Chapter 21- The Health Record Flashcards
Medical Record:(The Chart)
Important legal docs in the healthcare
CC:
Chief Complaint
EHR:
Electronic Health Record
PMH:
Past Medical History
SOAP: ( A method for charting)
Subjective, Objective, Assessment, Plan
HIPPA:
Health Insurance Portability & Accountability Act
HITECH:
Health Information Technology for Economic and Clinical Health Act
What is the advantage of EHR?
-Reducing the incidences of medical error by improving accuracy of medical record.
- It is efficient
-Management capabilities
- Able to read co workers notes/ handwriting
Parts of a Medical Records:
Demographics, PMH, Social History, CC
Demographics:
Pt’s name, DOB, Contact Info, Home Address, Healthcare Insurance, etc.
PMH: Past Medical History
Previous illnesses, injuries, usual childhood diseases (UCD), hospitalizations, surgeries; current health status
Social History: (SH)
Marital status, substance use, diet, occupation, pets, personal habits, sexual preferences, lifestyle
CC:
CC is the reason for the visit
Usually documented in patient’s own words (with quotation marks)
OLDCARTS
HPI:
History Present Illness
- The detailed part of the issue for coming into the office.
Signs:
Anything that can be measured or observed by others.
Ex: Edema, Rash, Bruise
Symptoms:
Something that is only perceived by the pt. also called subjective data/
( Pain, Headache, Dizziness, and Nausea)
Type of Chart Formats:
SOMR, POMR
SOMR:
Source Oriented Medical Records*
- Common in paper charts, which are divided by sources.
- It’s the most common and traditional
POMR:
Problem Oriented Medical Record
(4 components)
- Database, Problem List, Treatment Plan, Progress Notes
- Not very commonly used
SOAP Notes:
Subjective Data: obtained from PT. (Symptoms)
Objective Data: Clinical evidence or observations from the provider. (Signs)
Assessment: The provider indicates the problem number & diagnoses.
Plan: Includes providers suggested treatments.
- The MA fills our the S & O.
- The Provider does the A & P.
Anaphylaxis:
A severe reaction that can be life- threatening.
What is continuity of care?
Continuity of care is the smooth continuation of care from one provider to another. This allows the patient to receive the most benefit with no interruption or duplication of care.
Reasons to have accurate records:
- Proof needed for a legal defense
- Reimbursement
- Higher Quality of Care
- Track Vital Statistics
Who owns the medical record?
The Physians office
- The place where the chart was created.
HITECH:
- A law that enforces HIPAA.
- HIPAA on steroids x10”
- Gives providers incentives. $$
-Find doctors and providers and fine them for the ones not using electronic.
Introduction to the Health Record:
Serves as a legal document
Documents health information and provides support for treatment plan
Enables continuity of care
Supports reimbursement claims
Provides legal protection to provider(s)
Provides statistical information for research
Types of Health Records:
Paper and electronic (EHR)
Benefits of EHR:
Practice management capabilities
Scheduling
Billing and claims
Report generation for quality control, research
Storage space
Safety from accidental destruction
Financial incentives from government for implementation
Promotes communication and continuity of care
Ownership of the Health Record:
Health record itself (paper or electronic)
Provider or healthcare facility
Information in health record
(Patient)
Vested interest, right to confidentiality
Best practices for security of paper records
What are some best practices for maintaining security of paper records?
Never remove them from the facility; lock storage area when facility is closed)
Contents of the Health Record:
Personal demographics
Name, date of birth, home address, contact information, healthcare insurance, etc.
Past medical history (PH or PMH)
Previous illnesses, injuries, usual childhood diseases (UCD), hospitalizations, surgeries; current health status
Family history (FH)
Health or age and cause of death of grandparents, parents, siblings; hereditary diseases
Social and occupational history (SH, OH)
Marital status, substance use, diet, occupation, etc.
Contents of Health Record:
Chief complaint (CC) and history of present illness (HPI)
CC is the reason for the visit
Usually documented in patient’s own words (with quotation marks)
OLDCARTS
Allergies
Immunization and medication records
Physical exam
Range of systems (ROS) for new patients
Baseline
Provider’s findings
OLDCARTS:
Onset: When did it begin?
Location: Where is it?
Duration: How long has it been going on?
Characterization: How would you describe it?
Alleviating and aggravating factors: What makes it better? What makes it worse?
Radiation: Does it stay in one location or move?
Temporal factor: Isi it better or worse at different times of the day?
Severity: Using a scale of 0 to 10, with 0 being none and 10 being worse the worse, how does it rate?
Contents of the Health Record:
Progress notes
Signs, symptoms, feelings, concerns
Clinical findings from PE and labs, diagnostics
Provider’s impression and diagnosis
Treatment plan
Laboratory and diagnostic imaging results
Consultation reports
Hospital documents
Discharge summary, operative report, ED report.
What is the difference between the sign and a symptom?
A sign is something that can be measured or observed by others; also called objective data. Examples include redness, swelling or edema, blood pressure, and pulse. A symptom is something that is only perceived by the patient; also called subjective data. Examples include pain, headache, dizziness, and nausea.)
What are some examples of labs? Diagnostic imaging?
(Answers will vary and may include, for labs, tests on blood, urine, sputum, tissues, or other substances from the body; for diagnostic imaging, x-rays, CT scans, nuclear medicine scans, MRI, ultrasound.)
What is a medical consult?
A medical consult occurs when a patient is referred to another healthcare provider for examination and treatment.
Miscellaneous documents-
Correspondence, release of information forms, disclosure authorization forms, Notice of Privacy Practices (NPP), consent for treatment and authorization form, other consent forms, images/copies of health insurance card and patient ID, advance directives, past health records
Source-Oriented Medical Records (SOMR):
Observations and data categorized according to source
Examples:
Provider (progress notes)
Laboratory
Radiology
Hospital
Consultations
Reverse chronologic order