chapter 17 Flashcards
What do healthcare providers do to patient records (5)
enter it into the computer edit it file it search in it retrieve it
What must healthcare professionals adhere to
HIPPA
Health insurance portability and accountability act
name some documents in a patients record
insurance form patient health record physician order notes test reports
What is the most used medical record system
the electronic medical record system
- computerized documentation has transformed record keeping
What are two main purposes of organized medical documentation
What are the 4 less obvious purposes?
- communicating with other HC professionals
- describing patient’s current medical condition and history
- reimbursement requests
- maintaining a legal record
- education
supporting research
Describe communication and medical documentation
a patient has several healthcare providers, which do not interact. the medical documentation allows each healthcare professional to have access to accurate records
What does a patient’s health and well being depend on
the accuracy of his/her medical records
What are the four assessment data
vital signs - temperature - pulse - blood pressure - respiration rate circumstances surrounding visit symptoms medical history
What helps determine the right diagnoses and treatment plans
current and past assessment information
What is quality assurance
to provide evidence of the quality of care a patient received and the competence of the professionals who provided the care
How is quality assurance checked
a committee might select random medical records to review and compare to standards of care
OR
Accrediting agencies may review medical documents to determine whether an institution is meeting its standards
What happens if quality assurance defeciences are found
in service training is provided
Link patient records to reimbursment
Patient records verify the care a patient received when a provider seeks reimbursement from the insurance or government plan/policy.
What type of documents are used in reimbursement (5)
- reason for patients visit
- type of care made
- diagnosis made
- test ordered
- treatments provided
overall the plan administrator’s decision about how much the provider will be paid is dependent on this
What do medical record systems assign to the services a patient receives
a code
- the code is submitted to the insurance company or government plan for review
What two things do insurance companies or government plans review
billing codes
patient records
What three standards should healthcare professionals adhere to
legal
moral
ethical
= if not this results in a breach of contract
= the provider is subject to fines or lawsuits
When are patient records useful in court
if a healthcare professional is charged with improper care or malpractice
when a patient makes accident or injury claims
How are patient records used in education
providers use patient records as educational tools to train new people in the field
can be used during clinical portions of health education programs
Why do researchers use patient medical records
learn how to best recognize or treat health problems by examining similar cases
What three uses come form data gathered from patient records
- significant similarities in disease presentation
- contributing factors
- effectiveness of therapies
What advantages does computerized documentation have over traditional paper charts (6)
- information is easy to store and retrieve
- unlimited file space
- easy to backup for extra security
- information is easily added and attached
- charting is easier to read
- typing is faster than writing
What does computerized documentation allow that handwritten doesnt
multiple users to access the same portion of a record simultaneously
- ease of access
why do hc facilities use computers (3)
order supplies and services
store billing and financial data
maintain health care information
what has the increased use of computerized medical information brought about the need for
policies and procedures ensuring privacy and confidentiality of patient information
what should patient privacy policies state (3)
which types of patient information can be retrieved
who can retrieve information
why can someone retrieve information
What are recommendations by AHIMA for safe computer recordkeeping (9)
- never give personal password or signature to others
- do not leave computer terminal unattended after logging on
- follow correct protocol for correcting errors (e.g. mistaken entry or mistaken entry-wrong chart)
- allow authorized personnel to create, change, delete records
- ensure that records are backed up
- do not leave patient information on display
- keep a running log of electronic copies made of computerized files
- never use email to send protected health information
- follow agency confidentiality procedures for documenting sensitive material
What is a patients medical record
compilation of health-related information. permanent recordd etailing medical history, test results, and interactions with healthcare professionals
when is an admission sheet used
used to gather information from the patient before the visit with the provider.
- may be mailed to new patients before scheduled visit
What two types of data does admission information include
demographic data
insurance information
When is admission information updated? why
once a year
- a lot of patient information included address, phone number, insurance can change in one year
What do most healthcare facilities require with admission forms
copy of patients health insurance forms
What type of data does a graphic or flow sheet record
vital signs
- respiration rate
- blood pressure
- pulse
- temperature
weight
height
What is a graphic or flow sheet
used to record and monitor patient variables over time in a GRID LIKE FORM
what does a graphic sheet contain
history of patient vital signs and the date they were taken
- fluctuation in measurements can affect a person’s health
what is the physician’s order section
section of the patient record documents any orders for patient care including
- medications
- treatments
- tests
- follow up care
What does the physician’s orders section include (4)
information relating to the order
- medication dosage
- treatment specifics
- type of testing to be conducted
- dates for follow up care
what is the advantage of ‘physician’s orders’ being electronic
providers can send information to health care professionals including pharmacists, specialists, lab technicians
eliminates human error caused by lost paperwork and misread orders
what are progress notes
record each contact a provider has with the patient, whether in person, phone, mail, email
what information may be in progress notes
provider summarizes findings that resulted from the contact
- effects of treatment
- change in condition
- other provider information
provides snapshot of treatment, progress, and issues
provider must record date and time of entry + name
Why should progress notes be electronic
progress notes do not follow a standard format, so handwritten ones may be difficult to read
= leaves little room for human error and misunderstandings
What is in a medical history and examination sheet
patient history family history social history results of physical examination current medical condition
what does the patient history section do
address patient’s current and prior health status and helps provider plan appropriate care for present illness
what is in the patient history section (7)
allergies immunization childhood disease current and past medication previous illness surgeries hospitalizations
why is the family history section improtaant
some diseases may be hereditary
some diseases may be familial
cause of death of prev. family members
what does social history information cover (4)
patient lifestyle
- martial status
- occupation
- education
- hobbies
patient diet
use of alcohol and tobacco
sexual history
why is the social history information important
provide guide for patient education
what is the reports section of patient’s record
reports or findings from tests/lab work
tests in provider’s office and other
what is the correspondences and miscellaneous documentation section
correspondence
- correspondence btwn. provider and patient
- letter or memos a provider send to to others concerning patient
- correspondence regarding patient recieved from other provider
miscellaneous
- HIPPA privacy notice
- end of life decisions
- organ dontation, living will, durable power of attorney
what are the 5 char. of good med. documentation
accuracy completeness conciseness legibility organization
what 3 things should be ensured in accuracy
correct spelling, med term, abbreviation, acrononym
all entries include facts
errors are marked good
how should errors be marked in paper and electronic documentation
crossed with single line and identified with word error in paper
add note called mistaken entry in electronic
- initials
- date
- time
what is a key rule of accuracy in medical documentation
DO NOT delete or erase anything
what is the first rule of accuracy
make sure you are working on the correct patient
describe conciseness in medical records
brief entries with relevant information
partial sentences and phrases
use term patient
use acceptable abbreviations and acrnonyms
what is a rule of thumb in conciseness of med. documentation
when in doubt
spell in out
describe completeness in med. documentation
include ALL relevant information
describe legibility in med. documentation
take time to ensure that writing is neat and legible
describe legbility in electronic med. documentation
when using stylus to write, computer will let you know if writing is legible or illegible
what are the two organizatino methods in med. documentation
problem-oriented medical record (POMR)
source-oriented medical record (SOMR)
what are the four parts of the POMR system
- problem list
- contains every problem that patient has requiring med. treatment - database
- items (med. history, review of systems, lab reports) about patient - treatment plan
- tests and treatments each prob. needs - progress notes
- numbered and grouped together
describe the POMR problem list
medical problem listed on first page and assigned number
all documentation about that problem is assigned that number
when problem no longer exists, the information is recorded in the progress notes and an X is marked next to the problem
describe the source oriented medical record
group information by type not problem
e.g. all radiology reports are in one group
what is the rule followed w. medical organization
most recent information appears first in the section (on top of existing documentation)
- creating reverse order of information
all entries have date, time, and initials
what are the 3 types of progress notes
narrative
SOAP
charting by exception
describe paper used for progress notes
lined paper with two columns for progress notes
- date and time of the contract in narrow left column
- notes about contact in right column
some offices use plain or lined paper without column
What must be present regardless of paper used in progress notes
date
time
signature
credentials of individual
describe narrative format
oldest and least structured paragraph indicating - contact w. patient - what was done for patient - outcomes
time consuming and difficult to read
what type of organization are SOAP notes used for
problem oriented
what does soap stand for
subjective data
objective data
assessment
plan
what is subjective data
includes statements from patient describing condition
- symptoms w. patients exact words
- not measurable
what is objective data
information from the health care professionals observations
- measure
- see
- feel
- smell
- test results
- vital signs
what is assessment of SOAP notes
patient diagnosis based on analysis of subjective and objective data
either final diagnosis or possible disorders to be ruled out
what is the plan of SOAP notes
what should be done about the problem
- diagnostic tests
- treatments
- follow ups
what is charting by exception
abbreviated documentation method that uses SIGNIFICANT or ABNORMAL Findings
strictly problem-oriented
which type of progress notes are most common with electronic format
charting by exception
what are 8 advantages of charting by exception
decreased charting time = more free time for direct patient care
emphasis on significant data
easy retrieval of significant data
timely bedside charting
standardized assessment
interdisciplinary communication
better tracking of important patient responses
lower costs
what do times do in medical documentation
specify when an action was taken or when it should begin
what type of time is used in medicine
military time- 24 hour cycle that counts the hours of the day from 0000 to 2359
why is military time used
to prevent confusion with am and pm times
describe content in organization of medical doc.
enter information accurate, concise, current and factual
record patient findings not interpretation of findings
avoid words w. multiple meanings (good, normal)
avoid generalizations
use chronological order
chart precautions and prevention methods
document all medical visits and consultations
document concerns
avoid stereotypes or derogatory terms
why is documentation important
gives legal protection to you, other caregivers, health agency or institution, and patient
describe timing in organization of medical doc.
record information in timely manner indicate date and time of each entry use military time documentation when the action happened never document BEFORE action happens
describe formatting in organization of medical doc
make sure you have correct patient record
document in form noted by health institution
print legibility in dark ink
date and time each entry
do not skip lines
describe accountability in organization of medical doc.
title and sign each entry
draw a single line through errors
identify each page with patients name and identification number
describe confidentiality in medical doc
keep information private
do not use actual patient names and identifiers for students
