Chapter 11 Flashcards
-Medical records should include the following general information about the patient
- Address and phone number
- Occupation
- Medical history
- Current complain or condition
- Healthcare needs
- Treatment plan or services
-Radiology and lab reports - Response care
If information is not documented______
no one can prove that an event or a procedure took place.
What is documentation?
Is the process of recording information in the medical
What is the term noncompliant?
Is the medical term used to describe when the patient is not following the medical advice
What happen when there is inappropriate or inaccurately in a patient’s medical record in a court of law?
The practitioner also will be held responsible for that action
Patient medical records are frequently used to evaluate the quality of care and treatment a facility or specific physician provides.
Quality of Care
Team may be testing a new antihypertensive drug with volunteers who fit a certain medical category perhaps males between the ages of 45 and 54
Medical Research
What is the second part of the registration process?
The patient past medical history
- Illness, Surgeries, known allergies, and current medication, family history, social history and occupational.
Patient medical history is also know
As the history of present illness or HPI.
What is the review of system ?
Is an inventory of the body obtained by the healthcare provider through a series of questions.
What the purpose of review of systems?
To identify any signs or symptoms the patient is experiencing that reveal information about an illness or condition.
What is the hospital discharge summary?
The reason the patient entered the hospital
What include in the hospital discharge:
- Date of admission
- History of present illness
- Date of discharge
- Admitting diagnosis
- Surgeries or procedures
- Complications
- Patient instructions for follow up
- Discharging physician’s signature
What is a consent form?
Is a signed informed consents must be obtained when any procedure is being performed on a patient.
Dating and Initialing you should
must be careful not only to date everything you put into the patient chart but also to initial each entry.
Patient information is arranged within the medical record according to the provider type supplying the data.
Source-oriented medical record (SOMR)
What includes SOMR?
Includes areas for data from the patient treating provider, specialist, labs, hospitals or other locations to document in the record
One way to overcome the disadvantages of the source-oriented approach is to use the
problem-oriented medical record (POMR)
Includes a record of the patients past medical history; information gained in the initial interview with the patient.
Database
Each condition or diagnosis a patient has is listed seperately and given its own number, including the date onset.
Problem List
Signs are
objective or external
Symptoms are
subjective or internal
Each problem should have a
detailed educational, diagnostic, and treatment summary in the record
Are entered for each problem listed in the initial record.
Progress note
What stand each letter in SOAP?
S - Subjective data from the patient
O - Objective data come from the practitioner, examination
A - Assessment is the diagnosis or impressions
P - Plan of action treatment options
Cheddar stand for:
-C: Chief complaint
-H: History past medical history
-E: Examination
-D: Details of problem and complaints
-D: Drug and dosage
-A: Assessment of diagnostic process
-R: Return of visit
Every time a patient has has an X-ray or lab test or a letter arrives from a specialist order should be
inserted into the medical record and always in reverse chronological order which means the most current result will always be on the top
1- Client’s word
Be careful to record the patient exact words rather than your interpretation of them
2- Clarity
Use precise description and accepted medical terminology when describing a patients condition
3- Completeness
Fill out completely all the forms used in the patient record
4- Concisness
While striving for clarity also be concise or brief and to the point
5- Chronological order
All entries must be dated to show the order in which they are made
6- Confidentiality
Always remember that the information from the patient should be confidential
Means transforming spoken notes into accurate written form
Transcription
The healthcare provider must be able to trust the _______ of the information in the medical records.
Accuracy
What is the proper way to correct a mistake in a medical record?
Draw a single line through the error, making sure that the original entry is still legible.
If there is not enough room near the error to make full correction make
make a notation near the error as to where in the chart the correction may be found. and note the date and reason for the correction and initial the completed correction
Steps for realizing medical information
1- Obtain a signed and newly dated release from the patient
2- Make photocopies of the material
3- Call the recipient to confirm that all materials were received.
The a audit a record means
a records means to examine and a review a group of patient records for completeness and accuracy
What is internal audits?
The medical staff can perform internal audits.
What is external audits?
Government entities managed care organizations and private insurance carriers perform external audits.
