Chapter 38 Flashcards
Written record of important information regarding a patient.
Medical Record
Functions of Medical Record:
- To make decisions regarding patient’s care and treatment
- To document results of treatment and patient’s progress
- Communicate information to authorized personnel in the medical office
- Serves as a legal document
- Law requires that patient’s care and treatment be documented
Federal Law that protects patient’s privacy. Purpose is to provide patients with more control over use and disclosure of their health information what is this? What is it also known as?
HIPAA Privacy Rule (known as protected health insurance (PHI))
Who must comply to HIPPA privacy rule?
Anyone that uses, stores, maintains, or transmits health information
- Health care providers
- Health plans
- Health care clearing houses (Billing services)
Each document of medical records often consist of what 2 things?
- Preprinted forms
- Computer templates
Who complete preprinted forms?
These forms include medical records, vaccination records, and laboratory results flow sheets.
Why might preprinted forms be used in the clinic?
- physician and staff
- increase efficiency and make sure correct documentation is completed
Most of record is paper-based. Some patient data stored on computer. Example: patient registration information
Paper-based patient record (PPR)
Consists of a computerized record of the important health information regarding a patient and includes care of the individual and progress of patients condition. Contains more information than a traditional paper medical record and that also has the capacity to be shared among health organizations. Entire medical record is stored in a database on the computer. Used in many offices. Some medical offices have all records stored on computers. Others have only part on the computers and rest on paper.
Electronic health record (EHR)
- Disadvantages: time and financial investment and occupational tasks
Designates a patient health record generated by an individual health care provider or organization that is stored on a computer.
Electronic Medical Record (EMR)
EHR software can perform the following medical record functions:
- Creation
- Storage
- Organization
- Editing
- Retrieval
Allows the EHR to facilitate administrative tasks. Examples: billing and insurance
Practice management software
One of the Medical Record Formats. Used most often in the medical office. Organized into sections based on department, facility, or other source that generated information (ex: laboratory) Separated by chart dividers (color-coded tabs labeled with title of section. Within each section, documents are arranged according to date. Most recent document placed on top or in front of the other (reverse chronological order)
Source-Oriented Record
This medical record format is developed in the following stages:
Establishing a database, compiling a problem list, devising a plan of action for each problem, and following each problem with progress notes.
Problem-Oriented Record
Consists of a collection of subjective and objective data and includes:
- health history report, physical examination report, and results of baseline laboratory and diagnostic tests
Database
Consists of a list of patient’s problems. Includes medical problems, psychological problems, and social problems. Serves as a table of contents for the record. Updated at every visit. Can add diagnostic code in EHR. Separate screen for active/inactive problems. Helps provider organize and plan appropriate care.
Problem List
Any patient condition that requires observation, diagnosis, management, or patient education
Problem
Plan of action for each problem. May include plans for laboratory tests, diagnostic tests, medical treatment, surgical treatment, therapy, and patient education. Each plan begins with the problem number followed by the plan of action.
Plan
Follow up for each problem. Begins with the number of the problem. Includes subjective and objective data. Includes assessment and treatment plan. Purpose is to update medical record with new information when patient visits or telephones the office. Must include date and time and signature and credentials of individual making the entry.
Progress Notes
Data obtained from the patient
Subjective data
Data obtained by observation, physical examination, laboratory and diagnostic tests
Objective data
Physician’s interpretation of the current condition based on the subjective and objective data.
Assessment
Proposed treatment for the patient. What is this? What is this also known as?
Plan
-SOAP
Writing progress notes using the SOAP format.
Soaping
Information necessary for efficient management of the medical office.
Administrative Section of the Medical Record
Consists of demographic and billing information. In most EHR offices, patient completes a paper/pencil registration form. Data entered into a patient registration “computer” form. Paper form may be shredded (based on medical office policy). Patient may be asked to enter this information directly into the computer. Need to provide a private area for this task. MA must be available to answer patient questions
Patient registration record
Written document that explains to patients how their protected health information will be used and protected by the medical office. Patient signs a form acknowledgement of receiving this. This form is scanned into the computer and filed in the the patients EHR.
Notice of Privacy Practices (NPP)
This form is required to perform certain procedures and release information contained in the patient’s medical record. There are two types of this which are consent to treatment forms and release of medical information form. These are required for all surgical operations and nonroutine therapeutic and diagnostic procedure called sigmoidoscopy
Consent Forms
Signed by patient or legally authorized representative. Purpose provides written evidence that patient agrees to procedure (s) listed on form. Form must be in terms patient can understand. Patient must be given the opportunity to ask questions. Form should not be signed until patient has been provided with all necessary information
Consent Forms
Patient has received the following information before giving consent. Includes: - patients full name, name of procedure to be performed, statement indicating patient agrees to receive procedure. - Acknowledgement that a disclosure of information has been made. - Acknowledgement that all questions were answered in a satisfactory manner. - Statement that no guarantee as to the outcome has been made. - Signatures of patient (and his/her legal representative) and witness (and date obtained)
Informed consent
Learn:
Patient’s signature must be witnessed. Witnessing a signature means MA verified the patient’s identity and watched the patient sign the form. Does not mean MA is attesting to the accuracy of information on the form
Not required for medical treatment, payment, and health care operations (TPO) s stipulated by HIPPA. Required for purposes that are not part of TPO. Patient moves to another state and transfers medical records. Must be signed by patient (or parent/guardian).
Includes:
- Patient’s full name and address
- Name of medical practice releasing information
- Individual or facility to receive information
- Specific information to be released
- Purpose or need for information
- Method of release of information
- Signature of patient (or legal representative)
- Date consent form was signed
- Expiration date of form
- May be faxed or mailed if patient is unable to come to the office
Medical Records Release Form
Records and reports that assist physician in the care and treatment of the patient.
Clinical Section of the Medical Record
Collection of subjective data about the patient. Patient may complete this on paper/pencil and then MA enters data into the computer. MA asks patient questions related to his or her health status. Patient completes this on a compute using a computer-guided questionnaire.
Health History
Program displays list of available dosage strength and preparation forms. Physician highlights dosage, strength, and preparation desired–enters information into computer. Physician selects additional information required (dosage frequency; number of refills). Program automatically checks prescription against drug allergies and potential interactions with other medications taken by patient. Once prescription entered into the computer, medication recorded in the patient’s medication list. Prescription is printed out, signed by physician, and given to patient or sent electronically to pharmacy.
EHR prescription program
A report of the analysis or examination of body specimens. Office many communicate electronically with outside laboratory. Request form completed on a form displayed on the screen. Transmitted electronically to medical laboratory. Once patient’s tests have been completed, results are sent electronically to office–EH files report in patient’s EHR. Copy of report placed in physician’s “electronic review bin” for review and electronic signature. Abnormal values are highlighted on the report
Laboratory Data
Narrative description of a cardiologist’s interpretation of an ECG
Electrocardiogram report
Narrative description of the interpretation of a 24 to 48 hour ambulatory ECG
Holter monitor report
Narrative and graphic description of the interpretation of a patient’s breathing capacity as measured with a spirometer
Spirometry report
Information is obtained regarding changes in the patient’s illness or treatment (progress notes)
Subsequent visits
Components of Health History:
- Identification data
- Chief complaint
- Present illness
- Allergies, current medications, and immunizations
- Past history
- Family history
- Social history
- Review of systems
Included at the beginning of a paper health history form. Basic demographic data. Patient completes the identification data section. If office uses an EHR, selecting correct patient automatically links history information to patient demographic data
Identification Data
Patient’s reason for seeking care. Symptom causing the patient the most trouble. Foundation for present illness and review of systems. MA usually responsible for obtaining and recording this. Recorded on a preprinted lined form. Use open ended questions, Limit to one or two symptoms (should refer to specific rather than vague symptom). Record concisely and briefly in the patient’s own words as much as possible. Include duration of symptom. Do not use names of diseases or diagnostic terms.
Chief Complaint (CC)
A disease that occurs in blood relatives more frequently than would be expected by chance. Examples include hypertension, heart disease, allergies, diabetes mellitus.
Familial disease
Social History Includes:
- Education
- Occupation (past and present)
- Living environment
- Diet
- Personal history
- Use of tobacco, alcohol, drugs
- Exercise
Systematic review of each body system. Purpose is to detect any symptoms that have not yet been revealed. Physicians complete this section. Asks a series of detailed and direct questions related to each body system. Assists physician in determining the type and extent of physical examination required
Review of Symptoms (ROS)
