CHAPTER 23

Documentation

LEARNING OUTCOMES

Upon completion of this chapter, the nurse will:

INFORMATION

Without a doubt, you will be collecting a large amount of information, but you will need to know where to place this information within your clinical information system. Documentation would be so much easier if every organization, health plan, or wellness program used the same computer software for documentation, but this is not the case.

The first thing you will have to do is learn the computer software system. The most common platform for these software programs is a Windows-based operating system or something that closely resembles Windows. What this means is there are individual windows or screens that open up when a link is accessed. In layman’s terms, this means that when a word is in a different color, clicking the word will cause another screen or window to open up. Sometimes, the word that is to be clicked may also be underlined or italicized.

Some software applications may have a list of file folders along the left column of the screen. Each folder has a different part of the medical record. When the folder is clicked, the contents appear on the main screen.

The contents of a medical record for a client receiving telephonic care would include headings such as:

Keep in mind that this list is in no particular order. Your organization or program might have them listed or categorized in a different way.

Demographics

This is usually a good place to start when contacting a client. Demographics includes:

The content is entered into a “field” or a blank space to type information. Depending on the health plan, disease management, or wellness program, most of this information may already be populated, or filled in. You will need to validate this information for accuracy. Be sure to collect all possible telephone numbers for the client. If the client is providing you with a hardline work address, ask if you have permission to contact the client at work to discuss the client’s health. Employers differ in their policies about personal telephone calls during work hours.

With the use of social media, many clients may have Facebook pages and Instagram and Twitter accounts. If your software application has fields for this information in demographics, ask the client for this information as well. Keep in mind that communicating personal health information is not appropriate through Facebook, Instagram, or Twitter.

E-mail is becoming a preferred route to receive information. This may be used to remind the client of an upcoming scheduled care call or to send a client requested information about a teaching need. If the e-mail account is to a work address, check to make sure that the client is permitted to receive personal information through the account. Employers have policies about the use of e-mail for personal affairs, and depending on the policy, the employer may be able to read/access the employee’s e-mails. This could be a potential violation of privacy laws.

When documenting telephone numbers, designate if it is a mobile/smartphone device or a landline. If the client only has a mobile device, when you call them, ask if they are able to talk in a secure location. It would be unacceptable to discuss the latest results of blood work or a urinalysis while a client is grocery shopping or driving children to soccer practice.

Determine the best day and time to call the client when scheduling subsequent care calls. Some clients work during the day and will only be available for evening calls. Others are unable to take calls unless they occur on Saturday morning. Most health plans and disease management/wellness programs do not make scheduled care calls on Sundays; however, Saturday calls can be commonplace.

The “next of kin” or name of a family member may or may not be in your software. Some organizations, health plans, and wellness programs ask for permission to talk with a family member about the client’s health in the event that the client is hospitalized or unable to be reached for whatever reasons. This permission must be obtained from the client and documented as received by the client including the date the permission was received.

Past Health History

Again, depending on the organization, health plan, or program, this information may be prepopulated or blank. If it is prepopulated, ask the client to validate each item listed in the past health history. Keep in mind that errors can occur. A client who might have lost consciousness from heat exposure could have an entire battery of chemistry laboratory tests conducted. The health plan coders see that tests such as blood glucose were examined and automatically categorize the client as having diabetes. When the past health history information is populated in the software, diabetes appears as a past health problem. But, when you ask the client about the health problem, the client denies it exists. You will have to alter this entry so that it correctly reflects the client’s previous health problems.

If the fields are not populated, you will need to spend a few minutes asking the client about previous hospitalizations and/or surgeries. For someone in a wellness program, this part of the documentation process might be completed quickly. For someone in a disease management program or someone who is older, this part may take some time to complete. Be careful, thorough, and avoid rushing through this part of documentation.

Current Health Problems

Some might say that this part of the record is obvious because the client is enrolled in a disease management program, but that is not necessarily the case. People can and do have more than one health problem, all of which are not necessarily being treated through health insurance claims. An example might be the person who has asthma and is in a disease management program for this disorder. The client also works full time and has chronic neck and low back pain. The client has not seen a physician for the pain and chooses to use chiropractic medicine; however, chiropractic care is not a part of the client’s health benefits. Unless you ask about other health problems, there is no way of knowing that the client has neck and back pain.

When asking if a health problem is current, validate that the client is receiving some sort of treatment or medication for the problem now. A client may say that he or she is allergic to pet dander but has no pets, is not exposed to pets, and does not take any medication for the allergy. This health problem would most appropriately be documented as a past medical problem.

If you are assessing current health problems with an older client, take a few minutes and ask about different body areas. For example, do you have any problems with your vision or hearing? Your heart? Your breathing? Your joints or muscles? Your stomach or digestion? Being able to go to the bathroom without problems? An older client might have a chronic health problem that has existed for decades and not consider it a current health problem.

Another way to determine the existence of a current health problem is when you review current medications with the client. A person might deny having any other health problems but are prescribed a diuretic and beta blocker. These medications might be prescribed to treat hypertension, but the client considers these “pills” as something for the “blood pressure.” High blood pressure is not always considered a health problem by everyone.

Physical Assessment Data

The majority of this text explains the major systems to include with physical assessment data. The software system will have categories to complete for the major areas. Ideally, the software will also have an area to add “other” information that may not be included under a major heading. Or this text might have identified a health problem in one category, and your software application has it identified somewhere else. For example, a stroke is caused by a cardiovascular problem; however, it affects the neurologic system. Some software programs might have stroke under cardiovascular system, and in others it may appear under neurologic system. Another example would be post-polio syndrome. This syndrome may be documented under either musculoskeletal or neurologic systems.

Use this text as a resource when conducting the physical assessment portion of the conversation. Remember to ask, first, if the client has any issues or problems with a major body system before diving in and asking many questions, all of which can potentially be answered as “no.”

Medications

Documenting the client’s current medications can be tedious but is necessary. Before embarking on this part of the documentation, ask the client to collect all of the medication vials and have them near the telephone. Then have the client read the medication bottle to you, one by one. If you do not recognize something that the client is saying, ask the client to spell the medication and to spell out the words after the name of the medication. Ask also for the date of the last refill and when the prescription needs to be renewed.

Ask the client about any known allergies to medications or foods. This information is usually documented somewhere on the medications screen by either checking a box next to no known allergies or completing a field categorized as “allergies with.” If the client has no known allergies, type in the field the word “none.”

You will also need to ask the client about any medications or substances the client takes that are not obtained from a prescription. This includes over-the-counter analgesics (acetaminophen/Tylenol, ibuprofen/Motrin, aspirin), expectorants (guaifenesin/Mucinex), topical agents (hydrocortisone cream), sleeping aids, and vitamin supplements/nutraceuticals/herbal remedies. Some clients do not consider over-the-counter items as medications and will not automatically include these in a list of things that the client routinely takes. Vitamin supplements/nutraceuticals/herbal remedies are rarely acknowledged as medications so you will definitely have to ask about their use. When discussing vitamin supplements/nutraceuticals/herbal remedies, ask for:

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