PCM 2 Unit 3 Methods of Completing a Medical Record Review Flashcards
What is the Medical Record?
- This is multifactorial and applies to muliple body systems
- Legal Document
- Primary source of communication within and between disciplines
What are the Advantages of Electronic Health Records?
- Complete and Accurate data that is readily available and could easily be shared with other providers
- This improves coordination, the convenience of electronic prescriptions and the ability to track quality data, patient empowerment (patient can access their own documentation and notes) and potential for improved patient follow up
What is HIPPA?
Health Insurance Portability and Accountability Act
- This is a privacy Rule
- Protected Health Information (PHI) of any form should be protected
- Security rule (A subset of privacy rule)
-Ensure the saftey of ePHI
-Logging off the computer, Keep chart closed, and covering clipboards with PHI when not in use
What information falls under Protected Health Information (PHI)?
Any information that pertains to the past, present or future regarding the health (physical or mental), care provided, payment of care and demographics
What are different components of the Medical Record?
- Orders
- Admission Note
- Progress Note
- Reports
May differ from organization to organization
What information is usually in the Physicians Orders?
Who typically writes the Physicians Orders?
This is the Log of all instructions of the POC for the patient
- Medications
- Diagnostic or Therapeutic tests and procedures
- Activity status
- Diet
Typically Written by:
- Physician, Physician Assistant or Nurse Practitioner
- Can be taken by nurse or other health care provider (including PT), according to the departmental, facility and state policies
With Orders, What are the Physical Therapy Considerations?
- Orders should be reviewed prior to providing initial and subsequent PT interventions
-Orders for PT
-Patient activity level
-Weight bearing status
-Vital sign parameters
-Restrictions (Positioning, device needs)
-Changes in medications or health status (diagnostic test request) - If order is not complete or clearly stated, the order must be clarified prior to providing service
What is the Admissions Note?
This is often referred to as H&P, or History and Physical
- This is usually written by physician, physicians assistant or nurse practitioner
- This is often the first section of the chart, this is where we can find a lot of info of the patient, such as what led the patient to the hospital.
In the Admission Notes, what may we find in the History?
Subjective Information
- Data that identifies the patient
- History of present illness (HPI)
- Medical and surgical history, risk factors for disease, allergies
- Family Hx
- Personal and Social Hx
- Current Medication
In the Admission Notes, what may we find in the Physical Examination?
Objective Information from the Physician Examination
- General Information
- Skin
- Head, eyes, ears, nose, throat (HEENT)
- Neck, chest and back
- Heart
- Abdomen
- Genital/Rectal Exam
- Extremities
- Neurological system
In the Admission Notes, what may we find in the Assessment?
This provides a statement of the condition and prognosis of the patient based on the data collected from the evaluation
In the Admission Notes, what may we find in the Plan?
- Further Observations
- Tests
- Lab Analysis
- Consultations
- Pharmacological Therapies
- Interventions
- Discharge Planning
What is in the Progress Note?
- This is typically multidisciplinary and in chronological order
- Nursing staff may have thier own admission assessments in this section in addition to problem lists and care plans
In the Progress notes what information may we find in this section?
- Medication Reconciliations sheets
- Flow sheets
- Clinical pathways
- Consultation services provided from other physicians and health care professionals
- Operative and procedural notes may also be seen in this sections
What information is in the Reports section of the Medical Record Review?
This is also filed in chronological order
- This includes radiologic and labratory reports
- Includes an interpretation or normal reference ranges
- May also include pulmonary function test, stress testing, EEGs
After a Thorough chart review a clinician should be able to…
- Decide the need for appropriate PPE
- Recognize the need for assistance, approptriate AD, equipment (hoyer lift)
- Have an idea of the clinical presentation of the patient you are about to see
-Functional Limitations - Plan for the proper management of lines or devices attached to the patient
-Understand the purpose of each
-Be aware of the precautions associated with the lines and devices
With the Medical Record Review, what Precautions/Contraindications may we find?
- PMH
- Current medical status
- Lab Values
- Consultations/Diagnostic test orders
- Meds
- Alertness and mental status
- Fall risk
- Risk of further deterioration
- Medical review and PT review of systems
- Precautions
-Sternal, Abdominal, weight bearing, spinal
