The Patient’s Electronic Medical Record or Chart
On completion of this chapter, you will be able to:
1. Define the terms in the vocabulary list.
2. Write the meaning of the abbreviations in the abbreviations list.
3. List six purposes for maintaining an electronic medical record (EMR) or paper chart for each patient.
4. Demonstrate knowledge of military time by converting military time to standard time and standard time to military time.
5. List five guidelines to be followed by all personnel when entering information into a patient’s EMR.
6. Describe how the patient’s medical records are organized and identified when paper charts are used, and list five guidelines to be followed by all personnel when writing on a patient’s paper chart.
7. Identify four standard patient chart forms that are initiated in the admitting department.
8. State the purpose of seven standard chart forms included in a patient’s electronic or paper admission packet, and list information that is included on the history and physical form.
9. Define what is meant by a supplemental chart form, and provide at least two examples of supplemental chart forms.
10. Explain the importance of accurately charting vital signs in a timely manner, and explain the correction of three types of errors on a graphic record.
11. Describe the purpose of a consent form, and list five guidelines to follow in the preparation of a consent form.
12. List four types of permits or release forms that patients may be required to sign during a hospital stay.
13. Describe the methods for correcting a labeling error and a written entry error on a patient’s paper chart form.
14. List seven health unit coordinator (HUC) duties in monitoring and maintaining the patient’s EMR.
15. List eight HUC duties in maintaining a patient’s paper chart.
16. Explain the purposes and processes of splitting or thinning a patient’s chart and reproducing chart forms.
A preassembled packet of standard chart forms to be used on admission of a patient to the nursing unit.
An acquired, abnormal immune response to a substance that does not normally cause a reaction; such substances may include medications, food, tape, and many other items.
A plastic bracelet (usually red) that is worn by a patient that indicates allergies he or she may have.
A label affixed to the front cover of a patient’s paper chart that indicates the patient’s allergy/allergies.
Labels that contain individual patient information for identifying patient records or other personal items.
A method of alerting staff when two or more patients with the same or similarly spelled last names are located on a nursing unit.
A patient’s paper record from previous admissions, stored in the health information management department, that may be retrieved for review when a patient is admitted to the emergency room, nursing unit, or outpatient department; older microfilmed records also may be requested by the patient’s doctor.
Portions of the patient’s current paper chart are removed when the chart becomes so full that it is unmanageable.
Forms included in all inpatient paper charts that are used to regularly enter information about patients.
Placing extra chart forms in patients’ paper charts so they will be available when needed.
Patient chart forms used only when specific conditions or events dictate their use.
A locked workstation that is located on the wall outside a patient’s room; it stores the patient’s paper chart or a laptop computer, and when unlocked it forms a shelf to write on.
| Note: These abbreviations are listed as they are commonly written; however, they also may be seen in uppercase or lowercase letters and with or without periods. | |
| Abbreviation | Meaning |
| H&P | history and physical |
| Hx | history |
| ID labels | identification labels |
| MAR | medication administration record |
| NKA | no known allergies |
| NKDA | no known drug allergies |
| NKFA | no known food allergies |
| NKMA | no known medication allergies |
EXERCISE 1
EXERCISE 2Purposes and Use of a Patient’s Electronic Medical Record or Paper Chart
The patient’s electronic medical record (EMR) or paper chart serves many purposes, but for a health unit coordinator (HUC), the electronic record or chart is seen mainly as a means of communication between the doctor and the hospital staff.
The EMR or chart is also used for planning patient care, for research, and for educational purposes. As a legal electronic record or documentation, the medical record protects the patient, the doctor, the staff, and the hospital or health care facility. Careful entries and notations by doctors and other personnel provide an electronic or written record of the patient’s illness, care, treatment, and outcomes of hospitalization. If the patient is readmitted to the hospital or health care facility, the paper chart may be retrieved from the health information management system (HIMS) department, also commonly called the medical records department. The advantage of the EMR is that all previous health information is immediately available on the computer.
HIGH PRIORITYThe Patient Electronic Medical Record or Paper Chart as a Legal Document
When a patient is discharged, health information management personnel will analyze and check the EMR for completeness and will notify the appropriate nurses and/or doctors when they must go into the computer to complete the records. The patient’s previous EMR will be available on computer to the patient’s doctor, or if the patient is readmitted to the hospital. The Security Rule, a key part of the Health Insurance Portability and Accountability Act (HIPAA), protects a patient’s electronically stored information (see Chapter 6).
Doctors and nurses must go to HIMS to see or complete old patient records if the patient has not been readmitted to the hospital. Completed paper charts are indexed and stored where they are available for retrieval as needed.
Older paper records are microfilmed (documents are placed on film in reduced scale) and stored. On request, health information management personnel may retrieve microfilmed records. The length of time that the record must be stored depends on the laws of the state. Unless a patient has been readmitted to the hospital, HIMS will not send an old record to nursing units.
The patient’s electronic or paper medical record may be subpoenaed and may serve as evidence in a court of law. As a legal document, it must be maintained in an acceptable manner.
Military Time
Military time is a system that uses all 24 hours in a day (each hour has its own number) rather than repeating hours and using am and pm. When military time is used, there are always four digits, the first two digits representing hours and the second two representing minutes. For example, 1:45 am is recorded as 0145, and 1:45 pm is recorded as 1345; the colon is not needed when military time is used (Table 8-1). The hours after midnight are recorded as 0100, 0200, and so forth. Thirty minutes after midnight is written as 0030. Twelve noon is recorded as 1200, and the hours that follow are arrived at by adding the hours after noon to 1200. Thus 1:00 pm is 1200 + 100 = 1300, 2 pm is 1200 + 200 = 1400, and so forth. See Figure 8-1 for a comparison of standard and military times. Military time is used with the EMR and paper chart systems and eliminates confusion because hours are not repeated, and am or pm is unnecessary.
TABLE 8-1
Standard and Military Time Comparisons
| Standard Time | Military Time | Standard Time | Military Time |
| 12:15 am | 0015 | 1:00 pm | 1300 |
| 12:30 am | 0030 | 1:15 pm | 1315 |
| 12:45 am | 0045 | 1:30 pm | 1330 |
| 1:00 am | 0100 | 1:45 pm | 1345 |
| 2:00 am | 0200 | 2:00 pm | 1400 |
| 3:00 am | 0300 | 3:00 pm | 1500 |
| 4:00 am | 0400 | 4:00 pm | 1600 |
| 5:00 am | 0500 | 5:00 pm | 1700 |
| 6:00 am | 0600 | 6:00 pm | 1800 |
| 7:00 am | 0700 | 7:00 pm | 1900 |
| 8:00 am | 0800 | 8:00 pm | 2000 |
| 9:00 am | 0900 | 9:00 pm | 2100 |
| 10:00 am | 1000 | 10:00 pm | 2200 |
| 11:00 am | 1100 | 11:00 pm | 2300 |
| 12:00 Noon | 1200 | 12:00 Midnight | 2400 |
SKILLS CHALLENGEConfidentiality
As was discussed in Chapter 6, the EMR or paper chart is confidential, and the HUC is a custodian of all patient medical records (electronic or paper) on the unit. Any information provided by the patient to the health care facility and the medical staff is confidential. All health care personnel are required to have a code and a password to gain access to a patient’s EMR. Portions of the patient’s EMR may be available only to the patient’s doctor and nurses.
HIGH PRIORITYThe Electronic Medical Record
The patient’s EMR may be accessed by health care personnel after entering a user ID and a password. Once logged in, the health care personnel are able to access and should access only the EMR of the patients in their specific nursing unit. Health care personnel choose the patient’s name from the nursing unit census displayed on the screen; this will allow them to view and enter information into the patient’s EMR. An icon will be displayed next to a patient’s name when there is a task or communication for the nurse or HUC written by the patient’s doctor. A name alert flag may be placed on the patient’s EMR when two or more patients with the same or similarly spelled names are located on the unit. If an order has been written stating that the patient’s admission is not to be published, NINP (no information, no publication) is noted on the EMR or the patient may be listed as a “confidential patient.”
Guidelines to Follow When Entering Information into the Patient’s Electronic Medical Record
1. All entries into the EMR must be accurate.
2. Handwritten progress notes, electrocardiograms, consents, anesthesia records, and outside records and reports must be scanned into the EMR.
3. Errors made in care or treatment must be documented and cannot be falsified.
4. All entries into the EMR must include the date and time (military or standard) of the entry.
5. Abbreviations may be used in keeping with the health care facility’s list of “approved abbreviations.”
The Paper Chart
Guidelines to Follow When Writing in a Patient’s Paper Chart
All persons who write in the paper chart follow standard guidelines. The HUC has minor charting tasks but is responsible for patient charts and so should be aware of the following basic rules:
1. All paper chart form entries must be made in ink. This is to ensure permanence of the record. Black ink is preferred by many health care facilities because it produces a clearer picture when the record is microfilmed, faxed, or reproduced on a copier.
2. Written entries on paper chart forms must be legible and accurate. Entries may be made in script or printed. Diagnostic reports, history and physical examination reports, and surgery reports are usually computer generated.
3. Recorded entries on the paper chart may not be obliterated or erased. The method for correcting errors is outlined later in this chapter.
4. All written entries on paper chart forms must include the date and time (military or standard) of the entry.
5. Abbreviations may be used in keeping with the health care facility’s list of “approved abbreviations.”
The Chart Binder
Forms that constitute the patient’s paper chart are usually kept together in a three-ring binder. The binder may open from the bottom, or it may be a notebook that opens from the side, the top, or the bottom (Fig. 8-2).
The chart forms in the binder are sectioned off by dividers placed in the chart according to the sequence set forth by the health care facility (Fig. 8-3).
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