MODULE 2 UNIT 4 Flashcards
essential compilation of facts about a patient’s life and health
MEDICAL RECORD
includes documented data on past and present illnesses and treatment written by health care professionals caring for the patien
medical record
must contain sufficient data to identify the patient, support the diagnosis or reason for attendance at the health care facility, justify the treatment and accurately document the results of that treatment
medical record
record the facts about a patient’s health with an emphasis on events affecting the patient during the current admission or attendance at the health care facility, and for the continuing care of the patient when they require health care in the future.
primary purpose of medical record
patient’s medical record should provide accurate information on:
1) who the patient is and who provided health care;
2) what, when, why and how services were provided; and
3) the outcome of care and treatment.
medical records has four major sections
administrative
legal data
financial data
clinical data
includes demographic and socioeconomic data such as the name of the patient (identification), sex, date of birth, place of birth, patient’s permanent address, and medical record number;
administrative
including a signed consent for treatment by appointed doctors and authorization for the release of information;
legal data
relating to the payment of fees for medical services and hospital accommodation
financial data
data on the patient, whether admitted to the hospital or treated as an outpatient or an emergency patient
clinical data
main uses of the medical record are:
1) to document the course of the patient’s illness and treatment;
2) to communicate between attending doctors and other health care professionals providing care to the patient;
3) for the continuing care of the patient;
4) for research of specific diseases and treatment; and
5) the collection of health statistics.
first step in every admission procedure
assignment of a medical record number or verification of an existing medical record number
This number is then used during the current admission and in the future to identify a patient and his or her medical record.
medical record number
permanent identification number assigned in a straight numerical sequence by the admission staff and is recorded on all medical record forms relating to that particular patient.
medical record number
how we give a number to medical records
medical record numbering systems
how we file the record after a number has been given
filling system
physical medical record will eventually consist of the following:
1) medical record forms;
2) a clip or fastener to hold the papers together;
3) dividers between each admission and outpatient notes; and
4) a medical record folder.
covers identification, final diagnoses, disease and operation codes, and the attending doctors signature;
front sheet/ identification/ summary sheet
often on the back of the front sheet and must be signed by the patient at the time of admission.
consent for treatment
first half of the concent for treatment form
general consent for treatment
bottom half of teh consent for treatment form
consent to release information to authorized persons;
referral letter, requests for information
correspondence and legal documents received about the patient,
recording the patient’s daily treatment and reaction to that treatment written by the attending doctor and other health care professionals;
cilinal progress notes
recording regular nursing care including temperature, pulse and respiration charts, blood pressure charts, etc.;
nurse’s progress report
report if an operation or operations are performed;
operation report
listing daily medications ordered and given with signatures of the doctor prescribing the treatment and the nurse administering it
orders for treatmnet and medication forms
forms for observation of head injuries etc.
special nursing forms
to provide quality patient care to all patients, whether an inpatient, outpatient, or emergency patient
primary function of a hospital, clinic and helath care facility
legally responsible for the quality of care given to patients.
hospital administration
delegated to doctors, nurses, and other health care professionals.
responsibility for direct patient care and documentation in patient’s medicla record
person in charge of the Medical Record Department has delegated responsibility for the functions of that department and overall management of the medical record service. T
medical record officer
he or she is responsible for the management of patient health care data on a continuing daily basis.
Medical record officer
