Basic Medical Documentation Flashcards
What are some roles of medical assistants?
- documentation: recording information in the medical record
- maintenance: verifying accuracy
- releasing: with proper signatures and verification
What is the purpose of medicla records?
- support patient claims of malpractice against a doctor
- support the doctor in defense against a claim
- back up the information within the financial record
What is a noncompliant patient?
medical term used to describe a patient who does not follow the medical advice they receive
What is the content of the patient medical history?
- past illnesses, surgeries
- family medical history
social history (food, drinks, drugs) - history of present illness
What contents are found on a patient’s medical record?
- laboratory results and tests
- release of records
- operative reports, hospital discharge forms
- telephone calls
- specialist evaluations
- consent forms
What is included in a physical examination form?
- review of systems: identifies any signs or symptoms the patient may be experiencing that may reveal information about an illness
- doctor’s diagnosis and treatment plan
What are the patient rights regarding their PHI?
- right to notice of privacy practices
- right to limit or request restriction on their PHI and its use and disclosure
- right to confidential communications
- right to inspect and obtain a copy of their PHI
- right to request an amendment to their PHI
- right to know if their PHI has been disclosed and why
What is PHI?
protected health information
What is SOMR?
source-oriented medical records
How should SOMR information be grouped?
- progress notes
- laboratory
- radiology
- correspondence
What order should forms and progress notes be filed in?
reverse chronologic order
- newest on top
What is SOAP documentation?
S - subjective: chief complaint
O - objective: measurable data, vital signs, lab results, measurements
A - assessment: medical diagnosis
P - plan: treatment
What is the CHEDDAR format?
C - chief complaint, presenting problems, subjective statements
H - history, both social and physical
E - examination, including extent of body systems examined
D - documented details
D - drugs and dosage
A - assessment of diagnostic process and diagnosis
R - return visit information or referral
What color ink should we use for notes?
black or blue
- highlight specific items like allergies
How do you mark out mistakes?
single strike through line then insert correct information
- include date, add time, and initial correction
What is a release of information form?
- indication of who will receive the records and a reason
What is the legal and ethical principle?
protects the patient’s right to privacy at all times
Who is considered an adult?
- 18 years old
- emancipated minor
- mature minor (STI, birth control, drug or alcohol counseling)
What is an audit?
to examine and review a group of patient records for completeness and accuracy
Why are audits done?
- determine their ability to back up the charges sent to health insurance carriers
- verify that the medical documentation meets required minimum standards
What are the 2 types of audits and their features?
1) internal audits:
- review of their ability to back up the charges sent to health insurance carriers
- look for “failure to document”
- meet the required standards
2) External audits:
- performed by government entities, managed care organizations, and private insurance carriers
- to see if medical record documentation backs up billing
What must be established in a patient interview?
- a relationship
- information exchange
- reason for appointment
- chief complaint
What nonverbal clues should we pay attention to?
- facial expressions
- gestures
- tone of voice
- body language
- appearance
What are the main steps to interview a patient successfully?
- do research (review medical record)
- request the interview (consent)
- make the patient feel comfortable
- ensure privacy/no interruptions
- be respectful with sensitive topics
- don’t diagnose or give opinion
- summarize key points of signs and symptoms
- repeat back a summary of the information
- ask open-ended and closed-ended questions
- repeat information relayed by the patient
- clarify information
What are the 6 C’s of charting?
1) Client’s word - record exactly
2) Clarity - use medical terminology and precise descriptions
3) Completeness - fill in forms
4) Conciseness - saves time and space when you are recording information
5) Chronological order - date all entries
6) Confidentiality - protects patient’s privacy
How should you document all current medications?
- ask to see a list or actual medications
- never ask if they’re taking the same medications as last time
- encourage patients to maintain a current list of medications
