CHAPTER 19 Flashcards
What does OSHA stand for and what is the function of the organization?
OSHA stands for Occupational Safety and Health Administration. Its function is to ensure safe and healthy working conditions by setting and enforcing
standards and by providing training, outreach, education, and assistance.
True or false: Incomplete documentation can result in denial of payment to health providers by insurance companies.
True
Medical documentation
The process of recording patient information,
treatment, and care in a medical record.
Medical record
A legal document that includes a patient’s medical history, treatments, test results, and progress.
Charting
The act of recording information in a patient’s medical record
Chief complaint
The main reason a patient seeks medical care, stated in their own words.
Assessment
The healthcare provider’s evaluation or diagnosis based on the patient’s history and examination.
Medical history
A comprehensive record of a patient’s past and present health conditions, surgeries, and treatments.
Graphics
Visual recordings in the medical record (e.g., temperature, pulse, respiration charts).
Diagnostic tests
Tests ordered to determine a diagnosis (e.g., blood tests,
imaging, EKG).
Are Medical Records legal documents?
Yes, medical records are legal documents.
What are physician’s orders?
Instructions written by a physician regarding a patient’s care, medications, treatments, tests, or procedures.
What are the main features of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?
● Protects patient health information (PHI)
● Ensures patient privacy and confidentiality
● Provides rights for patients to access their medical records
● Sets standards for electronic health transactions and national identifiers
What is “charting by exception”
A method of charting in which only significant or abnormal findings are documented; normal findings are assumed unless otherwise noted
How do healthcare professionals select the right abbreviations to use in written documentation?
By using approved facility-specific abbreviation lists and avoiding ambiguous or unsafe abbreviations as per The Joint Commission standards.
What’s a progress note?
A written record of a patient’s condition, response to treatment, and updates in the care plan, typically documented by healthcare professionals during a visit or hospital stay.
Discuss the meaning of the phrase “If it isn’t documented, it isn’t done.”
This phrase emphasizes the importance of thorough documentation. If an action or care isn’t recorded in the medical record, legally and professionally, it is considered not to have happened, which can lead to:
● Legal liability
● Denied insurance claims
● Poor communication among care providers
● Compromised patient safety
Every entry on a medical record must include the:
● Date
● Time
● Signature and credentials of the healthcare professional who made the entry
What’s included in family history?
● Health conditions of immediate family members
● Genetic diseases, chronic illnesses (e.g., diabetes, cancer, heart disease)
What’s included in personal history?
● Patient’s past illnesses, surgeries, medications
● Allergies, lifestyle (e.g., smoking, alcohol, drug use)
● Occupational and social history
What is SOAP?
A method of charting used in problem-oriented medical records:
● S: Subjective (what the patient says)
● O: Objective (what is observed/measured)
● A: Assessment (diagnosis or condition)
● P: Plan (treatment plan or next steps)
What is PHI?
Protected Health Information — any information about a patient’s health, treatment, or payment that can identify them.
List the four steps required when correcting an error on a medical record:
- Draw a single line through the error
- Write the word “error” above or beside it
- Add the correct information
- Include the date, time, and initials of the person making the correction
