BASIC MEDICAL DOCUMENTATION

Question 1

Basic Medical Documentation & RECORDS
IF not documented, it didnt exist

Answer 1

*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

Question 2

SOAP DOCUMENTATION

Answer 2

Subjective - chief complaint
Objective - measurable by data - vitals, labs, measurements
Assessment - Medical Diagnosis
Plan - For treatment

Question 3

PATIENT INTERVIEW

Answer 3

First step in exam process
establishes a relationship
exchange information

Question 4

REASON FOR APPOINTMENT

Answer 4

COULD BE:
routine check up
Follow up
Established patient with symptoms
New patient

Question 5

Determine chief complaint

Answer 5

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

Question 6

Objective

Answer 6

Vitals: includes Pulse, respirations, blood pressure and pain assessment

Question 7

Systolic BP - top number

Answer 7

presssure when left ventricle contracts

Question 8

Diastolic

Answer 8

pressure when heart relaxes, minimum pressure exerted against artery walls

Question 9

Respiration

Answer 9

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

Question 10

PULSE

Answer 10

**Measure at radial artery
Count for 30 x 2 or 1 minute
If irregular, count for 1 minute
Normal - 60 - 100

Question 11

Pulse greater than 100

Answer 11

Tachycardia

Question 12

Pulse less than 60

Answer 12

Bradycardia

Question 13

PULSE - RHYTHM

Answer 13

Regular or irregular

Question 14

PULSE VOLUME

Answer 14

weak, strong, bounding

Question 15

Apical Pulse

Answer 15

for infant, use stethoscope in apex, 5th intercoastal space between ribs on left and sternum of chest

Question 16

Contents

Answer 16

*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

Question 17

NON COMPLIANT PATIENT

Answer 17

terms used to describe a pt who does not follow received medical advice

Question 18

Patient’s rights - CONFIDENTIALITY re: PHI (Protected health information)

Answer 18

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

Question 19

SOMR records
Source oriented medical records

Answer 19

Info grouped by progress notes, labs, radiology, correspondence

Question 20

SOAP Documentation - Subjective, Objective, Assessement and Plan

Question 21

CHEDDAR FORMAT - expands on SOAP

Answer 21

Chief complaint
History
Examination
Details
Drugs & Dosage
Assessemnt
Return visit info or referral

Question 22

6 Cs of Charting

Answer 22

1) CLIENT WORDS
2) CLARITY
3) COMPLETENESS
4) CONCISENESS
5) CHRONOLOGICAL ORDER
6) CONFIDENTIALITY

Question 23

CHART RULES

Answer 23

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

Question 24

DOCUMENT MEDS

Answer 24

Ask for list or actual meds
Never ask patient if meds are the same from last time

Question 25

Active listening

Answer 25

Using techniques that allow the reciever to fully understand the message being communicated

Question 26

OPEN ENDED QUESTIONS

Answer 26

Questions that lead to more info
NOT YES OR NO

Question 27

Restatement

Answer 27

repeating or rephrasing information

Question 28

Reflection

Answer 28

When the Pt focuses on main topic but incorporates feelings or opinion

Question 29

Clarification

Answer 29

Summarizing the info relayed to clear up confusion

Question 30

Non verbal communication

Answer 30

gestures and actions that leave interpretation up to receiver

Question 31

CLOSE ENDED QUESTIONS

Answer 31

YES OR NO

Question 32

Chief complaint

Answer 32

reason for visit

Question 33

Recording

Answer 33

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

Question 34

Release of Records Request

Answer 34

Records are property of practive
Written consent needed to release - ROI FORM
File release in record
Verbal consent is a NONO

Question 35

Interviewing Skills

Answer 35

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

Question 36

For Successful interview

Answer 36

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