In the clinical environment of healthcare, meaningful documentation plays a vital part in enabling high-quality patient care, adequate information sharing among care providers and confirming legal compliance. Documentation has many distinct forms in healthcare information management, each having different but essential functions in the process of information creation, as well as transmission, sending, and receiving in healthcare information systems. This paper explores four key types of documentation used in the HIM field: On the patient health record, we will produce a progress note, history and physical (H&P), operative report, and discharge summary.
Progress Note
The patient’s medical record incorporates the progress note as one of the well-known components, and it is mainly used for the purpose of documenting the patient’s condition and how the treatment progressed daily during their stay in the hospital (Faisal et al., 2022). Its primary role is to maintain the ongoing record of the patient’s clinical status and treatment therapy, which will help in unanimous understanding among healthcare providers that are working together for a better patient outcome. The main elements of the progress note would be vital signs, drug administration, laboratory test results, assessment, and subsequent plans of therapy or treatment.
With regard to the patient’s education, our session with the patient will consist of subjective and objective information, assessment, and plan (SOAP). A subjective data set description may include any of the symptoms or complaints shared by the patient themselves or their family members. Quantitative data includes measurable, accurate information that is received through viewing, touch, or investigation. The evaluation part concludes the postheld view or the tests based on the information that has been gathered. Then, the treatment program details the proposed interventions, medication, diagnostic tests, or consultants for long-term care that are needed.
Progress notes constitute a section of medical documentation that is found across different healthcare settings, such as hospitals, clinics, nursing homes, and rehabilitation centers, where patients receive ongoing care. They constitute a real-time type of record that allows caretakers to track the effects of the treatment, and as a consequence, it permits them to modify the therapeutic plan if required.
History and Physical (H&P)
The History and Physical (H&P) is the comprehensive record that gives the patient’s past medical history, current complaints, physical findings, and the first diagnosis. It is an essential document from which health professionals can get information about the patient’s health condition in order to develop a care plan that focuses on the patient appropriately (Akbari, 2021). Creating the medical history and past evidence gathering the data on the past medical history of the family among all the social data reviews all the systems are their prime purpose.
The H&P generally comprises the thorough data of the patient’s medical history interview, which may involve the chief complaint, the present illness, the past illness (including surgeries, illnesses, and hospitalizations), the medications and drugs, and the society history (smoking, alcohol, and drugs). On the other hand, it should cover the data received from the physical checkup, which consists of general appearance, vital signs like heartbeat, breathing, digestive tract, nervous system, and musculoskeletal system.
Operative Report
The operative report is a document that notices the details of surgery that is performed on a patient, giving a complete summary of interventional surgery, the findings, the complications, and the instructions postoperatively (Sattar et al., 2021). It is a legal document and serves as the reference for future medical care and a correct record of the surgery procedure with its outcomes so that the whole conditions of the surgery are documented perfectly. The main objective of the operative report is to disclose medical information about the surgery to other healthcare providers whose services a patient might need and to keep a written record of all the peculiarities of the operations. This record is vital in the case of emergency for re-admission or in future lawsuits.
The operative report invariably contains the patient’s data, the date of operation, diagnosis of the pre-operative state, given surgical operation (including the operative technique, anatomical structures involved, and the surgeon’s observation made during the operation), and the diagnosis of the condition after operation. The record may also be used to report any intraoperative problems (such as complications or processes performed), and special instructions may be given to the patient or their caregivers after surgery.
Investigatory reports are utilized predominantly in hospitals and surgical centers to register surgical procedures, which are worked out by surgeons, anesthesiologists, and other surgical team members. They perform essential functions such as ensuring that the inferential data is collected before, during, and after surgery, helping doctors communicate with each other, and providing good health care to the patients.
Discharge Summary
The discharge summary is the conclusive document, which gives a complete picture of the stay of the patient in the hospital, including the chief complaints, the discharge diagnosis, and the treatment, as well as the instructions for the administration of medication at home (Simon et al., 2020). It plays the role of the bridge between the care delivery during hospitalization and post-discharge care, offering beneficiaries, the primary care provider, and other healthcare players involved with the ongoing care of the patient all the necessary information. The first function of the summary is to provide for seamless communication of care from the hospital to the community stage of care by reducing the gaps.
A summarized discharge letter usually comprises the patient’s name, address, insurance details, medical history, reason/cause of hospitalization, patient’s hospital course (includes significant events, lab results, medications prescribed, procedures, and medical procedures provided during the hospitalization or admission period), final diagnosis, medications prescribed at discharge, follow-up instructions, and instructions for home care or home management plan. Additionally, it is expected that it would include recommendations for long-term management of the problem, references to other healthcare providers or community resources, and any unaddressed issues or concerns that require re-visiting, and granular follow-up.
Conclusion
Comprehensive recording of patient data in health facility management is a fundamental part of the operation, ensuring that all processes run smoothly, patients receive continuous care, and the state health laws and rules are followed. Three critical types of documents that are utilized in the healthcare settings are the progress note, history and physical, operative report, and discharge summary, each playing a significant role in keeping the communication line open and protecting the patient from harmful risk. The appropriateness of these documents is a concept that all healthcare workers must realize so the documentation of patient care along the healthcare continuum becomes a reality.
References
Akbari, Z. (2021). A Holonic Multi-Agent System for the Support of the Differential Diagnosis Process in Medicine (Doctoral dissertation, Dissertation, Duisburg, Essen, Universität Duisburg-Essen, 2021).
Faisal, M., Sadia, H., Ahmed, T., & Javed, N. (2022). Blockchain Technology for Healthcare Record Management. Pervasive Healthcare: A Compendium of Critical Factors for Success, pp. 255–286.
Sattar, A. K., Zahid, N., Shahzad, H., Soomro, R., Saleem, O., & Mahmood, S. F. (2021). Impact of duration of antibiotic prophylaxis on rates of surgical site infection (SSI) in patients undergoing mastectomy without immediate reconstruction, comparing a single prophylactic dose versus continued antibiotic prophylaxis postoperatively: a multicentre, double-blinded randomized control trial protocol. BMJ open, 11(7), e049572.
Simon, R., Snow, R., & Wakeman, S. (2020). Understanding why patients with substance use disorders leave the hospital against medical advice: a qualitative study. Substance abuse, 41(4), 519-525.
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