Medical Documentation Flashcards
The ER
all problems are episodic, meaning every problem is a new problem. The doctor more than likely does not know the patient too well
Clinic problems
- chronic: problem has been previously diagnosed and patient comes in for regular visits. Patient Hx referred.
- Exacerbation of chronic problems: a “flare up” of a chronic problem and visiting to figure out why it happened.
- New problems: these are usually not emergency problems.
- follow up visit: as told by physician after labs or new medications.
Documentation: why is it important?
- mandated by the CMS (center for medical services)
- rec. patient complaint, treatment, history and plan in chronological order.
- will serve as legal documentation for litigation.
- communication tool for health care providers.
Complete documentation of each patient includes:
reason for encounter and relevant history
physical examination and lab results (labs/x-rays).
assessment, clinical impression, or diagnosis.
plan for care.
date and legible id of observer.
past and present…
diagnosis should be accessible to the treating/consulting physician
health and risk factors
should be identified
final part of documentation
patient’s progress, response to and changes in medications, and revision of diagnosis should be documented.
Billing
the CPI and ICD-9CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
Patient record
when done properly it can be used for: billing correctly and timely used for litigation used as a communication tool ensure proper patient care.
subjective
opinion judgement assumption belief recollection patient's perception: this is the q&a part with the physician
objective
the physical exam able to be seen (heard, touched, smelled) factual able to be counted (described, imitated) same for multiple reports.
Patient’s whole visit
S-subjective
O-objective
A-action
P-plan
Patient Medical Record
6 aspects CC HPI ROS PFSH PE MDM
CC
this is the chief complaint ie the reason for visit. this statement describes symptom, problem, condition, diagnosis, and anything else pertaining to the encounter. These are the patient’s own words usually.
HPI
history of present illness (see PQRSTA&C cards)
chronological description of the patient’s present illness from the first sign and or symptom or from the previous encounter to the present.
P
pallaitive/provocative
what the patient did to make it better
Q
quality
what does it feel like?
R
region/radiation
where is it? has it moved?
S
severity
how bad
T
timing
when and how did it start? progress? constant? is it hurting now?
A
associated symptoms
what else is bothering you?
C
context
situation or environment that it occurred in.
ROS
the review of systems. this is where you take a step back and look at everything else. it is the inventory of body systems.
PFSH
past, family, and social history. includes: -prior illnesses -prior operations -prior hospitalizations -current medications -allergies -age approp. immunization records -feeding and dietary status
patient history
q&a, subjective. 4 parts: 1. reason for visit 2. HPI 3. ROS 4. PFSH
4 ways PE takes place
1 inspection- looking
2 palpation- hands on pressing
3 percussion- thumping on patient
4 auscultation- listening with stethoscope
3 types of findings in the PE
- normal findings
- abnormal findings
- pertinent negative abnormal findings: those that may have been expected to be abnormal based on CC but are not.
