problem-oriented medical records and progress notes.

2.3.6.1. Source-Oriented Medical Records

Source-oriented records are considered to be traditional client records where the record is organised into sections according to the patient's care departments which provide the care. Each therapist makes notes in a separate section or sections of the patient's medical record. Within each section, the forms are arranged according to date. On discharge, the information in each section is normally filed in strict chronological order. In this type of record, information about a particular patient problem is distributed throughout the medical records. For example, if a person had right hemiplegia (paralysis of the right side of the body), this information can be found in different sections of the medical record

Narrative charting is a traditional part of source-oriented records. It is one of the most commonly used approaches in healthcare professions including physiotherapy documentation, resulting in the chronological ordering of the healthcare provided. This method consists of straightforward documentation consisting of written notes that include regular daily care, normal findings, the patient's problems, interventions performed, and the patient’s response to those interventions.

There is no right or wrong order to the information, although a chronological order is frequently used.

However, it remains questionable how effective narrative charting and source-oriented records are as a communication tool, and whether the information stored is easily and readily retrievable.

Although the narrative notes format gives the therapist the freedom to describe or explain the rehabilitation process and activity in as much depth and detail as they desire, the challenges to and disadvantages of narrative documentation are numerous (Byrne, 2012). The challenges include issues such as ambiguity of expression, lack of structure in the data entered in the medical record, redundancy in care capture, a host of transcription and cognitive errors, and limited opportunities for aggregation or reuse in databases or by clinical decision-support systems.

Narrative charting often becomes bulky, disorganised and scattered during the rehabilitation process without making reference to the condition or problem to which it refers, thus hampering communication between healthcare providers and making the retrieval of vital information very difficult (International Federation of Health Information Management Association, 2012). It has also been reported that narrative notes introduce a great deal of opportunity for confusion about what is being expressed. Human expression can increase the risk of error and miscommunication in a healthcare setting, where concise and timely communication between therapists is very important (Byrne, 2012). The use of structured or standardised terms in a flow sheet or template can mitigate some of these problems (Byrne, 2012).

Nurses have recently replaced the narrative recording by other more structured systems, called focus charting. Focus charting is another method of documentation which is based on open text notes whereby all information is typically organised by keywords listed in columns. Therapists have the flexibility to choose the keywords, which may be a patient’s problems, signs or

symptoms, a specific patient behaviour and/or the patient’s progress. In one column the therapist writes a keyword and in the next column there is a detailed note about this topic. Although this method is sometimes very complex, it has been reported that it requires less written notation than other methods. Some therapists believe this method of charting makes it easier to document the true rehabilitation process (Manning, 1997) as, to some extent, it has a structured format since the data are organised in the chart according to focus and it is flexible enough to adapt to any clinical practice setting and promotes interdisciplinary documentation. However, the documentation style in focus charting is not monitored and the therapist can easily revert to narrative documentation (Hafernick, 2007).

In conclusion, source-oriented records offer a convenient method for keeping medical records since healthcare providers from each discipline can easily locate the sections in which to record

data and it is easy to trace the information specific to one’s own discipline. However, the disadvantages of this method are that the medical record becomes bulky, disorganised and unstructured and information about a particular patient problem is scattered throughout the file, so it is difficult to find chronological information about a patient’s problems and progress. This has been reported as potentially affecting both communication and coordination among

therapists (LaTour and Eichenwald, 2002).

2.3.6.2. Problem-Oriented Medical Records (POMR)

According to Sames (2009) the problem-oriented medical record (POMR) was introduced in the 1968s by Prof. L Lawrence (Sames, 2009). Weed (Weed, 1969) was trying to improve the

structure and incompleteness of patient records. Weed proposed separating a patient’s record into problems, to give a number and name to each problem, and to record progress notes and care plans under the same problem number and name. A POMR documents the data in an easily accessible way that promotes the on-going assessment and revision of the healthcare plan by all members of the healthcare team. It provides a systematic method of documentation in the medical field which reflects the logical thinking of healthcare providers. Compared to the source-oriented record, the POMR is more structured and less scattered (Sames, 2009). The restricted format of the POMR offers better organisation of medical records which makes this method of

documentation useful as a management tool for patient care and to evaluate the service. The POMR has gained acceptance in most rehabilitation centres. It has been suggested that this method could become the standard type of record keeping in most hospitals. The POMR formats used vary from place to place, but the components of the method are similar. It begins by

building a database about the patient’s problem which can be collected from either the patient or his/her carer, or via health assessment and/or physical examination, and all other possible

resources of information (Borcherding and Kappel, 2006). Once all the information is collected, a

problem list will be created. Each identified problem represents a conclusion or a decision resulting from examination, investigation and analysis of the database. This step is followed by a treatment plan, in which each separate problem is named and described, usually in the progress notes via a method which focuses on providing a structured format such as the SOAP format, where: S, subjective data describe what the patients complains of from his/her point of view; O, objective data describe what the physiotherapist or other therapists actually see, touch or feel by inspection, percussion, auscultation and palpation; A, assessment of the problem that is an analysis of the subjective and objective data; and P, plan of action, including the proposed interventions to solve the problem (Borcherding and Kappel, 2006, Sames, 2009). The level of ability & consistency of SOAP formats may however vary between the therapists and

maintaining a well-ordered up to date problem list takes time to review (Borcherding and Kappel, 2006). Although the POMR offers simplicity of progression through the data, which makes it quicker and easier to find the information needed from the medical record, it forms a bulky medical record system in use. For example, each problem requires a separate SOAP entry even though there may be an overlap between problems. Moreover, to consider a single problem in a consultation is rare. Many different issues may be discussed within a single consultation and sometimes information may legitimately belong under more than one problem heading, so either data will be recorded twice or missed between headings (Badia et al., 1999).

2.3.6.3. Progress Notes

The documentation of an individual physiotherapy session is often called a progress note.

Producing a progress note is the process of documenting the sequential implementation of the treatment plan established by the physiotherapist, including changes in patient status and the progress in any interventions made. The progress note might also contain specific plans for the next treatment session or visit (British Society of Rehabilitation Medicine, 2003).

According to Mann & Williams (2003), Tunbridge, in 1965. took the first major step to

standardise medical records in the UK (Mann and Williams, 2003). This publication resulted in some of the standard hospital medical records forms that we use today. Since then, researchers and commissioners have emphasised service to improve the standardisation of medical records (Mann and Williams, 2003).

There is currently a major drive to develop and improve the documentation process across the UK (NHS Information Authority and Welsh Assembly Government). Wyatt and Wright (1998) argued that structured records are easier and quicker to search and can therefore improve decision-making, but they have the disadvantage of being more difficult to write (Wyatt and Wright, 1998). However, some have found no significant difference in the time taken to complete structured proformas and free-text history sheets (Belmin et al., 1998). Structured medical

records have been reported to improve the continuity of care and make it easier to extract and summarise information (Brazy et al., 1993).

The British Society of Rehabilitation medicine has emphasised the importance of having a standardised, single and collaborative recording system in all in-patient rehabilitation settings in which all members of the team record their interventions (British Society of Rehabilitation Medicine, 2003). It has been reported that collaborative notes help to facilitate the continuity of patient care by serving as a vehicle for communication between the therapy team and help to evaluate, plan and monitor patients’ care plans (Salter et al., 2006). Although the British Society of Rehabilitation medicine (2003) has recommended the use of multidisciplinary notes within the inpatient rehabilitation service, not all rehabilitation services are actually using collaborative notes. Turner-Stokes et al. (2001) conducted a study on behalf of the British Society of Rehabilitation medicine (BSRM) amongst its consultant members who were providing a

rehabilitation service for ABI patients in the UK. Consultants were asked to assess their service in

relation to the BSRM standards. The result showed that only twenty-three consultants out of fifty (46%) used a multidisciplinary record system in their rehabilitation centres (Turner-Stokes et al., 2001).