Module 3 Health Records and Forms Flashcards
What are the three types of health records?
- paper
- electronic (EHR)
- hybrid
Information in a health record can be grouped into what two main categories?
- Administrative
2. Clinical
What is a common clinical documentation method?
SOAP
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
- Traditional paper-based health records organize information by ____ or use of an ____
source or problem, integrated format
EHR’s organize patient information by _____ and _____ type, in _____ order
EHR’s organize patient information by encounter and document type, in chronological order
What are the three traditional sections of source-oriented health records (SOMR)?
Identification Section
Medical Section
Nursing Section
Source oriented health records are organized into _____ categories.
Organized into practitioner categories.
Source-oriented health records are arranged in _____ order while the patient is on the floor, and are then ____ following separation in the facility determined chart order.
chronological order; reassembled following separation
What are the two advantages of source-oriented health records?
- Quickly find individual sheets
- Easy to see the work of each department in providing patient care
quick find, each department’s work
QFED
Q Federline
What are the disadvantages of source-oriented health records?
- difficult to get an overall picture of the patient’s problem(s)
- can’t quickly see all of the patient’s problems
- treatment may overlap therapeutic areas, and may be hard to categorize
overall picture; overlap therapeutic areas; hard to categorize
OP OT HC
original poster occupational therapy hot chocolate
What are three traditional sections in problem-oriented health records?
bowel obstruction
diabetes
high blood pressure
What are the advantages of problem-oriented health records?
- creates a HOLISTIC picture of the patient and their care
- a physician can consider each of the problems in CONTEXT with other problems
- GOALS and METHODS of treatment are clearly documented
- QUALITY assurance can be easier
holistic picture; context; goals and methods; quality
HP CG QA
harry potter context goals quality assurance
What are the disadvantages of problem-oriented health records?
- TIME consuming to implement
- may require additional TRAINING for staff
- only successful if most/all physicians seeing a patient are DOCUMENTING this way
TTAP
Health record format where information is organized in strict chronological order without any divisions by source
integrated health records
Health record format where the physician defines and follows each clinical problem individually and organizes them for a solution.
problem-oriented health records
Health record format broadly organized into practitioner categories
source-oriented health records
Health record format where forms from different sources are mixed together
integrated health records
Health record format sorted by origin of report
source-oriented health records
Health record format sorted by each problem
problem-oriented health records
Health record format sorted by date chronologically
integrated health records
What does the S in SOAP stand for?
subjective symptoms; intangible symptoms personal to each patient
What does the O in SOAP stand for?
objective symptoms; measurable symptoms by health professionals
What does the A in SOAP stand for?
assessment or examination
What does the P in SOAP stand for?
plan or course of action
What is an alternate name for a discharge summary?
narrative summary
The history and physical must be completed within how many hours of admission?
within 24 hours after admission and always prior to surgery
What are alternate names for Physician’s Orders?
requisitions, doctors notes
What is the difference between Physician Progress Notes and Multidisciplinary Notes?
progress notes can only be written by physicians involved in the patient’s care; multidisciplinary notes can be completed by any healthcare professional involved in patient care
In the case of a stillborn patient, is a new chart created or is the information filed on the mother’s chart?
Filed on mother’s chart
What are the advantages of using standardized forms?
- reduces cost
- helpful to physicians who move between facilities
- decreased duplication of information results in reduced clerical work, decreased number of errors, increased efficiency
CMPDD
What 3 types of information that should be held in the forms inventory?
- drafts
- approval requests
- authorization (who and when)
All forms used in a facility should be reviewed regularly for what purpose?
- addition of new data elements
- removal of obsolete or repeated data elements
- reformatting for easier use as EHR becomes more advanced
- correction of errors
NDE ORDE REF COE
What are the roles and responsibilities of healthcare professionals in the completion of forms?
Providing input on data collection requirements, physical layout, user completion, identification, ongoing review, revisions
What is the purpose of forms?
Communication tool between providers, standardization of data collection, ensures documentation consistency, collection of data to support clinical decision making
List some basic principles in forms design.
- consider the purpose, use, and user of the form
- keep it simple
- use headings to identify the purpose
- include the facility ID and patient chart number on each page
- use standard formatting and terminology
- Include guidelines for data collection
- sequence the data in a logical order
- use standardized font type and size
- use shading and lines to separate sections
- use checkboxes/dropdown menus for easy data collection elements
What are the advantages of having forms in an EHR?
- Can add built-in edits and present entry requirements to ensure accurate and consistent data collection
- Allow for various methods of inputting and retrieving information (voice recognition, scanning, direct entry, etc)
- Has the potential to decrease workload and minimize errors
list the basic principles in EHR forms design.
- Ensure users aren’t arbitrarily designing their own forms (have policies and guidelines to follow)
- Ensure all legal requirements are met so that necessary data elements are included and confidentiality maintained
- Have an audit trail that can be monitored
- Ensure efficiency and integration into your EHR
- Maintain the same specifications as paper forms
- Control the printing of forms
- Provide standardized terminology (data dictionary)
- Provide unauthorized changes/duplications
- Ensure that forms can be indexed/scanned
History of all editions of forms in use in a facility that includes drafts, approval requests, and authorization
forms inventory
What are the components of forms identification?
- title identifying form and its use
- numerical identification system (ex bar code)
- creation and revision dates
The act of regularly reviewing forms
forms analysis
Forms analysis focuses on which 4 areas?
- addition of new data elements
- removal of obsolete or repeated data elements
- reformatting for easier use as EHR become more advanced
- correction of errors
What is the main purpose of administrative data
uniquely identify the person
What does administrative data contain?
demographic, identification, financial and legal data
What does clinical data contain?
information about the patient’s illness, treatment, treatment results, prognosis, and continuing care plan
List examples of common administrative forms.
- patient registration record
- release of responsibility for belongings
- consents
- personal directives
One of the most commonly computerized forms and its contents are downloaded into other systems in the hospital, such as the transcription/coding/abstracting computer applications
patient registration record
Consists of the demographic information about the patient and their next of kin, and key clinical information
patient registration record
Who completes and who signs the patient registration record?
admitting clerk completes, attending physician signs
T or F. It is common for pre-booked (elective and urgent) patients to be pre-registered days prior to the actual admission
T
When are emergency patients registered?
At the time they are seen
Alternate names for patient registration record
identification form, face sheet, admission-discharge record
What are the contents of patient registration records?
- socioeconomic data
- admission data
- separation data
- clinical data
Patient registration record data: contains patient name, address, phone #, DOB, age, sex, marital status, occupation and employers name, medical insurance coverage and policy numbers, next-of-kin information
socio-economic data
Patient registration record data: contains name of admitting physician, admitting diagnosis, type of admission
admission data
List different types of admission.
- elective
- urgent
- emergent
- outpatient
- day surgery
A unique ____ is assigned when collecting admission data and will be contained on each and every report within the patient’s health record
patient chart number
Patient registration record data: contains the date and time of separation from the nursing unit or other area of the hospital; recorded when the patient is discharged from the facility or expires
separation data
Patient registration record data: contains admitting diagnoses, preliminary statement of planned procedures, signed by admitting physician
clinical data
Common form that contains a statement in which the patient releases the hospital from liability if personal belongings such as jewelry or money are lost, stolen or damaged; may contain an itemized Property/Valuables list
release of responsibility for belongings
____ envelopes can be provided and belongings may be kept in a safe place until patient discharge
safekeeping
Who signs the release of responsibility for belongings form?
the patient or the guardian
Common form that is signed by a patient/guardian; may also be signed by a relative in an emergency situation
consent forms
What are the 2 types of consents?
- consent for admission and treatment
2. special consents
Consent form that covers the consent only to basic, routine care and services; doesn’t include surgical procedures/medications or non-surgical procedures involving risk
consent for admission and treatment
Who signs the consent for admission and treatment?
the admitting department at time of admission, or elective patients during the pre-admission process
Consent form required for any non-routine diagnostic or therapeutic procedure
special consents
What is an example of a special consent form?
consent to surgery
Consents must be ___, that is, the physician discusses the procedure, risks, alternatives, probable outcomes, and the patient must demonstrate that they understand the explanations
informed
T or F. Discussions for informed consent must be explained in a language and terminology the patient can understand; an interpreter must be provided if needed
T
Common administrative form that allows the patient to prepare written instruction on personal matters in case you become incapable of making those decisions later
personal directives form
Who signs the personal directives form?
patient
T or F. The law in Alberta allows another person to automatically make decisions for a patient.
F
Anyone over the age of __ can complete a personal directive
18.
Personal directives become legal documents when it is ___, ___, and ___
dated, signed and witnessed
Power of Attorney covers ____ only, not health related matters
financial
List examples of common clinical forms.
- discharge summary
- emergency chart
- history & physical (H&P)
- physician’s orders
- consultation report
- progress notes
Who signs the discharge summary?
attending physician
What are alternate names for the discharge summary?
narrative summary
Common clinical form that is a concise summary of the patient’s course in hospital including the reason for hospitalization, significant findings, events, condition upon discharge/release from the hospital, recommendations and arrangements for future care
discharge summary
Dictated by the attending physician at the time of or immediately following discharged; usually filed at the front of the chart
discharge summary
Copies of the discharge summary are usually sent to the ___ or ___
attending physician or any medical practitioner responsible for the future care of the patient (family physician)
Who signs the emergency chart?
physician who saw and treated the patient in the emergency department
Common clinical form that provides a concise report regarding the events surrounding the patient’s visit to the ER.
emergency chart
If the patient is admitted to a hospital as an inpatient from the ER, the ER record accompanies them and becomes part of the ___ for that admission
IP record
If the patient is not admitted as an inpatient, the ER record is sent to the ___ for coding and filing once the patient is released
health information department
Who signs the history and physical?
examining physician, usually the same as the attending physician, unless a consultant takes over the care of the patient
Common clinical form that provides the foundation needed to establish a provisional or tentative diagnosis and to develop a treatment plan
history and physical (H&P)
When should the H&P be completed by?
within 24 hours after admission and always prior to surgery
H&P findings are both ____ and ____
subjective and objective
What does the H&P contain?
- chief complaint (CC)
- present illness/history of present illness (HPI)
- psychosocial history/personal history/social history
- past medical history/past health
- family history
- review of systems (ROS)
- physical examination (PE)
- impression
In the H&P, contains a subjective description of why the patient is seeking medical attention
chief complaint
In the H&P, contains a detailed chronological account of development of the patient’s illness
present illness/history of present illness (HPI)
In the H&P, contains daily routine, use of drug/alcohol, education, occupation, home environment, marital status, important experiences. religious beliefs, recent travel, habits etc
psychosocial history/personal history/social history
In the H&P, contains a summary of childhood and adult illness and condition, allergies, treatment history, past surgeries
past medical history, past health
In the H&P, contains age and health or cause of death of immediate family members, hereditary diseases
family history
In the H&P, contains a review by body system of the patient’s symptoms and subjective sensations; begins with an overview of the patient’s general health and concerns, and then describes complaints by body system
review of systems (ROS)
ROS documentation often uses __ terms the patient uses rather than medical terms
lay
In the H&P, this is the actual examination that adds objective data to the subjective data provided by the patient in the ROS
physical examination (PE)
In the H&P, documented by the physician using medical terminology; provides the foundation from which a diagnosis can be made and a treatment plan developed
physical examination (PE)
What are the four basic procedures used during a general physical exam?
IPPA
What does IPPA stand for?
inspection, palpation, percussion, and auscultation
In the H&P, can be either a provisional/tentative diagnosis or a differential diagnosis
impression
Diagnosis based on incomplete information and subject to change
provisional/tentative diagnosis
Statement of more than one possible diagnosis due to similar signs and/or symptoms
differential diagnosis
Who signs the physicians’ orders?
the physician responsible for each order or group of orders must date and sign these
Physicians use this common clinical form to communicate their plans for the therapeutic care and diagnostic procedures of their patients by giving written or verbal directions to the nursing staff and other practitioners
physician’s orders
T or F. Only members of the hospital medical staff are permitted to give orders, which are now usually entered into the hospital EMR and printed to add to the patient’s chart
T
Who signs the consultation report?
the consulting physician
Common clinical form that contains the opinion of another physician, usually a specialist, about the patient’s condition
consultation report
Where can consultations be written?
on a form designed for this purpose, dictated, transcribed, or may be documented in progress notes
T or F. Routine investigations such as x-rays, medical imaging, tissue analysis and ECGs constitute as a consultation
F.
Who signs progress notes?
author of the note
What are the two formats for documenting progress notes?
physician progress notes and multidisciplinary progress notes
Only the physician can document in this common clinical form; provide observations including changes in symptoms or diagnosis, changes in treatment, response to treatment, significant diagnostic test results, operation and procedures performed, unusual occurences, complications, consultation findings
physician progress notes
In physician progress notes, there should be documentation including the exact ___ the death was pronounced, the ___ who pronounced the death, ___ surrounding the death, any significant findings, suspected cause of death, and whether consent was obtained for autopsy and/or organ donation
time, name of the physician, circumstances
Common clinical form that contains all of the above documentation, but used by all healthcare providers caring for the patient on one location
multidisciplinary progress notes
T or F. Nurses document on forms exclusively used by them to record their observations and care of the patient.
T
List examples of nursing forms.
- nurses’ notes
- clinical/graphic record
- medication records
- other nursing record/forms
Who signs nurses notes?
Nurse who made the entry along with credentials
This nursing form fills in the gaps of information not found on other nursing forms like medication sheets
nurses notes
Nursing form where nurses document the care provided and the patient’s signs and symptoms in response to care; does not diagnose the patient
nurses notes
Physicians must first ___ all treatments carried out.
authorize
What do nurses notes include?
- date and time of entry
- signature or initial of the nurse who made it
- nursing care and treatment including significant events
- documentation of visits by physicians, other healthcare providers, family and friends
- discharge date, time, manner of disposition, destination of the patient, accompaniment of the patient
- if patient signs out AMA
What do nurses have to include in their nurses notes if patient dies?
- time heart and respirations stopped
- name of physician notified
- time/date/name/ of physician who pronounced the death
- whether relatives were present or otherwise notified and by whom
- disposition of the clothes and valuables
- destination of the body (morgue/funeral home/medical examiner)
This nursing form records a continuous graphic picture or plot of the patient’s vital signs and other information on a daily basis
clinical/graphic record
Nursing form containing vital signs (TPR + BP), intake an output of fluid, height and weight, diet, elimination, physician visits, number of days since admission and or surgery
clinical/graphic record
Who signs medication records?
the person who administered the drug
This nursing form provides documentation of medication given, or if a drug isn’t given as ordered, this is also documented
medication record
What must be recorded on a medication record?
- date and time of administration
- name of the drug
- dosage
- route of administration
What are other nursing records/forms?
sensitivity record, nursing assessment/nursing care plan, BP record, fluid balance record, diabetic record, anticoagulant record, IV therapy record, patient education/discharge instructions
Nursing form that lists patient sensitivities and allergies
sensitivity record
Nursing form that lists nursing measures to be taken to facilitate medical care and comfort needs of the patient
nursing assessment/nursing care plan
Nursing form used if vital signs need to be recorded more frequently than allowed on the graphic sheet
BP record
Nursing form that shows I&O by route and by shift, with 8 and 24 hour totals
fluid balance record
Nursing form that shows urine/blood testing for glucose, diet restrictions and insulin administration
diabetic record
Nursing form that shows daily prothrombin times in relation to the dosage of anticoagulants
anticoagulant record
__ and __ notes replace the graphic sheet/nurses notes when the patient is on a special care unit
ICU and CCU notes
Nursing form that provides info regarding the types of IV or blood components administered and the condition of the IV site(s)
intravenous therapy record
Nursing form that provides a record of patient teaching and discharge instructions, including medications to be taken at home
patient education/discharge instructions
Additional investigations and treatments carried out by the appropriate department and only when ordered by a physician
ancillary reports
Ancillary report that contains patient identification information, place of death, and the medical cause(s) and contributing factors of the death
Medical Certificate of Death (VS)
A copy of the Medical Certificate of Death is left on the patient chart and the original goes to the ____
government
Ancillary report that contains the date/time of of the ECG, interpretation of the tracings, portions or copies of the actual tracings, and diagnosis or impression
ECG/EKG report
Who signs ECG/EKG report?
cardiologist
Graphic tracing representing the electrical changes in the heart muscle as the heart beats
ECG
ECG is normally performed by a ___ while a ___ interprets the results
qualified ECG technician, cardiologist
Amplifies the electrical fluctuations of the brain and provides a graphic tracing of the activity of the brain
EEG
May be on its own form or may be documented in the progress notes, or both
EEG/ECG/EKG
T or F. EEGs are usually very in-depth and therefore dictated by the physician for transcription
T
EEGs are performed by a qualified ____ while a ___ interprets the results are these are significantly more difficult to read than an ECG
EEG technician, neurologist/neurosurgeon
T or F. A general practitioner or other type of specialist wouldn’t attempt to interpret an EEG
True
Ancillary report that contains the date and time of EEG tracings, portions or copies of the actual tracings, interpretation of the tracings by a neurologist or neurosurgeon, and diagnosis or impression
EEG report
Ancillary report that include diagnostic imaging procedure reports such as x-ray, nuclear medicine, CT, MRI and ultrasound
radiology/medical imaging reports
DI tests are performed by the appropriate ___ and are interpreted by ___
medical imaging technician; radiologist/qualified physician
Ancillary report that contains information about the preparation/positioning of the patient, identity, date, amount of radiopharmaceutical used, dose, time and route of administration of contrast or drugs, and radiological findings
radiology/medical imaging reports
Ancillary report that details the assessment and treatments used to restore the patient to useful activity and patient education
physical therapy/physiotherapy record
May be continued on an outpatient basis after discharge from the hospital
physiotherapy
Physiotherapy is ordered by the ___ and is performed by a ___ either at bedside or in the Physio Department
attending physician; physiotherapist
Ancillary report that contains info about the initial assessment, methods used, patient response, additional exercises for patient to do on their own, discharge note/summary when service is discontinued
physical therapy/physiotherapy record
Ancillary report that involves not only treatment but also diagnostic testing when required (PFT, spirometry, lung volume measurements, arterial blood gas analysis, etc)
respiratory therapy record
Examples of respiratory treatments.
administration of oxygen and other therapeutic gases, aerosols and humidity, mechanical ventilation, emergency resuscitation
Respiratory services are provided usually at the __ by a ___
bedside, respiratory therapist
Ancillary report that contains a description of the therapy; date and time of administration; patient response to breathing therapy
respiratory therapy record
Social services is becoming more necessary especially as ___ continue to shorten based on arranging homecare and other community report
length of stays
Ancillary report that contains background/social info about the patient and family, problems identified by the patient, family and social worker, plan of action, referrals for various types of social assistance if required
social services record
Ancillary report that is a standard form in AB with mandatory use in cases of patient transfer
patient transfer information form
How are two copies of patient transfer information forms distributed?
One for the health record of the sending hospital, other copy for the health record at the receiving hospital
Ancillary report that contains patient information, diagnoses, medications, when the most recent medications were administered, activity and mental status of the patient, other helpful information
patient transfer information form
Surgical form that provides a concise report of the patient’s immediate postoperative or postanesthetic care
postanesthetic recovery room (PARR) record
Each entry on the PARR record is signed by ___, usually the PARR nurse or anesthetist
person who makes the entry
Surgical form that contains the condition of the patient on arrival to PARR, VS, colour, breathing, condition of surgical wound, level of consciousness, response to stimuli, procedures or medications given in the PARR, discharge note to the nursing unit including the condition of the patient on transfer to the unit
PARR record
