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FORUM
OF ESRD NETWORKS
MEDICAL RECORD MODEL
NOTE: The Forum of ESRD
Networks, working through the Quality Improvement Directors,
has developed and endorsed this Medical Record Model for use
by all dialysis facilities. The goal of this Model is to enhance
quality care by promoting consistent content for medical records.
Although use of this Model is not mandatory, it is hoped that
dialysis providers will voluntarily adopt the Model for use
within their own programs.
The Medical Record Model defines the components
necessary to achieve a consistent approach to ESRD medical
records, thereby decreasing the fragmentation that frequently
occurs in the medical records of ESRD patients.
It was developed using existing guidelines,
standards and ideas regarding medical records, with input
from the major nephrology professional organizations, the
18 ESRD networks, and dialysis facilities around the country.
All medical records should be completed in
accordance with applicable state laws.
| Items
in this font and color are recommendations from Network
Directors and Forum BOD |
|
| Developed:
4/1993 |
| Revised:
8/2001 |
| Approved
by BOD: 10/2001 |
|
RECOMMENDATIONS:
CONTENT OF ACTIVE RECORDS
Identifying Information:
- Name
- Address
- Telephone #
- Date of birth
- Sex
- Race
- Ethnicity
- Primary/secondary ESRD diagnosis
- Current comorbid
conditions
- Primary/attending physician & phone
number
- Facility patient registration #
- Date/type of first renal therapy (first
acute, chronic, location)
- Date of admission to current facility
- Next of kin/significant other
- Emergency contact person & phone
number
- Social security #
- HIC (Medicare) #
- Copy of patient's driver's license and
Medicare or insurance card
- Allergy stickers/information
Computerized Records:
Acceptable, if meet all requirements
of paper records (i.e., confidentiality and retention laws)
Consents and Notifications:
- Informed consent for treatment
- Informed consent for reprocessed dialyzer
(if applicable)
- Informed consent for blood transfusion
- Receipt of "Patient Rights and Responsibilities"
- Receipt of "Patient Grievance Form" and
process information
- Receipt of ESRD Network
grievance / contact information
- Release of records form
- Medical records request form
- Advance directives forms (e.g. DNR),
or documentation that issues have been discussed and/or
information received when applicable
- Hepatitis and other vaccination consent
forms (if applicable)
History and Physical (done by physician
extenders):
- Initial H&P to include:
- Previous health history, including
hospitalizations, procedures and other medical diagnoses.
- ESRD history, including predialysis
lab data (BUN, Cr, electrolytes, serum albumin, hemoglobin/hematocrit
minimum), uremic symptoms, justification for need
for renal replacement therapy.
- Annual exam by primary/attending physician,
including review of systems and current problems.
- Current history and physical should be
included within 2 weeks of initiation of renal replacement
therapy and/or admission to the facility, and included
in the patient's record. (Also include amputations)
Assessments/Evaluations:
- Initial: within 30 days of admission
to facility
- Nursing, social worker, dietitian
- Annual update
Transplantation Status:
- Treatment options discussed & documented
- If patient not candidate, reason/choice
documented on record
Hospitalization Records:
- Admission history and physical
- Hospital discharge summary (If not obtained,
a physician summary of each hospitalization should be
completed.)
Language Translation:
In some states/counties, health
facilities are required to provide information/education to
patients in their native language. Check for state and
local requirements.
Miscellaneous:
- Medical record checklist
- HCFA 2728
- Insurance information
- Correspondence
- Transient dialysis information
Progress Notes:
Progress notes should provide an
accurate picture of the patient, which reflects changes in
patient status, plans and results of changes in treatment
regimen, diagnostic testing, consultations, unusual events,
etc. Either single discipline or integrated multidisciplinary
progress notes may be utilized. The following are minimum
entries:
-
Each discipline (physician,
nurse, social worker, dietitian) should record the progress
of the patient at regular intervals:
-
monthly - unstable patients*
-
semi-annually (6 months)
- stable patients*
(*as defined by facility or physician)
-
Patient condition and
response to treatment noted on daily treatment record
-
Regular review of abnormal
labs/clinical findings and any action taken
-
Monthly review of laboratory
results (including adequacy) & hepatitis status
-
Vascular
Access Assessment
Patient Education (routine or facility-specific):
- Disease, treatment, modality options,
access care
- Services available
- Emergency preparedness: initial,
quarterly or semi-annual
- Vaccine Information Statements (VIS)
- required
Problem List (optional):
- Initial
- Updated as needed, at least minimum annual
review
- Either separate or integrated cumulative
list of patient's medical, psychosocial, nutritional problems
Care Plans:
Long term program
Initial
Current year, annual update
Reflects interdisciplinary approach
Monthly for unstable patients
Every 6 months (minimum) for stable patients
Prior 12 months in active record
-
Significant change in medical
status or modality
-
Advanced care planning, clinical
end of life directives annual update
-
Patient's signature (or responsible
party) - reflects participation
Physician Orders:
- Standing Orders (i.e. emergency procedures,
cramp management): initial, annual update (minimum)
- Dialysis prescription and medication
update - initial, annual (minimum). Include EPO/iron
- Post-hospitalization update
Current 6 months of orders in active record
(minimum)
Medication Record:
- Initial
- Update
- Whenever changes occur
- After hospitalization
- Annually (minimum)
- Reviewed at monthly intervals, including:
- Name of drug
- Dose
- Route of administration
- Date ordered
- Any changes to be dated
- Drug allergies
- EPO, Calcijex, etc. flowsheets, if
such flowsheets are utilized by the facility (medication
lists for outpatient, home meds may be separated from
in-center meds)
- Other allergy alerts (e.g. latex,
food, etc.)
Daily Treatment Records:
- May be kept separately
- Current year readily available (past
12 months)
- Filed separately for each individual
patient
Consults:
Reports/letters from consulting
physicians (past 12 months or readily available)
Vascular Access Record:
- Type of access (if catheter, specify
type, length, etc.)
- Date of insertion/creation/revision/declotting
- Reports on any access surgeries or interventions
- Name of surgeon(s)
- Diagram of location, flow direction,
configurations
- Monitoring records (e.g. pressure run
charts, recirculation, etc.)
Laboratory:
- Past 12 months on active chart (or readily
available)
- Cumulative lab records acceptable, original
reports must be included in a permanent record if cumulative
record is not generated by original laboratory. (Lab normals/reference
ranges)
- Flowsheets (e.g. clotting times, adequacy
of dialysis testing, recirculation studies)
- Patient-specific run charts (optional),
and adequacy calculations
Transfusion Record (past 12 months)
Diagnostic Studies (past 12 months):
- Radiology, nerve conduction, bone densitometery,
EEG, current and prior EKG
Preventive Care Measures:
- Vaccination Status (HBV, pneumococcal,
flu)
- Exams: mammography, PAP smears,
retinal & foot exams (diabetics), etc.
Transient Records:
- Identifying information (refer to Active
Records)
- Most recent physician's orders, to include
dialysis prescription dialyzer type, reuse practice, BFR/DFR,
treatment time, dry weight), EPO dose and route, dosages
of other intradialytic medications)
- Most recent progress notes
- Most recent problem list (include special
needs)
- Current history and physical (include
cause of ESRD)
- Medication record
- Most recent laboratory (past 2 months),
to include: albumin, alkaline phosphatase, BUN, Ca++,
Cl-, C02, creatinine, LDH, SGPT, SGOT, total protein,
Hgb, glucose or HgBAIC
(if diabetic), PT (if on Coumadin), Hepatitis status (within
12 months).
- Last six treatment records
- Most recent long-term care plan
- Most recent psychological (or social
worker) evaluation
- Insurance information
- Chest X-ray and EKG (within last 12 months)
- Facility-specific forms for reporting
transient dialysis experiences back to home unit
- HBV status (antigen positive or immune)
- Type of vascular access, location, flow
diagram
- Emergency contact (local)
- Phone number of primary nephrologist
- Allergies
- Advance directives
CLOSED RECORDS
(transferred, transplanted, recovered
function, withdrew from therapy, expired)
All Records, must include:
-
Treatment records and thinned
records
-
Additional confidential files
(e.g. HIV if kept separately)
-
Business file may be kept
separately
File Chronologically in sections, as outlined
in Active Record Recommendations
Discharge Summary
-
Clearly identifies the disposition
of the patient (final diagnosis/cause of death, date of
discharge/death, location of death, HCFA 2746)
Maintained per state law, and actual chart
(or copies for satellite facilities) should be available within
two weeks. Check state law
for minimum requirement for record retention timeframe.
Acknowledgments
The Forum wishes to thank the Network Quality
Improvement Directors, Medical Record Subcommittee:
Vickie Peters, ESRD Network 18 (chair)
Alex Rosenblum, ESRD Network 14
Mary Turner, ESRD Network 5
Debra McClure, ESRD Network 7
Sandra Waring, ESRD Network 2
Additional acknowledgment goes to:
Dr. Alan Kliger, Past Chair, Forum Q.I. Committee
Dr. Allen Nissenson, Past President, Renal
Physician's Association
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