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Dynamics of Health Care > chapter 17 > Flashcards

chapter 17 Flashcards

1
Q

What do healthcare providers do to patient records (5)

A 
enter it into the computer
edit it 
file it 
search in it 
retrieve it
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2
Q

What must healthcare professionals adhere to

A

HIPPA

Health insurance portability and accountability act

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3
Q

name some documents in a patients record

A 
insurance form
patient health record
physician order
notes 
test reports
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4
Q

What is the most used medical record system

A

the electronic medical record system

- computerized documentation has transformed record keeping

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5
Q

What are two main purposes of organized medical documentation

What are the 4 less obvious purposes?

A
  • communicating with other HC professionals
  • describing patient’s current medical condition and history
  • reimbursement requests
  • maintaining a legal record
  • education
    supporting research
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6
Q

Describe communication and medical documentation

A

a patient has several healthcare providers, which do not interact. the medical documentation allows each healthcare professional to have access to accurate records

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7
Q

What does a patient’s health and well being depend on

A

the accuracy of his/her medical records

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8
Q

What are the four assessment data

A 
vital signs 
- temperature 
- pulse
- blood pressure
- respiration rate 
circumstances surrounding visit
symptoms 
medical history
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9
Q

What helps determine the right diagnoses and treatment plans

A

current and past assessment information

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10
Q

What is quality assurance

A

to provide evidence of the quality of care a patient received and the competence of the professionals who provided the care

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11
Q

How is quality assurance checked

A

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

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12
Q

What happens if quality assurance defeciences are found

A

in service training is provided

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13
Q

Link patient records to reimbursment

A

Patient records verify the care a patient received when a provider seeks reimbursement from the insurance or government plan/policy.

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14
Q

What type of documents are used in reimbursement (5)

A
  • 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

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15
Q

What do medical record systems assign to the services a patient receives

A

a code

- the code is submitted to the insurance company or government plan for review

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16
Q

What two things do insurance companies or government plans review

A

billing codes

patient records

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17
Q

What three standards should healthcare professionals adhere to

A

legal
moral
ethical

= if not this results in a breach of contract
= the provider is subject to fines or lawsuits

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18
Q

When are patient records useful in court

A

if a healthcare professional is charged with improper care or malpractice

when a patient makes accident or injury claims

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19
Q

How are patient records used in education

A

providers use patient records as educational tools to train new people in the field

can be used during clinical portions of health education programs

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20
Q

Why do researchers use patient medical records

A

learn how to best recognize or treat health problems by examining similar cases

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21
Q

What three uses come form data gathered from patient records

A
  • significant similarities in disease presentation
  • contributing factors
  • effectiveness of therapies
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22
Q

What advantages does computerized documentation have over traditional paper charts (6)

A
  1. information is easy to store and retrieve
  2. unlimited file space
  3. easy to backup for extra security
  4. information is easily added and attached
  5. charting is easier to read
  6. typing is faster than writing
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23
Q

What does computerized documentation allow that handwritten doesnt

A

multiple users to access the same portion of a record simultaneously
- ease of access

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24
Q

why do hc facilities use computers (3)

A

order supplies and services
store billing and financial data
maintain health care information

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25
Q

what has the increased use of computerized medical information brought about the need for

A

policies and procedures ensuring privacy and confidentiality of patient information

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26
Q

what should patient privacy policies state (3)

A

which types of patient information can be retrieved
who can retrieve information
why can someone retrieve information

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27
Q

What are recommendations by AHIMA for safe computer recordkeeping (9)

A
  • 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
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28
Q

What is a patients medical record

A

compilation of health-related information. permanent recordd etailing medical history, test results, and interactions with healthcare professionals

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29
Q

when is an admission sheet used

A

used to gather information from the patient before the visit with the provider.
- may be mailed to new patients before scheduled visit

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30
Q

What two types of data does admission information include

A

demographic data

insurance information

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31
Q

When is admission information updated? why

A

once a year

- a lot of patient information included address, phone number, insurance can change in one year

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32
Q

What do most healthcare facilities require with admission forms

A

copy of patients health insurance forms

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33
Q

What type of data does a graphic or flow sheet record

A

vital signs

  • respiration rate
  • blood pressure
  • pulse
  • temperature

weight
height

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34
Q

What is a graphic or flow sheet

A

used to record and monitor patient variables over time in a GRID LIKE FORM

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35
Q

what does a graphic sheet contain

A

history of patient vital signs and the date they were taken

- fluctuation in measurements can affect a person’s health

36
Q

what is the physician’s order section

A

section of the patient record documents any orders for patient care including

  • medications
  • treatments
  • tests
  • follow up care
37
Q

What does the physician’s orders section include (4)

A

information relating to the order

  • medication dosage
  • treatment specifics
  • type of testing to be conducted
  • dates for follow up care
38
Q

what is the advantage of ‘physician’s orders’ being electronic

A

providers can send information to health care professionals including pharmacists, specialists, lab technicians

eliminates human error caused by lost paperwork and misread orders

39
Q

what are progress notes

A

record each contact a provider has with the patient, whether in person, phone, mail, email

40
Q

what information may be in progress notes

A

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

41
Q

Why should progress notes be electronic

A

progress notes do not follow a standard format, so handwritten ones may be difficult to read
= leaves little room for human error and misunderstandings

42
Q

What is in a medical history and examination sheet

A 
patient history 
family history
social history
results of physical examination 
current medical condition
43
Q

what does the patient history section do

A

address patient’s current and prior health status and helps provider plan appropriate care for present illness

44
Q

what is in the patient history section (7)

A 
allergies
immunization
childhood disease
current and past medication 
previous illness
surgeries
hospitalizations
45
Q

why is the family history section improtaant

A

some diseases may be hereditary
some diseases may be familial
cause of death of prev. family members

46
Q

what does social history information cover (4)

A

patient lifestyle

  • martial status
  • occupation
  • education
  • hobbies

patient diet
use of alcohol and tobacco
sexual history

47
Q

why is the social history information important

A

provide guide for patient education

48
Q

what is the reports section of patient’s record

A

reports or findings from tests/lab work

tests in provider’s office and other

49
Q

what is the correspondences and miscellaneous documentation section

A

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
50
Q

what are the 5 char. of good med. documentation

A 
accuracy
completeness
conciseness
legibility
organization
51
Q

what 3 things should be ensured in accuracy

A

correct spelling, med term, abbreviation, acrononym

all entries include facts

errors are marked good

52
Q

how should errors be marked in paper and electronic documentation

A

crossed with single line and identified with word error in paper

add note called mistaken entry in electronic

  • initials
  • date
  • time
53
Q

what is a key rule of accuracy in medical documentation

A

DO NOT delete or erase anything

54
Q

what is the first rule of accuracy

A

make sure you are working on the correct patient

55
Q

describe conciseness in medical records

A

brief entries with relevant information
partial sentences and phrases
use term patient
use acceptable abbreviations and acrnonyms

56
Q

what is a rule of thumb in conciseness of med. documentation

A

when in doubt

spell in out

57
Q

describe completeness in med. documentation

A

include ALL relevant information

58
Q

describe legibility in med. documentation

A

take time to ensure that writing is neat and legible

59
Q

describe legbility in electronic med. documentation

A

when using stylus to write, computer will let you know if writing is legible or illegible

60
Q

what are the two organizatino methods in med. documentation

A

problem-oriented medical record (POMR)

source-oriented medical record (SOMR)

61
Q

what are the four parts of the POMR system

A
  1. problem list
    - contains every problem that patient has requiring med. treatment
  2. database
    - items (med. history, review of systems, lab reports) about patient
  3. treatment plan
    - tests and treatments each prob. needs
  4. progress notes
    - numbered and grouped together
62
Q

describe the POMR problem list

A

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

63
Q

describe the source oriented medical record

A

group information by type not problem

e.g. all radiology reports are in one group

64
Q

what is the rule followed w. medical organization

A

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

65
Q

what are the 3 types of progress notes

A

narrative
SOAP
charting by exception

66
Q

describe paper used for progress notes

A

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

67
Q

What must be present regardless of paper used in progress notes

A

date
time
signature
credentials of individual

68
Q

describe narrative format

A 
oldest and least structured
paragraph indicating 
- contact w. patient
- what was done for patient
- outcomes

time consuming and difficult to read

69
Q

what type of organization are SOAP notes used for

A

problem oriented

70
Q

what does soap stand for

A

subjective data
objective data
assessment
plan

71
Q

what is subjective data

A

includes statements from patient describing condition

  • symptoms w. patients exact words
  • not measurable
72
Q

what is objective data

A

information from the health care professionals observations

  • measure
  • see
  • feel
  • smell
  • test results
  • vital signs
73
Q

what is assessment of SOAP notes

A

patient diagnosis based on analysis of subjective and objective data

either final diagnosis or possible disorders to be ruled out

74
Q

what is the plan of SOAP notes

A

what should be done about the problem

  • diagnostic tests
  • treatments
  • follow ups
75
Q

what is charting by exception

A

abbreviated documentation method that uses SIGNIFICANT or ABNORMAL Findings

strictly problem-oriented

76
Q

which type of progress notes are most common with electronic format

A

charting by exception

77
Q

what are 8 advantages of charting by exception

A

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

78
Q

what do times do in medical documentation

A

specify when an action was taken or when it should begin

79
Q

what type of time is used in medicine

A

military time- 24 hour cycle that counts the hours of the day from 0000 to 2359

80
Q

why is military time used

A

to prevent confusion with am and pm times

81
Q

describe content in organization of medical doc.

A

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

82
Q

why is documentation important

A

gives legal protection to you, other caregivers, health agency or institution, and patient

83
Q

describe timing in organization of medical doc.

A 
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
84
Q

describe formatting in organization of medical doc

A

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

85
Q

describe accountability in organization of medical doc.

A

title and sign each entry
draw a single line through errors
identify each page with patients name and identification number

86
Q

describe confidentiality in medical doc

A

keep information private

do not use actual patient names and identifiers for students

Dynamics of Health Care (21 decks)

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