Medical Records Flashcards
What are medical assitant’s role and duties concerning medical records?
- Documentation: Recording information in the medical record (if it isn’t documented, it didn’t happen)
- Maintenance: verifying accuracy
- Releasing: with proper signatures and verifications
List the reasons medical records are important
- Information about a patient’s medical history and present condition
- Used as a communication tool and legal document
- Used for patient and staff education and quality control and research
- Provides a “map” or plan to follow for thr continuity of patient care
- Is a supporting documentation for biling and coding purpose
What are the contents of Medical records?
General information
* Contact information
* Occupation
* Medical history
* Current complaint
* Healthcare needs
* Treatment plan or services provided
* Radiology and laboratory reports
* Response to care
How are medical records used legally?
- Support a patient’s claim of malpractice against a doctor
- Support the doctor in defense against a claim
- Back up information within the financial record
What are the requirements of documentation needed for medical records?
- All medical care, evaluation, and instruction the physican gives to the patient
- Must be clear, accurate, legible, dated and per HIPAA guidelines
What is a noncompliant patient?
Noncompliant is the medical term used to describe a patient who does not follow the medical achieve he or she receives
List the specific information needed in a patient’s medical records.
- Date of visit
- Patient’s legal name
- Physical address
- Phone number
- Email address
- Patient’s date of birth, sex, martial staus, and SSN
- Medical insurance information/Employer
- Emergency contact
- Primary care physician
What information is needed in the patient’s medical history?
- Past illnesses, surgeries
- Family medical history
- Social history-diet,exercise, smoking, alcohol use, drug use
- History of present illness
- Chief complaint (patient’s own words)
- Results of laboratory and other tests
- Patient’s written request authorizing release of recorfs
- Operative reports, hospital discharge forms
- Telephone calls
- Special evalutions
- Consent forms:signed and witnessed
What is present in a physical examination form?
- Review of System (ROS)
- Doctor’s diagnosis and treatment plan
What is the Review of Systems (ROS)?
Physical Examination Form
Identify any signs or symptoms the patient may be experiencing that may reveal information about an illness
What is the Doctor’s diagnosis and treatment plan?
Physical Examination Form
- Treatment options and plan
- Instructions
- Medication prescribed
- comments or impressions
What is the PHI?
PHI is protected health information
List the rights patient’s have regarding their PHI and their medical records
- The right to notice of private practices
- The right to limit request restriction of thei PHI and its use and disclosure
- The right to confidential communications
- The right to inspect and obtain a copy of their PHI
- The right to request amendment to their PHI
- The right to knoe if their PHI has been disclosed and why
