LNCtips.com: Analysis of Computer-Generated Records
Computer-generated records are those that are input directly into a computer by healthcare staff, either by typing or using a touch screen. I've worked with computerized records as a staff nurse. Good computer systems make a lot of sense in the clinical setting. The computer prompts make it easy to document thoroughly. However, that same thoroughness presents some special challenges for legal nurse consultants.
When printed (which isn't usually done in the clinical setting), computer-generated medical records are often voluminous. For example, I just reviewed a 4-week hospital stay that generated over 8,000 pages of medical records. Computer-generated medical records have a different appearance than a paper-based chart. Let's look at some differences and the implications for LNC analysis of the records.
Reading computer-generated records is a breeze because everything is typed. No more trying to interpret signatures either. Caregivers digitally sign their entries with either a full signature or a code. A list of corresponding caregiver names is printed for coded signatures. Implications: You can easily create a list of all treaters
The records may be organized and printed differently than a traditional paper chart. For example, I once received computer-generated records that were organized by section (progress notes, orders, etc.) but they weren't in date order. Some of the notes were organized by the date that the notes were transcribed. I received another set of records from the same facility that were organized not by section but by date and time so that I had a minute by minute chronology. The only problem was that orders, nursing notes, progress notes, labs, x-rays, etc. were all mixed together. While this helped me with my own chronology, it wasn't very easy to find the information I needed. When I wanted to read the next progress note, it was 10 pages later than the first one. Implications: When obtaining computer-generated records by authorization or subpoena, call the medical records department to see if they will sort the record the way you want. Some facilities will be happy to sort them; others won't. If they won't, you'll need to sift through the records, page by page to find pertinent information.
Nursing flow sheets are a thing of the past. We've all seen those 6-page hospital flow sheets that list the nurse's important documentation for the shift. Flow sheets typically contain an area to assess body systems (cardiovascular, respiratory, etc.), as well as information on ADLs, IVs and other nursing care for the kind of unit. The flow sheets allow caregivers to see at a glance what occurred during the shift. The last page of the flow sheet is usually a section for handwritten nursing notes and comments. In computer-generated records, you can't view the nursing care by shift. Nursing comments have their own chart section and are usually in chronological order. Each body system has its own section of the chart, also in chronological order from admission to discharge. For example, there may be a section for lines, drains, and tubes, another section for fluid balance, another for cardiovascular assessments, etc. Implications: It can be difficult to get a complete picture of what occurred at any given time. For pertinent time periods, a medical chronology is helpful to integrate the information from the record. The nursing comments section is also useful. I usually read the comments first to identify condition changes and physician notifications.
Some computer-generated physician office documentation uses black bullets to indicate abnormal values and white bullets to indicate normal values as seen below. Implications: Viewing the color of the bullets is a quick way to determine the reason for the office visit and pertinent symptoms.
Progress notes may be repetitious. Some are just typed versions of handwritten notes but others contain the same information over and over and over. For example, if a physician indicates that blood cultures drawn on 12/12/10 were negative, that comment may be included in each of that physician's progress notes until the patient is discharged. Implications: It's easy to get lulled by reading the same information repeatedly but new information may be interspersed throughout the notes. I like to read repetitive notes in one sitting so that I can recognize the new items easily and include them in my report.
Sometimes lab results are included in progress notes as well as in a separate section for labs. Implications: Be careful with the lab times in the progress notes. Some of the labs results are from hand-held point of care systems, such as i-STAT. Other results may indicate the time the physician accessed lab reports, not the time the specimen was obtained. Cross-reference lab results with those in the separate lab section to ensure accuracy.
Medication Administration Records (MARs) may look completely different. Instead of having a day by day chart of medications as seen on MARs, computer-generated records may list each med in alphabetical order by generic name. Under each generic medication name is a list of dates, times and caregivers who administered the medication. Implications: The alphabetical listing of meds can be helpful at times. For example, I recently needed to find the start date for tuberculosis medications. It was easy to locate the generic names and determine when the meds were started. However, if medications are an integral part of the case, you may need to construct your own MAR-type table or put the times of the medications into a chronology so that you can see all the meds given on a specific day or at a specific time.
We've all done this: We write the time we render care on a sheet of paper. Then at the end of the shift, we use the sheet of paper to chart the time the care was given. With computer-generated records, both the time the care was rendered and the time of the documentation (if different) are recorded. Implications: Be careful to obtain the correct time; it should be the time the care was rendered. However, if there is a large time discrepancy that's important to the case, inform the attorney of the variance.
The computer-generated chart may not be the whole chart. Some facilities require all caregivers to input their notes and orders via the computer but others still allow handwritten orders and progress notes. Implications: Look for gaps in computer-generated records, particularly in progress notes and orders. When requesting medical records from a provider that uses computer-generated records , specify the inclusion of all handwritten records as well.
With the implementation of HITECH, we have seen more computer-generated medical records. And you'll know how to analyze them.