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Title

Medical Charting and Documentation, Part 2: The Documentation Process (0.5 credit hours)

Abstract

This module discusses important documentation characteristics addressed by accrediting agencies, identifies the most common procedures used for proper documentation and describes common problems associated with charting medical information. In addition, documentation practices applicable to diagnostic imaging are included. Course Approval Expiration/End Date: August 1, 2011 Category A Credit

This activity may be available in multiple formats or from different sponsors. The ARRT does not allow CE activities such as internet courses, home study programs or directed readings to be repeated for CE credit in the same or any subsequent biennium.

Author

Katherine Ott, M.S.W., ELS

Katherine Ott, M.S.W., ELS, is a managing editor for the American Society of Radiologic Technologists and a certified Editor in the Life Sciences. She has written and edited several articles on medical imaging and radiation therapy for various ASRT publications.

Barbara Wallace, RHIA, CCS, CCS-P

Contributing Author
Barbara Wallace is an associate professor of Health Information Management at Sinclair Community College (Dayton, OH). She has over 12 years experience as an HIM educator and 14 years experience as a department director and vice president in the healthcare industry.

Objectives

After studying the information presented, the reader should be able to:

Articulate important documentation characteristics addressed by accrediting bodies and legal entities and apply general rules to each.
Describe the most common charting problems.
Describe documentation practices applicable to diagnostic imaging.
Identify procedures for charting common events such as vital signs, medication administration, IV therapy, contrast administration and incident reports.

Resources

Bibliography

Abdelhak, M. Health Information: Management of a Strategic Resource. Philadelphia, PA: W.B. Saunders Co;1996:135-141.

Bruce JAC. Privacy and Confidentiality of Healthcare Information. Chicago, Ill: American Hospital Publishing Inc; 1984:7-18.

Carroll QB. Evaluating Radiographs. Springfield, Ill: Charles C Thomas Publisher; 1993:5-17.

Clinical Performance Standards of the American Society of Radiologic Technologists. January 2000.

Department of Justice Bulletin on Computer Records and the Federal Rules of Evidence. March 2001.

Ehrlich RA, McCloskey ED. Patient Care in Radiography: 4th ed. St. Louis, Mo; Mosby Year Book Inc; 1993:76,78,160-161.

George, JE. The emergency department medical record. Emerg Med Clin North Am. 1993; 11:889-903.

Huffman EK. Health Information Management. 10th ed. Berwyn, Ill: Physicians' Record Company; 1994.

Iyer PW; Camp NH. Nursing Documentation. St. Louis, Mo: Mosby Year Book Inc; 1991: 102, 105-107.

Mastering Documentation. 2nd ed. Springhouse, Pa: Springhouse Corporation; 1999.

McWay, DC. Legal Aspects of Health Information:2nd ed Clifton Park, NY: Thomson Delmar Learning; 2003; 73,214-215.

Medical Economics. July 10, 1995.

Practice Brief: Maintaining a Legally Sound Health Record � Paper and Electronic, American Health Information Management Association. Revised November, 2005.

Southwick AF. The Law of Hospital and Health Care Administration. Ann Arbor, Mich: Health Administration Press; 1993.

Webliography

General Info

The Joint Commission. The Official "Do Not Use" List. Available at: http://www.jointcommission.org/patientsafety/donotuselist/. Accessed July 1, 2009.

Diagnostic Imaging
Diagnostic Imaging.com. Diagnostic Imaging (Online Magazine). 1996 - 2007. Available at: http://www.dimag.com/. Accessed July 1, 2009.

U.S. National Libraries of Science and the National Institutes of Health. MedLinePlus: Diagnostic Imaging. March 7, 2007. Available at: http://www.nlm.nih.gov/medlineplus/diagnosticimaging.html. Accessed July 1, 2009.

Documenting Common Events
Masoorli S. Medi-Smart. Pitfalls of IV Therapy. 1999 - 2004. Available at: http://medi-smart.com/pitfalls.htm. Accessed July 1, 2009.

Contrast Media
Radiology InfoNet. RADIOLOGY InfoNet Homepage. 2006. Available at: http://www.radinfonet.com/. Accessed July 1, 2009.