BASIC MEDICAL DOCUMENTATION Flashcards
Basic Medical Documentation & RECORDS
IF not documented, it didnt exist
*Info about pt medical history & present condition
*Used as comm tool and legal document
*Used for pt & Staff education, quality control & research
*Provides a map or plan for continuity of care
documentation for billing & coding
Support pt claim of malpractice
Support dr in defense of claim
SOAP DOCUMENTATION
Subjective - chief complaint
Objective - measurable by data - vitals, labs, measurements
Assessment - Medical Diagnosis
Plan - For treatment
PATIENT INTERVIEW
First step in exam process
establishes a relationship
exchange information
REASON FOR APPOINTMENT
COULD BE:
routine check up
Follow up
Established patient with symptoms
New patient
Determine chief complaint
Subjective statement by patient describing most significant symptom - CHIEF COMPLAINT. identify and signs or symptoms that pt may be experiences that may reveal info about illness / condition
Objective
Vitals: includes Pulse, respirations, blood pressure and pain assessment
Systolic BP - top number
presssure when left ventricle contracts
Diastolic
pressure when heart relaxes, minimum pressure exerted against artery walls
Respiration
how well body provides oxygen to tissues
one inhale and one exhale = 1 respiration
Normal - 12-20 breaths / minute
Count SUBTLY so respirations arent altered subconsicously
PULSE
**Measure at radial artery
Count for 30 x 2 or 1 minute
If irregular, count for 1 minute
Normal - 60 - 100
Pulse greater than 100
Tachycardia
Pulse less than 60
Bradycardia
PULSE - RHYTHM
Regular or irregular
PULSE VOLUME
weak, strong, bounding
Apical Pulse
for infant, use stethoscope in apex, 5th intercoastal space between ribs on left and sternum of chest
Contents
*general info
* contact info
*occupation
*medical history
*Current complaint
*Healthcare needs
*treatment plan or services provided
*radiology and lab reports
*response to care
*registration form
*Date of visit
*legal name, address, phone number, email address
*DOB, marital status, sex and SSN
*emergency contact
*PCP
Social History: Diet, exercise, smoking, alcohol & Drug use
*family medical history
Chief complaint in patients own words
*Patients written request to release records
*Hospital discharge forms
*telpehone calls
*specialist evaulations
*consent forms, signed and witnessed
NON COMPLIANT PATIENT
terms used to describe a pt who does not follow received medical advice
Patient’s rights - CONFIDENTIALITY re: PHI (Protected health information)
RIght to:
1) Notice of privacy practices
2) limit / restrict use of PHI
3) Confidential communications
4) Inspect and obtain PHI
5) Request ammedment to PHI
6) To know if PHI has been disclosed and why
SOMR records
Source oriented medical records
Info grouped by progress notes, labs, radiology, correspondence
SOAP Documentation - Subjective, Objective, Assessement and Plan
CHEDDAR FORMAT - expands on SOAP
Chief complaint
History
Examination
Details
Drugs & Dosage
Assessemnt
Return visit info or referral
6 Cs of Charting
1) CLIENT WORDS
2) CLARITY
3) COMPLETENESS
4) CONCISENESS
5) CHRONOLOGICAL ORDER
6) CONFIDENTIALITY
CHART RULES
Blue or black ink only
Mistakes: Draw line thru original info, insert correct info, date, time and initial
Use only approved abbreviations
pay attention to spelling
DOCUMENT MEDS
Ask for list or actual meds
Never ask patient if meds are the same from last time
Active listening
Using techniques that allow the reciever to fully understand the message being communicated
OPEN ENDED QUESTIONS
Questions that lead to more info
NOT YES OR NO
Restatement
repeating or rephrasing information
Reflection
When the Pt focuses on main topic but incorporates feelings or opinion
Clarification
Summarizing the info relayed to clear up confusion
Non verbal communication
gestures and actions that leave interpretation up to receiver
CLOSE ENDED QUESTIONS
YES OR NO
Chief complaint
reason for visit
Recording
NO Personal or subjective comments, judgements, opinions or speculating
May call attention to problems or observations by attaching note to chart or sticky note to dr. NOT PART OF MEDICAL RECORDS
Release of Records Request
Records are property of practive
Written consent needed to release - ROI FORM
File release in record
Verbal consent is a NONO
Interviewing Skills
Listen and comprehend details
Look at patient directly
Pay attention
Provide feedback and restate info
Be aware - watch closely:
Non verbal cues: Facial expressions, gestures, tone of voice, body language, appearance
For Successful interview
DO Research (review record and ensure reports are there)
Request the interview (ask pt if ok to speak to them about their medical issues)
Make the patient feel comfortable, create a relaxed atmosphere
Ensure privacy - no interruptions
Be respectful with sensitive topics (Watch your non verbal cues)
Do not diagnose or give opinion
Formulate general pic of signs / symptoms
Summarize key points
Ask if patient has questions
