IV.A DOCUMENTATION OF CLINICAL CARE

Effective Date: 
Mon, 08/01/2011
Reviewed: 
Thu, 05/28/2015
Revised: 
Thu, 05/28/2015
Policy: 

All clinical interactions with patients are documented by CAPS professional staff with a signed, contemporaneous note in the medical record in accordance with professional standards and regulatory guidelines.

Clinical documentation is accurate and completed in a timely manner.

Clinical records are maintained in an electronic medical record with security features that preserve privacy but allow timely viewing by health care practitioners with appropriate permissions.

Information that is shared with Primary Care Student Health Center staff can be found in the Sharing of CAPS Clinical Information with Student Health Center Policy.

The SOAP (subjective findings, objective findings, assessment and plan of care) format use is encouraged in all standard initial evaluation and follow-up clinical notes.

Procedure: 

1) Patient encounters or telephone encounters are completed soon after the clinical interaction and within two working days of the visit. The electronic record provides the time and date when notes are electronically signed. Notes written on a subsequent date are dated with the actual date of signature, even if referring to an earlier interaction. Dictation of complex visit types and initial psychiatric evaluation is available. Dictations are reviewed, edited and signed off by the responsible health care practitioner when they return from the transcriptionist.  Sign-off of dictation must occur within 3 working days of entry into the medical record.

2) Content Notes of clinical visits are done using templates and transcriptions in the electronic medical record utilizing the SOAP format when appropriate. Entries include, at minimum:

  • Date of service
  • Provider name and title
  • Chief complaint or nature of visit, with appropriate history
  • Objective clinical findings
  • Diagnosis, assessment or impression
  • Diagnostic testing ordered (lab, xray etc)
  • Treatment plan
  • Therapies administered or ordered, with discussion of necessity, risks, and alternatives as appropriate
  • Follow up instructions, if applicable
  • Practitioner’s electronic signature

An initial psychiatric evaluation intake note will include history of present illness, past history including psychiatric, medical and substance use problems, brief family history, mental status examination, DSM-5 diagnosis, assessment or impression and a treatment plan, including any medications prescribed. A re-intake evaluation should be completed if it has been more than one year since the last visit .At the clinician’s discretion, a re-intake note may be added to the chart when a student sees a new provider, or if there has been a significant lapse of time or change of condition since the last visit.

3) Psychotropic medication lists and allergies to medications are updated with each clinical visit.

4) Telephone contact with a patient is clearly identified as such in the medical record and content of the call is noted in the EMR, with appropriate clinician signature.

5) Entries made into the wrong patient record are reported by clinicians to the Medical Record Systems Administrator for correction.

6) If it necessary to correct or clarify an entry in a patient chart an addendum to the note is made by the clinician.

7) Lab results are sent by the ordering clinician to the patient using the secure message system or communicated to the patient by phone or in person.The chart note will reflect discussion of labs if a secure message is not utilized.  The secure message system has more stringent security features than campus email.  Campus email is not used for protected health information.

8) Security of Medical Records - Health practitioners lock the computer screen prior to leaving the exam room and screens automatically time out after 5 minutes if they inadvertently forget to lock the screen. Reminders to lock the screens are found on the work station. Paper protected health materials are collected throughout the day and locked up at the end of each day in the alarmed medical records office.

Key Points: 

1.  Documentation of clinical care occurs in the patient’s electronic medical record.

2. Documentation occurs in a timely manner, using standard clinical templates.

3. Documentation errors are corrected using addendums to the note unless the documentation was entered into the wrong patient's chart in which case follow the Medical Records Standards policy & procedure: XI. Corrections and Amendments to Records

4. Security features to assure the safety of protected health information include the lock-out features in the EMR and regular collection of paper materials for storage in the locked Medical Records office.