Hybrid Patient Care Records

All patients’ charts flow from the patient registration/admission process. The type of patient record that is produced depends on the clinical information system the hospital uses, the level of electronic health records adopted, and even the department or type of admission. Patient records may be fully electronic or hybrid, using both electronic portions and paper-based portions.

Hybrid Records—Care of the Physical Chart

With hybrid charts, the electronic chart (e-Chart) portion is stored electronically in the clinical information system while the physical chart (p-Chart) is stored at the communication centre in a designated chart area. With hybrid charts, it is the HUC’s role to:

• create the initial p-Chart (includes labelling the exterior and adding and physically labelling the required paper chart forms for the type of admission with pre-printed patient labels),
• file patient records/reports in the p-Chart,
• maintain the p-Chart by adding additional chart forms when required or thinning the p-Chart when it becomes too cumbersome, and
• dissemble the p-Chart to send to the health information management (HIM) department for processing when the patient is discharged home or to another facility, or expires.

Physical charts are often housed in three-ring binders and arranged on a chart rack in the unit by room number instead of alphabetically to facilitate ease of removal and replacement in the corresponding chart slot.  Most p-Charts have a plastic exterior sleeve for identification, which typically includes an initial, last name, bed number, and doctor’s name. No diagnoses should even be indicated on the outside of a physical chart.

An inpatient p-Chart has several sections within, which are arranged in universal order, which allows for quicker filing and access to records. Health information in each of these sections is arranged in “reverse chronological” order, which means that the most current information is at the top of each section.

Regardless of whether the hospital is using a hybrid system with a p-Chart or a stand-alone e-Chart, the HUC may expect to see the same type of patient care forms or sections. Some common types of chart forms in a standard inpatient medical chart and inpatient surgical chart are outlined below.

Inpatient Medical Chart Forms

• Face sheet/Admission record
  • This initial record produced from the registration process summarizes the relevant demographic, clinical, and financial information for the patient encounter. The record is the “face” of the chart, arranged at the start of the physical record. Upon discharge, the physician must document key facts of the stay on this record.
• Advance directives
  • This legal document communicates a person’s wishes about health care decisions in the event they become incapable of making health care decisions (either permanently or temporarily). There are two basic kinds of advance directives: living wills and health care powers of attorney.
    • Living wills express a person’s instructions or preferences about future medical treatments, particularly end-of-life care, in the event the person loses the capacity to make health care decisions.
    • Health care power of attorney appoints a person (called a POA) to make decisions for them in the event of incapacity (temporary or permanent) to make health care decisions.
  • If a patient presents to the hospital with an advance directive, the HUC should make a copy of this document and return the original to the patient. If a patient does not have an advance directive upon admission, it may be hospital policy for the patient (and/or their family) to complete a form outlining their preferences for end-of-life care (Sabatino, 2021).
• ER record
  • This form, resulting from a patient’s visit to the emergency department, documents the care received during their emergency stay. If a patient is discharged from the ER, this record is the single record of their encounter. If a patient is admitted to an inpatient unit, this document will become part of their inpatient chart. When receiving an admission from the ER, the HUC should review the ER record for any outstanding physician orders which need to be processed.
• Drs. order sheet
  • This form is where physicians record all orders related to the patient. Two types of paper-based “doctor’s orders” sheets are common:
    • Blank record where the physician handwrites in all their orders for the patient (typically used when orders are very specific to a patient).
    • “Pre-printed” order sheet where a physician must fill in blanks or tick off boxes besides interventions they wish to order. These are typically used for standard procedures such as knee replacement (Thompson, 2018).
• History and physical
  • This dictated formal transcription report results from the physician’s interview with the patient, the physical exam, and the summary of the testing either obtained or pending. In a hospital, the H&P result should be dictated within 24 hours of admission. If a patient is a surgical patient, the H&P must be on the physical chart or EMR prior to the procedure. The H&P should include
    • Chief complaint history of present illness
    • Past medical & surgical history, personal/social history
    • Family history
    • Drugs on admission
    • History of allergies (if any)
    • Systems review
    • Physical examination
    • Diagnostic impression. (South Shore District Health Authority, 2007).
• Progress record
  • This record is the main form of communication between physicians and other staff. The physician typically documents on this record after each interaction with the patient, outlining their progress, prognosis and plan of treatment. Progress notes should be written as events occur to give a chronological report of the patient’s progress and should be sufficient to describe the changes in the patient’s condition and the outcome of treatment. A minimum standard for written progress notes by the MRP is daily for acutely ill patients and at least once every 3 days following an acute illness. Each progress note must be dated and signed by the physician (South Shore District Health Authority, 2007).
• Consultation record
  • This record documents a second physician’s written opinion based on an examination of the patient and a review of the patient’s health record. This is a form on which a specialist who is asked to provide a consult for a patient would document their assessment, findings, and medical opinion (South Shore District Health Authority, 2007).
• Diagnostic imaging report
  • This refers broadly to reports from tests completed in the hospital’s diagnostic imaging department. These reports may be further broken down into x-ray reports, ultrasound reports, nuclear medicine reports, mammography reports, MRI and CT reports, etc.
• Lab report
  • This refers broadly to all tests completed in the hospital’s laboratory. These may be further broken down into biochemistry reports, microbiology reports, hematology reports, pathology reports, etc.
• ECG report
  • These are the reports resulting from electrocardiograms. An ECG report may include a visual tracing as well as a dictated report once the tracing is read by a cardiologist (Thompson, 2018).
• MARs
  • These are the forms that nurses document all medications given to a patient. MARs (medication administration records) may be electronic or paper-based. Paper-based MARs vary in length of use, usually from 1 to 7 days. In some areas, it may be part of the HUC’s role to transcribe all medications ordered by the physician to the MARs (Thompson, 2018). When MARs documentation is restricted to initials only, a separate signature sheet may be required to record full names and designations.

Inpatient Surgical Chart Forms

In addition to the above records, the surgical chart will also include the following records:

• Consent form
  • This is the written form a patient signs before a surgical procedure. In many areas, the HUC prepares this form, outlining the physician’s name and the full surgical procedure. This may also be called a “verification of procedure” form.
• Pre-anaesthetic questionnaire
  • This questionnaire is completed by the patient/patient’s family prior to the surgical procedure. In the case of elective surgery, this form is provided to the patient by the surgeon’s office, and the patient brings the completed form to their pre-surgical clinic visit or with them on the day of surgery. Emergent surgical patients will be given this form to complete in the nursing unit.
• Anaesthetic record
  • This record is the main document of the intraoperative course of anaesthesia administration. This record is completed by the anaesthetist throughout the operative procedure, who documents the anaesthetic given and the physiologic responses of the patient (Schwartz, 2016).
• OR checklist
  • This form assists nursing staff in preparing the surgical patient for their procedure.  It provides a set of general and surgical-specific items which the nurse must “check off” prior to sending the patient to the Operating Room; for example, removal of glasses and hearing aids, signing the consent form, or having an electrocardiogram completed.
• Operative report
  • This dictated transcription report provides a detailed account of the patient’s procedural or operative encounters. The operating surgeon must dictate an operative report for all major and minor procedures performed in the hospital within 24 hours following the procedure. (South Shore District Health Authority, 2007).

Discharge Summary

Regardless of the reason for admission, all inpatients require a dictated discharge summary. This summary is a concise record of the patient’s clinical progress in the hospital and includes the following (South Short District Health Authority, 2007):

• Admitting diagnosis
• Final diagnosis (primary & secondary)
• Operations performed
• History of present illness
• Relevant past history,
• Family & social history
• Allergies
• Relevant functional inquiry
• Physical findings on admission
• Appropriate investigations
• Course in hospital
• Medications on discharge
• Arrangements for follow-up

Medical Transcription and the Patient Chart

Some of the above chart forms are created automatically from the clinical software system upon the completion of a process; for example, the face sheet is generated from the admission process, a lab report is generated from the automated analysis of the specimen obtained. Other records may be physically completed by the health care provider, such as a physician hand writing or keying in orders or a progress note, or a nurse or allied health care worker documenting on nursing notes or interdisciplinary notes. Finally, some reports are created through the medical transcription process, where the health care provider (typically the physician or consultant) dictates a report, which is then transcribed by the transcription department.

While full dictation of medical records was once the norm in hospitals, changes in voice recognition software technology have shifted the responsibilities of the hospital medical transcriptionist. While the position used to entail keying full reports from dictated voice files, the focus is now editing and catching errors which may occur when technology translates complex medical terms (Fast Chart, 2018).

Common transcribed reports in a hospital include:

• History and physical,
• Operative report,
• Discharge summary,
• Consult report and,
• any diagnostic testing report which is reviewed by a physician such as x-ray/MRI/US/CT/EKG/mammography reports.

Old Charts

If a patient is readmitted to a hospital, the doctor may request to see their previous patient care records. Old physical records may be scanned into the patient’s EHR and visible electronically under their “history” section, or they may be stored as physical charts (Thompson, 2018). Physical charts must be requested from the HIM department, which may also be referred to as health records or medical records. The HUC can request these through an electronic request, or through a telephone call to the HIM department. Once received, these previous records are often stored beside the current p-Chart.

References

American Health Information Management Association. (2019). AHIMA’s long-term care health information practice and documentation guidelines.

Fast Chart. (2018). How medical transcription services have changed over the years.

Relias Media. (2000, May). Universal chart order aids HIM professionals.

Sabatino, C. (2021, May). Advance directives. Merk Manual.

Schwartz, A. J. (2016, June). Anesthetic records: Lesson about ethics and education. Anesthesiology, 124 (6).

South Shore District Health Authority. (2007). Documentation: Standards for medical. Nova Scotia Health Policy Office.

Thompson, V. D. (2018). Administrative and clinical procedures for the Canadian health professional (4th ed.). Pearson Canada.

Attributions

“Patient writing her Signature on a Document” by SHVETS production; used under the Pexels license.