Medical Documentation: A Comprehensive Guide to Clinical History and Epidemiology

Posted on Apr 27, 2024 in Medicine & Health

LESSON 1: BASIC CONCEPTS OF MEDICAL DOCUMENTATION

1.1. General Document Concepts

A document is a combination of a support and the information recorded on it.

Support: The physical environment where information is recorded.

Ex.: Paper, RX, microfiche, CD, …

Documents can be classified based on external and internal characteristics:

External:

1. Class: Written, audio, image, …

2. Type: List, report, questionnaire, …

3. Format: Determined by the support characteristics (e.g., A4)

4. Form: Original or copy (single copy, numbered copy)

Internal:

1. Center logo

2. Patient identification (stickers)

3. Document reason (full clinical, emergency, …)

4. Information or content

5. Place and date

6. Signature

1.2. Healthcare Documentation

Types:

1. Non-healthcare documents: Used in any type of work.

Ex.: Invoice, order, delivery note, …

2. Healthcare documents: Information generated in patient care, specific to health organizations.

a. Clinical documents: Directly related to patient care aspects.

Ex.: Clinical history

b. Non-clinical documents: Related to management or administrative issues.

i. Intrahospital: Internal documents of the center.

Ex.: Employee vacation schedule

ii. Extrahospital: Documents affecting outside the hospital.

Ex.: Legal statements

iii. Intercenter: Used for communication between hospitals.

Ex.: Transfer/referral forms

THEME 2: CLINICAL HISTORY

2.1. Introduction

The clinical history (CH) is the most important document for patient care in a hospital. It includes all documentation generated during a patient’s attendance.

The concept of CH has evolved over time:

1946: Dr. Dunn established the concept of “Record Linkage,” a unified registry.

1957: The term “Family Record Linkage” emerged, encompassing health information of all family members.

1969: The WHO proposed the term HCUP (unique patient CH), a single, permanently open health document with chronological information.

2.2. Traditional Clinical History

Main data:

  1. Personal information: Name, age, sex, date and place of birth, telephone, …

  2. Reason for consultation: Patient’s explanation of the issue.

  3. Family history of major diseases: Metabolic diseases, allergies, medical history (hypertension, cancer, …)

  4. History of infectious diseases: Asthma, hypertension, diabetes, …

  5. Surgical history

  6. Physiological habits: Stool, urination, diet, physical activity, sexual habits, …

  7. Current disease: Detailed explanation of signs and symptoms in chronological order, including case history.

  8. Physical examination: Vital signs, general assessment, and body explorations (thorax, abdomen, neurological, …)

  9. Complementary examinations: Analytical tests, X-rays, CT scans, …

  10. Diagnosis range: Possible diagnoses based on the doctor’s assessment.

  11. Directions: Treatments or referrals to other specialties.

If the patient is hospitalized:

  1. Clinical course: Records the patient’s evolution, including modifications in diagnosis, treatment plans, and test results.

  2. Nursing sheets: Document care provided by nurses and nursing assistants, including nurse rating, course planning, and therapeutic application.

  3. Final diagnosis: The definitive diagnosis after all assessments and tests.

  4. Directions: Doctor’s orders.

Structure and organization of the clinical history:

In a HCUP system, a folder holds all documents for a patient. The folder should:

  • Be made of thick, durable cardboard.
  • Be larger than A4 size.
  • Include the patient’s name, HC number, and center identification externally.
  • Have a binding system to keep pages together while allowing insertion of new documents.
  • Not display any markings that identify the patient’s illness.

Three basic models of organization:

  • Conversa
  • In-service
  • For episodes

Advantages and disadvantages of the traditional medical history:

Advantages:

  • Fast information retrieval.
  • Chronological order of documents.
  • Comprehensive patient information.

Disadvantages:

  • Limited accessibility for multiple doctors.
  • Requires reading the entire history for a global understanding.
  • Information collection varies based on individual doctor’s style.

2.3. Computerized Medical Record

Computerized or digitized medical records (HCI) are being introduced to address the challenges of traditional paper-based systems.

Conditions for implementing HCI:

  • Centralized computer system with a powerful connection.
  • Powerful software applications.
  • Standardized work procedures for all users.

Advantages:

  • Standardization and space savings.
  • Instant access to information from anywhere.
  • Faster service and availability of medical history across centers.

Disadvantages:

  • Significant economic expense.
  • Confidentiality concerns.
  • Potential for computer system failures.

Security systems of a computer system:

Possible alterations:

  • Unauthorized access to information.
  • Information alteration.
  • Unauthorized access to the system.

Security mechanisms:

  • User identification and passwords.
  • Cryptography.
  • Frequent password changes.
  • System blocking after repeated failed attempts.
  • Uninterruptible Power Supply (UPS).
  • Backups of information.

2.4. Problem-Oriented Clinical History

In 1969, Dr. Weed proposed organizing patient information around a “List of problems.”

Example of a problem-oriented CH:

  • Initial data: Patient data.
  • List of problems: Active or inactive problems.
  • Initial plan: Diagnosis and treatment suggestions.
  • Evolution: Patient’s progress.
  • Narrative notes: Doctor’s justifications for decisions.
  • Full and constant evaluation.
  • Discharge report.

ITEM 3. EPIDEMIOLOGY

3.1. Concept and History of Epidemiology

Epidemiology is the scientific study of what happens to a population.

Mcmahan’s definition (1975): The study of the distributions and determinants of disease prevalence in men.

  • Distribution: Characteristics of the group affected by a disease (sex, age, place of residence, …).
  • Determinants: Factors influencing the distribution, including causative, risk, and protective factors.

Prevalence: The probability of having the disease in a population.

History:

  • Hippocrates: Linked disease and health to geographical location, season, and water quality.
  • John Graunt (1662): Introduced quantitative methods in health studies.
  • James Lind (1747): Conducted the first experimental studies with people on scurvy.
  • William Farr (1839): Studied mortality in specific locations like mines and prisons.
  • John Snow (1849): Investigated the incidence of cholera in London.

Epidemiology as a science:

Epidemiological studies follow the scientific method:

  1. Observation of the phenomenon.
  2. Formulation of a hypothesis.
  3. Demonstration of assumptions using statistical techniques.
  4. Emission of a general law (if a definitive explanation is found).

3.2. Biodemography: Demographic Indicators (Censuses and Registers)

Biodemography studies population characteristics for medical purposes.

Data sources:

  • Census: Regular and simultaneous counting of the entire population, recording various data (economic, demographic, social, …).
  • Register: Similar to censuses but at the municipal level, used for administrative and planning purposes.

Population pyramids:

Visual representations of age distribution, calculated using methods like Friz, Burdofer, and Sundbarg.

3.3. Health Indicators

Epidemiology studies the distribution and determinants of diseases.

Ratios: Express the relationship between two numbers from different sets.

Proportions: Express the relationship between a part and the total.

3.4. Measures of Disease Frequency

  • Prevalence: Cases of illness at a given time.
  • Incidence: New cases appearing in a given period.

Types of incidence:

  • Accumulated incidence (AI)
  • Odds of disease
  • Incidence rate (TI)

ITEM 4. EPIDEMIOLOGICAL STUDY DESIGN

4.1. Introduction

Epidemiological studies can be observational or experimental.

Observational studies: Observe how two population groups differ based on a factor.

  • Transverse study: Individuals are selected and assessed for exposure and disease status.
  • Case-control study: Compares exposure history between a group of patients (cases) and healthy individuals (controls).
  • Cohort study: Follows exposed and unexposed groups over time to compare disease development.

Experimental studies:

  • Clinical trials: Researchers manipulate exposure and select individuals to assess disease occurrence.

4.2. Transverse Studies

These studies can suggest a relationship between a factor and disease using relative prevalence (RR).

4.3. Case-Control Studies

These studies compare exposure history between cases and controls to identify potential causes of rare diseases.

Control selection:

  • Matched: Controls are similar to cases in variables like age and sex.
  • Unmatched: Controls are selected without restrictions.

Potential errors:

  • Selection bias
  • Retrospective exposure measurement

The relationship between exposure and disease is measured using the odds ratio (OR).

4.4. Cohort Studies

These studies follow exposed and unexposed groups over time to compare disease development.

The relationship between exposure and disease is measured using relative risk (RR).

4.5. Clinical Trials

These are experimental cohort studies where researchers manipulate exposure and select individuals.

Double-blind trials are used to minimize bias.

4.6. Types of Errors in Epidemiological Studies

  • Random errors: Affect accuracy or reliability, reduced by using larger samples.
  • Systematic errors (biases): Affect accuracy or validity, reduced by reviewing study mechanics.