Lecture 2: Documentation Flashcards
What is the purpose and definition of medical record?
- Purpose: Communication & Information
- Definition: A repository of information compiled by many individuals regarding a single patient.
Who does the medical record serve?
- The Patient
- Health professionals involved in the patient’s care
- Supervisors & Administrators
- Clinical investigators/researchers
- May be used in legal proceedings
- Performing a procedure without documenting it in the clinical note can result in what?
- Undocumented procedures cannot be what?
- What is Medicolegal
- Performing a procedure without documenting it in the clinical note can result in loss of critical information affecting patient care
- Undocumented procedures cannot be reimbursed
- Medicolegal – if it is not documented it never happened
What is the HIPAA privacy rule?
The Privacy Rule standards address the use and disclosure of individuals’ health information (known asprotected health informationorPHI) by entities subject to the Privacy Rule.
These individuals and organizations are called “covered entities.”
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
What are the procedure note guidelines?
What are the procedure Documentation Purposes
- Communication Device
- Memory Aid
- Quality Assurance Instrument
- Risk Reduction Aid
- Reimbursement Aid
- Evaluation Tool
- Research Tool
How is documentation a communication device?
Communication about the procedure performed and its findings to other members on the patient’s healthcare team.
How is documentation a memory aid?
Serves as a method of recording patient medical condition information that may be forgotten
How is documentation a quality assurance instrument?
Monitoring of the quality of care
* Involves medical record review by peers.
How is documentation a risk reduction aid?
Medical record serves as a legal document that may be used in court as evidence.
How is documentation a reimbursement aid?
The medical record is used to verify that the procedure performed was indicated and performed appropriately
How is documentation a evaluation tool?
- Student documentation evaluation reviewed by supervising faculty
- Employee documentation reviewed by supervisors or orientation staff
How is documentation a research tool?
The Medical Record
* A data source for clinical research
In patient’s chart, what do you need to record, be what and consider using what?
Record all the Pertinent Data
* pertinent positives & pertinent negatives
Be Objective
Consider the use of Diagrams
For a patient’s note what do you need to avoid using? What do you need to make sure? Consider using what?
- Avoid the use of nonstandard Abbreviations-> The Joint Commission Official “Do Not Use” List
- Make sure if the record is handwritten that it is legible
- Consider using digital Photographs
