Self-Study Modules on Tuberculosis
Module 8: Tuberculosis Surveillance and Case Management in Hospitals
Collect Patient Information
Figure 8.7 This is a flow chart that describes the four processes for TB Surveillance and Case Management in Hospitals and Institutions: including, (1) Identifying suspected or confirmed TB cases; (2) Collect patient information; (3) Conduct an initial interview; (4)Plan for follow-up care. Step 2, Collect Patient Information is highlighted.
Once a TB case has been reported, the identified patient is usually assigned to a specific public health worker who will manage his or her case. When a patient is hospitalized or in an institution, the public health worker will need to locate the patient, identify available information sources in the hospital or institution, and review the patient's medical record. To gather the necessary information and ensure that it is complete and accurate, the public health worker may need to go to several different locations.
It is important to collect information on reported TB cases in order to
- Complete all necessary forms for reporting requirements, in accordance with local laws and regulations
- Determine the need for and scope of a contact investigation
- Be alerted to the presence of drug resistance or potential adherence problems
- Gather background information needed to conduct the initial interview
- Plan for and arrange the patient's care both during and after hospitalization or stay in an institution
Locating the Patient
To locate a hospitalized patient or an institutional resident, the public health worker should call the central information number, if available, or check with the information desk receptionist. He or she should ask for the patient's current room number and ward or building location, as well as a phone number, if available. If necessary, the public health worker may need to go to the admissions or administrative office. Because patients are often transferred from ward to ward or from room to room, it is important to get current locating information. If a patient with suspected or confirmed TB disease has left the facility or has died, record any available patient addresses (for example, home address, next of kin, receiving facility) from the medical record and report this immediately to the TB program.
Sources of Information
Specific information on the patient's treatment regimen, infectiousness, and symptoms can be found at the hospital ward or location in the institution where the patient is receiving care. There, patient information can be obtained from the facility's computer or the patient's medical record. The nursing staff or clerks on the ward should be able to help the public health worker locate the patient's medical record. Hospital or institutional policies on the use of computers will vary; the public health worker will need explicit permission and, in most cases, basic training in the system used and an access code in order to access computer records. In some jurisdictions, it is necessary to obtain patient consent to access the medical record. When gathering personal information about a patient, it is crucial to respect confidentiality and prevent unauthorized persons from gaining access to the record (see Module 7, Confidentiality in Tuberculosis Control, for further information).
As discussed in the previous section, a hospital's mycobacteriology laboratory has a logbook or database containing AFB smear results, culture results, and drug susceptibility patterns. The pathology laboratory will have the results of AFB smears done on any tissue specimens submitted. Although a computer database or the patient's medical record will also have much of this information, it may not be complete or accurate; laboratory reports are the definitive source for laboratory results and should always be reviewed or obtained. Pharmacy records may also be available for review and verification.
Sources of Patient Information
|Patient's understanding and acceptance of TB diagnosis||Patient|
|Patient location (in the facility) and addresses||Central information phone number
Information desk receptionist
Hospital admissions office
Institution administration office
|Results of diagnostic evaluation||Computer database
Patient's medical record
|Treatment regimen and progress||Computer database
Patient's medical record
Nursing staff and physicians
|Potential adherence problems||Patient's medical record
Nursing staff and physicians
Family members and other visitors
|Past TB history||Patient's medical record
TB program records and staff
Medical Record Review
For each reported or suspected TB case, the public health worker should review the patient's medical record and summarize information that is pertinent to TB treatment. The medical record (Figure 8.8) contains a wealth of information, but finding specific information can be difficult unless the public health worker knows where to look. A medical record, labeled with a medical record number, is usually organized into several sections, each of which contains different information. While the patient is hospitalized or under care in a facility, these sections are usually clearly marked, divided, and are often color-coded. After the patient is discharged, the medical record is sent to the medical records department, a department in a hospital or other health care facility that houses the records of patients who have been admitted to the hospital and subsequently have been discharged, transferred to ambulatory care services, left against medical advice, or died. It is rare to find clearly differentiated sections. Although there may be some variability from facility to facility, most will follow the general pattern presented in this section.
Medical records contain a lot of abbreviated medical terminology. It is important to know what these terms mean in order to understand what is written in the medical record. A list of common abbreviations found in medical records is presented at the end of this module in the appendix.
Figure 8.8 Health care worker reviewing medical records.
This is a picture of a health care worker reviewing medical records
The main sections of the patient's medical record are as follows:
Identification data, including the patient's name, address, social security number, date of birth, and other demographic information (may be a separate registration form)
Progress notes, in which all physicians and other specialists continuously record patient information during a patient's hospital stay; they are an important resource for information and may include nurses' notes and notes from other ancillary staff
Nurses' notes, in which the nurses who directly care for the patient continuously record information, including the patient's symptoms, medications given, and scheduled procedures or activities, and may be included in the progress notes section
Physician's orders, in which the physician(s) prescribes medications, orders laboratory tests or procedures (for example, bronchoscopy or gastric aspiration), and delivers other patient-care instructions to staff. Medication orders specify date, name of medication, dosage, and duration of treatment (in days or in number of doses)
Medication record, an information sheet on which the nurses record the date, time, and amount of prescribed medications given to the patient during hospitalization or care in a facility; may not be included in patient's medical record (for example, may be kept in a separate medication logbook)
Laboratory results, records presenting the results of every laboratory test that has been done on the patient, such as AFB smear examinations, cultures, and drug susceptibility tests performed in a laboratory
Radiology reports, reports summarizing all radiology procedures performed on the patient (for example, chest radiographs or CT scans)
Knowing how the basic sections of a medical record are organized can help the public health worker locate important patient information. The best place to begin is usually the progress notes.
Progress Notes. The progress notes section contains a great deal of information, and is often preceded by
An admission note, patient information recorded at the time of admission to a hospital, usually including the admission diagnosis and initial plan for diagnostic work-up; usually included in the progress notes.
A history and physical exam (H&P) form, a standardized form sometimes used to record patient information at the time of the patient's first evaluation; may be used instead of an admission note and is usually included in the progress notes.
An emergency room/department assessment form, patient information recorded when a patient is brought to an emergency room; may be used instead of an admission note and is usually included in the progress notes.
These forms are used to record patient information at the time of the patient's first evaluation. This section should contain a patient's full medical history, his or her reasons for hospitalization, and the physician's initial diagnosis and plans for evaluation.
General Outline for Admission Notes
|Chief complaint||The patient's symptoms and reason for seeking medical help|
|History of present illness||A full history of the current illness|
|Past medical history||All relevant medical and surgical information and prior hospitalizations|
|Social history||The patient's marital status, occupation, and any social problems (for example, alcohol or drug abuse)|
|Family history||A brief description of illnesses or cause of death in the family|
|Physical exam||A record of the findings of a full physical exam|
|Laboratory||The results of laboratory tests done on admission|
|Radiology||A record of all radiology procedures (i.e., chest x-rays) done on admission|
|Assessment||A brief summary of the preceding sections and a statement of the possible diagnoses|
|Plan||Usually a problem list and the plan for diagnosis and treatment|
Following the admission note, the physicians caring for the patient write daily progress notes for the patient and any results from the ongoing diagnostic evaluation. These are usually dated and sometimes will be titled, too. Progress notes are occasionally referred to as SOAP notes and include
- Subjective progress - symptoms
- Objective progress - relevant medical, laboratory, or exam results
- Assessment - An evaluation of the patient's illness and progress
- Plans - plans for further diagnostic tests or treatment
Other notes in the progress section may include
- Service notes (used to give information to the next physician in a rotation)
- Consultation notes from specialists (for example, infectious disease physicians or social workers)
- Notes of procedures performed on the patient (for example, sputum induction or bronchoscopy)
The progress notes section contains a great deal of information,
much of which is repetitive or irrelevant to TB care. It is helpful
if the section is organized chronologically, with a title and the
date of the note recorded in the first line; unfortunately, this
is not always the case. Depending on the facility's procedures,
sections may be grouped
- In an integrated, strictly chronologic sequence
- By department or specialty
- In a "problem-oriented" format that divides the record by the patient's major presenting problems
Rarely, the medical records for a family are grouped together into a single file.
TB-Related Information. The public health worker should check the admission notes for information on prior treatment (completed or not) with TB medications or evidence of a prior hospitalization for TB. Again, if this is missing from the medical record for a patient with a past history of TB, the public health worker should search the TB program records and provide this information to the patient's providers. The patient's past medical history and the possible diagnoses listed in the assessment section may also include important information about previously documented TB infection or medical conditions that can increase the risk that TB infection will progress to disease (for example, HIV infection, injection of illicit drugs, or immunosuppressive therapy); the public health worker should make a note of these conditions when present. The public health worker may also find information about the patient's current living situation and potential barriers to completion of therapy.
Table 8.5 summarizes important information and the most likely places it can be found.
The health care worker should have a standard form or checklist to gather important information from the patient's medical record and other sources to report back to the health department.
TB-Related Information in the Medical Record
|Type of Information||Probable Location|
|Patient identification||Identification data sheet or registration form|
|Locating information||Identification data sheet
Progress notes by social workers
|Status of TB diagnosis||Admission note (under history of present illness
Laboratory results section
|TB exposure||Admission note (under history of present illness,
past medical history, or family history)
|TB symptoms||Admission note (under chief complaint or history of present illness)|
|Past history of TB||Admission note (under history of present illness or past medical history)|
|Skin test results||Admission note (under history of present illness)
Progress notes, especially nurses' notes
|Chest radiograph readings||Admission note (under laboratory)
Laboratory results section
|Response to treatment||Progress notes
Laboratory results section
|Social history||Admission note (under past medical history and social
Progress notes by nurses and social workers
Figure 8.9 Sample of a medical records abstract form; adapted from the New York City reporting form.
This is an example of a medical records abstract form.
Diagnosis. The public health worker should follow the daily progress notes chronologically to find skin test results. The administration of the PPD should be noted, followed by the results (in millimeters of induration) 48 to 72 hours later. This information may be included in the nurses' notes, if these are separate. If no results are given and the PPD has not yet been read, the public health worker may need to read the skin test reaction himself or herself; however, the public health worker should never record results in a medical record. It is better for the public health worker to ask a nurse from the institution to read the skin test and document the results in the patient's record.
Look in the radiology section for chest radiograph readings. When reviewing these reports, look in the concluding summary for a mention of cavities, infiltrates, pleural effusions, or hilar adenopathy and words like "stable" or "improving."
The public health worker's source for smear and culture results should be the actual report included in the laboratory results section or the laboratory's records. When smear or culture results are listed in the laboratory results section as pending, record the specimen number and date of submission and collect the results from the laboratory, provided adequate time has elapsed since specimen collection. All laboratory results listed in the progress notes should be verified for accuracy.
Treatment. When looking for information on the current treatment regimen, the public health worker should use the medication record section. This is the most accurate record of which doses were actually given and when; orders written in the physician's orders section will sometimes not be immediately acted upon. Some hospitals or institutions use a separate book to record all medications administered to patients on a specific ward. The public health worker should clarify with hospital staff what is meant by administration of medication; often, this does not include watching the patient swallow the medication. If the public health worker is aware of potential adherence problems, he or she may request that the administering nurse provide DOT.
To evaluate the patient's response to treatment, the public health worker should find information on the patient's symptoms in the admission note and the start date of his or her medication. The public health worker should look through the medical record from this date on for specific TB symptoms (especially cough, fever, and weight loss). Also, the public health worker should look through the laboratory results section for smear and culture results on specimens collected after treatment has begun.
It is important to collect information on the patient's potential adherence in order to plan for and arrange the patient's care both during and after hospitalization or stay in an institution. Information about potential adherence problems may come from the patient's medical record, social worker, nursing staff and physicians, and family members or other visitors.
To help evaluate the patient's potential adherence to therapy, it is important to note pertinent social history. The public health worker should find out if the patient is foreign-born or does not speak English; if so, the public health worker will need a translator for the patient interview and subsequent care. The public health worker should look for and note a history of residence in a congregate setting such as a prison, nursing home, hospital, or shelter. Also, note any history of drug or alcohol abuse, homelessness, mental health problems, or previous nonadherence.
After reviewing the patient's medical record thoroughly, the
public health worker should summarize important information in a
clearly written, organized report. This is important, because once
a patient is discharged, the medical record becomes more difficult
to access. A thorough review while the patient is in the facility
can save the public health worker a great deal of backtracking and
extra work at a later date. The public health worker may also need
to formulate an action plan for determining
- What information is missing or pending?
- Where and when to collect this information?
- Who will need the information?
|Study Questions 8.13-8.16
8.13. How should a public health worker locate a patient in a facility and where would he or she find patient addresses?
8.14. Where can smear and culture results for a reported TB case be found?
8.15. Describe seven main sections of the patient's medical record.
8.16. Why is it important to gather information on the patient's potential adherence?
|Case Study 8.4
You have received notification of a suspected TB case in Hospital Y and have located the patient's medical record. The admission note reads as follows:
This is a 35 y.o. man presenting with a productive cough, CP, and hemoptysis. On exam he is found to be cachectic with coarse breath sounds bilaterally. Lab values are significant for a low WBC. He has a cavity in the LUL on CXR. Most likely diagnosis is TB, however will r/o pneumonia.