Ch # 38: The Medical Record Flashcards
The name 4 a physician who is responsible 4 the care of a hospitalized patient
Attending Physician
The statement of the most important symptom(s) 4 which a patient is seeking care
Chief complaint
A clinical section of the medical record
It’s a narrative report of an opinion about a patient’s condition from a practitioner other than the attending physician
Requirements 4 this report include: - documentation that the physician reviewed the patient's health history and examined the patient - physician's impressions - any care or treatment provided - any recommendations
Consultation report
The scientific method of determining and identifying a patient’s condition
Diagnosis
A procedure performed 2 assist in the diagnosis, management or treatment of a patient’s condition
This type of procedure can include a variety of reports:
- EKG
- holter monitor
- spirometry
- radiology
- diagnostic imaging
Diagnostic procedure
A picture that is stored electronically 2 allow viewing on a computer
Digital image
A brief summary of the significant events of a patient’s hospitalization
Discharge summary report
The process of making written or electronic entries about a patient in the medical record
Documenting
2 names 4 a patient health record that is stored on a computer
Contains important health info on the patient including the care received and the progress of the patient’s condition
It incorporates software 4 scheduling, billing and filing insurance claims
Electronic medical record
(EMR)
Electronic health record
(EHR)
Occurring in or affecting members of a family more frequently than would be expected by chance
Familial
A paper document or electronic screen that allows similar data 2 b recorded and viewed chronologically
Flow sheet
A collection of subjective data about a patient
Health history
A type of continuity of care report
The provision of medical and nonmedical care in a patient’s home or place of residence because familiar surroundings contribute positively to a patient’s emotional and physical well-being (and is a lot cheaper than inpatient care).
This must be ordered by a patient’s physician 4 the purpose of minimizing the effect of disease or disability by promoting, maintaining and restoring the patient’s health.
The skilled professional that provides the care must periodically provide a summary report 2 the patient’s physician and includes the following information:
- observations and evaluations
- type of care or service provided
- instructions given 2 the patient about medications
- safety measures recommended 4 the home
- diet
- activities permitted
Home health care
A patient who has been admitted 2 a hospital 4 atleast 1 overnight stay
Inpatient
A written record of important information regarding a patient, including the care of that individual and progress of the patient’s condition
Serves as a legal document
Medical record
The way that a medical record is organized
2 types: source-oriented record
problem-oriented record
Medical record format
A symptom that can b observed by an examiner
Objective symptom
2 names 4 a medical record in paper form
It’s more time consuming and takes up a lot of storage space compared 2 digital records
Paper-based patient record
Problem-oriented medical record
An assessment of each part of the patient’s body 2 obtain objective data about the patient that assists the physician in determining the patient’s state of health
Physical examination
Any condition that requires further observation, diagnosis, management or patient education
Problem
Arranging documents w/the most recent document on top or in front, which means the oldest document is on the bottom or at the back of a section or file
Reverse chronological order
A method of organization 4 recording progress notes
Contains 4 categories: Subjective data
Objective data
Assessment
Plan
SOAP
A symptom that is felt by the patient but is not observable by an examiner
Subjective symptom
Any change in the body or it’s functioning that indicates the presence of disease
Symptom
Was part of the 2009 stimulus package that has accelerated the adoption of EMR’s because of financial incentive payments 4 medical offices that made the conversion
Health Information Technology 4 Economic and Clinical Health Act
(HITECH)
A type of record format that is used for organizing a paper-based patient records
They r organized in2 sections based on the department, facility or other source that generated the info. Within each section the documents r arranged by date
Because documents from each source r filed 2gether, it is easier 2 compare info from lab or diagnostic test results, assessments and treatments
Source-oriented record
A type of medical record format that is organized according
2 the patient’s health problems
Developed in 4 stages:
1) establishing a database
2) compiling a problem list
3) devising a plan of action 4 each problem
4) following each problem w/progress notes
Allows 4 each of the patient’s problems 2 b defined and followed individually
Problem-oriented record
POR or POMR
1st step in developing a POR
Consists of a collection of objective and subjective data:
- health history report
- physical examination report
- results of lab or diagnostic tests
This information is used to identify and compile a problem list
Database
2nd step in developing a POR
This is a list of all the patient’s conditions and they require observation, diagnosis, management or patient education
This list is made up of physiological, psychological and social problems.
Problem list
3rd step in developing a POR
This involves devising a course to take for further evaluation and treatment 4 each problem
Plan
4th and final step in developing a POR and a clinical section of the medical record
This section is up dated every time the patient visits or calls the medical office and is documented and signed by the MA (this includes credentials, date and time)
This is the follow-up stage 4 each problem the patient has and is organized in2 4 categories:
1) Subjective data
2) Objective data
3) Assessment
4) Plan
Progress notes
A type of medical record format that combines elements from the POR and the source-oriented formats.
This record is divided in2 3 categories:
1) clinical
2) scheduling
3) billing
EMR format
A type of administrative form
It consists of demographic and billing information
This information is used 4:
- scheduling appointments
- posting patient transactions
- processing patient statements and insurance claims
Patient registration records
A type of administrative form
A written document that explains 2 patients how their protected health information (PHI) will be used and protected by the medical office.
Notice of Privacy Practices
NPP
A type of administrative form
This form names an individual 2 make medical decisions 4 the patient should the patient become incapacitated and/or state the patient’s wishes if they become unable 2 direct care
Advanced directives
A type of administrative form
This form is a legal document that is required in order 2 perform certain procedures or 2 release information contained in the patient’s medical record
This signed form is required 2 perform all surgeries and nonroutine therapeutic and diagnostic procedures
Consent form
A type of administrative form
Anything other than medical treatment, payment or health care operations require this detailed form be filled out and signed by the patient or legal guardian
Data requirements 4 this form include:
- patient’s full name and address
- name of the medical practice releasing the PHI
- name of individual or faculty receiving the PHI
- specified information 2 b released
- purpose or need 4 the information
- method of release of the PHI
- signature of the patient or legal guardian
- date signed
- expiration date
Medical records release form
A type of administrative form
This form is filled out anytime anyone or any facility contacts the medical office regarding the patient (including the patient)
Correspondence and messages
A type of administrative form
This form contains information on future appointments and payment information
Schedule and billing information
A section of the medical record that includes a variety of records and reports that assist the physician in the care and treatment of the patient
These sections include the patient’s:
- database
- problem list
- progress notes
- laboratory data
- diagnostic procedures
- continuity of care
Clinical section
A clinical section of the medical record
The information of the patient it includes are:
- health history
- physical examination
- allergies
- medication record
Database
A clinical section of the medical record
This section is up dated at every time the patient has an appointment so that active problems can b identified.
It helps the provider organize and plan appropriate care 4 the patient
Problem list
A clinical section of the medical record
These reports are usually filled 2gether in a paper-based medical record and can b accessed from 1 tab in an EMR
Laboratory data
A type of diagnostic procedural report
This is a narrative report of a cardiologist’s interpretation of an EKG test and it includes the implications 4 the patient
EKG report
A type of diagnostic procedural report
This is a narrative description of the interpretation of a 24 - 48 hour EKG and includes the evaluator’s impressions
Holder monitor report
A type of diagnostic procedural report
This is a narrative and graphic description of the interpretation of a patient’s breathing capacity as measured w/a spirometer
Spirometry report
A type of diagnostic procedural report
A narrative description of a diagnostic or therapeutic radiologic procedure and includes a detailed interpretation of the radiograph and their impressions
Radiology report
A type of diagnostic procedural report
This is a narrative description of a diagnostic imaging procedure and includes a detailed interpretation of the diagnostic image and the practitioner’s impressions
Diagnostic imaging report
A clinical section of the medical record
This section is 4 summary care reports which are generated anytime a patient is referred 2 another setting of care or provider of care.
This section includes a variety of reports:
- consultation
- home health care
- therapeutic service documents
- hospital documents
Continuity of care
A type of continuity of care report
This type of report documents the assessments and treatments designed to restore a patient’s ability 2 function.
Some examples include:
- physical therapy
- occupational therapy
- speech therapy
Therapeutic services documents
A type of continuity of care report
These documents are prepared by the attending physician anytime a patient stay’s in the hospital or visits the ER. A copy is sent to the patient’s primary care physician and this aide’s the primary in reviewing the hospital visit and providing follow-up care.
Hospital documents
