Medical Information and records Flashcards
Effective documentation ?
Keeping is a way to meet ongoing patient need
Refers to any records and more extensive information such as emergency department ?
Charting
Medical Recording on computers ?
Creates an individual file for each patient.
Basic information like :
about the patient , birth date and diagnosis
Responsibilities for Record Keeping ?
Should be objective , All information in patient records is considered confidential
Like :
Patient’s progress and current status for other health team members
Encourages a systematic approach to therapeutic care
Always initial and date corrections
Insurance companies
SOAP documentation ?
S - Subjective Data
O Objective data
A - Assessment
P- Plan
When patient tells you about their symptoms ?
Subjective data
When the data observed by physician during examination ?
Objective Data
Impression of patient’s problem that lead to a diagnosis ?
Assessment
An action which consists of treatment to correct the illness ?
Plan
Medical Recording by Radiographers ?
Is Requisitions and reports like :
X-ray requisition serves as the formal order for a diagnostic procedure
It includes patient data, a brief medical history, and specific instructions
Documenting in radiology includes ?
Administration of contrast media
Medications
Changes in patient status
reactions to contrast or medications
Any treatment received in the radiology department like (Oxygen given to a patient)
Medical Recording by Radiographers ?
The information chart should include
The Date, time , a specific statement of what occurred and signature
How many years can diagnostic Images can be kept ?
legally 5 to 7 years
Images (Diagnostic) of minors be kept 5 to 7 years after the patient reaches the legal age
Changes are applicable depending on ?
Legislation
Recommended that films be sent directly to ?
A consulting physician rather than allowing the patient to transport them
