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THE MEDICAL RECORD

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CHAPTER 1 THE MEDICAL RECORD Content Outline Medical record: Written record of important information regarding a patient Patient: An individual receiving medical care ... – PowerPoint PPT presentation

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Title: THE MEDICAL RECORD


1
CHAPTER 1
  • THE MEDICAL RECORD

2
PRETEST
True or False
  1. The medical record serves as a legal document.
  2. The purpose of progress notes is to update the
    medical record with new information.
  3. The patient registration record consists of a
    list of the problems associated with the
    patient's illness.
  4. All over-the-counter medications taken by the
    patient should be charted on the medication
    record form.
  5. A consultation report is a narrative report of a
    clinical opinion about a patient's condition by a
    practitioner other than the primary physician.

3
PRETEST, cont.
True or False
  1. A report of the analysis of body specimens is
    known as a diagnostic report.
  2. Medical impressions are conclusions drawn from an
    interpretation of data.
  3. A consent to treatment form is required for
    tuberculin skin testing.
  4. Diabetes mellitus is an example of a familial
    disease.
  5. Pain is an example of an objective symptom.

4
Content Outline
Introduction to the Medical Record
  • Medical record Written record of important
    information regarding a patient
  • Patient An individual receiving medical care
  • Function
  • To make decisions regarding patient's care and
    treatment
  • To document results of treatment and patient's
    progress
  • Communicate information to authorized personnel
    in medical office
  • Serves as a legal document
  • Law requires that patient's care and treatment be
    documented

5
Introduction to the Medical Record, cont.
  • Good documentation
  • Works to legally protect the physician and
    medical staff
  • Incomplete records
  • Can be used as evidence to show that patient did
    not receive quality care
  • Information is strictly confidential
  • Must not be read or discussed by anyone not
    involved in care of the patient

6
Highlight on the HIPAA Privacy Rule
  • HIPAA Health Insurance Portability and
    Accountability Act
  • HIPAA Privacy Rule Federal law that protects
    patient's privacy
  • Went into effect April 14, 2003
  • Purpose
  • Provide patients with more control over use and
    disclosure of their health information (Known as
    PHI Protected health information)

7
Highlight on the HIPAA Privacy Rule, cont.
  • Who must comply Anyone that uses, stores,
    maintains or transmits health information
  • Health care providers
  • Health plans
  • Health care clearinghouses (e.g., billing
    services)
  • What is included in the HIPAA Privacy Rule
  • See Highlight on the HIPAA Privacy Rule

8
Components of the Medical Record
  • Consists of numerous documents
  • Each document has a specific function
  • Preprinted forms are often used
  • Documents can be classified into categories

9
Medical Office Administrative Documents
Contain information for efficient record keeping
of office
Patient Registration Record
  1. Consists of demographic and billing information
  2. Must be completed by all new patients

10
Patient Registration Record, cont.
  • Most offices enter this information into the
    computer
  • Original placed in front of patient's chart
  • Information is used for a number of computerized
    functions (e.g., scheduling appointments, posting
    patient transactions, processing patient
    statements and insurance claims)
  • Original registration record
  • Placed in front of patients medical record

11
Patient Registration Record, cont.
  • 6. Includes
  • Demographic information
  • Full name
  • Address
  • Phone (home and work)
  • Date of birth
  • Gender
  • Marital status
  • Employer

12
Patient Registration Record, cont.
  • Billing information
  • Name of responsible party
  • Social Security number
  • Address of responsible party
  • Name of insured
  • Insurance company
  • Policy and group number

13
Correspondence
  • May be received from
  • Insurance companies
  • Example Precertification authorization
  • Patients attorney
  • Patient

14
Correspondence, cont.
  • May be sent from office
  • Patient referral letter
  • Collection letter

15
Medical Office Clinical Documents
Records and reports that assist physician in care
and treatment of patient
Health History Report
  • Subjective data about the patient

16
Health History Report, cont.
  • Health history obtained by
  • Having patient complete a preprinted form
  • Physician or MA during an interview

17
Health History Report, cont.
  • Health history, physical examination, and
    laboratory and diagnostic tests are used to
  • Determine patient's state of health
  • Arrive at a diagnosis
  • Diagnosis The scientific method of determining
    and identifying a patient's condition
  • Prescribe treatment
  • Document change in patient's illness after
    treatment

18
Health History Report, cont.
  • Thorough history obtained on each new patient
  • Subsequent visits
  • Provides additional information regarding changes
    in
  • Patient's condition
  • Treatment

19
Physical Examination Report
  • Physical examination Assessment of each part of
    patient's body
  • Purpose Provides objective data about the
    patient
  • Assists physician in determining patient's state
    of health

20
Physical Examination Report, cont.
  • Physical Examination Report
  • A summary of the physician's findings from each
    part of the body
  • Includes
  • General appearance
  • Head and neck
  • Eyes
  • Ears
  • Nose

21
Physical Examination Report, cont.
  • Mouth and pharynx
  • Arms and hands
  • Chest and lungs
  • Heart
  • Breasts
  • Abdomen
  • Genitalia and rectum
  • Legs and feet

22
Progress Notes
  • Purpose
  • Update medical record with new information when
    patient visits the office or telephones
  • Must include
  • Date and time
  • Signature and credentials of individual making
    entry

23
Medication Record
  • Detailed information on patient's medications
  • Includes
  • Prescription meds
  • Over-the-counter medications
  • Meds administered at medical office

24
Medication Record, cont.
  • Types of forms
  • Prescription and Over-the-Counter Medication
    Record Form
  • Medications Administration Record Form

25
Medication Record, cont.
26
Consultation Report
  • Narrative report of clinical opinion about a
    patient's condition by a practitioner other than
    primary physician (consultant)
  • Usually is usually a specialist (e.g.,
    cardiologist)
  • Consultant's opinion is based on
  • Review of patient's record
  • Examination of patient

27
Consultation Report,cont.
Modified from Diehl MO, Fordney MT Medical
transcription techniques and procedures, ed 5,
Philadelphia, 2003, Saunders.
28
Home Health Care Report
  • Home health care The provision of medical and
    nonmedical care in a patient's home
  • Purpose
  • Minimize effect of disease or disability on the
    patient by
  • Promoting health
  • Maintaining health
  • Restoring health
  • Home health care must be ordered by physician

29
Home Health Care Report, cont.
  • Home health care professionals
  • Nurses
  • Home health aides
  • Dietitians
  • Physical therapists
  • Occupational therapists
  • Speech therapists
  • Social workers

30
Home Health Care Report, cont.
  • Home health services
  • Cardiac
  • Infusion (IV) therapy
  • Respiratory therapy
  • Pain management
  • Diabetes management
  • Rehabilitation
  • Maternal-child care
  • Summary report sent to patient's physician

31
Home Health Care Report, cont.
Courtesy of and Modified from Briggs, Des Moines,
Iowa.
32
Laboratory Documents
  • Laboratory Report A report of the analysis or
    examination of body specimens
  • Purpose
  • Relay results of laboratory tests to physician to
    assist in diagnosis and treatment of disease

33
Laboratory Documents, cont.
  • Categories of Laboratory tests
  • Hematology
  • Clinical chemistry
  • Serology
  • Urinalysis
  • Microbiology
  • Parasitology
  • Cytology
  • Histology

34
Diagnostic Procedure Documents
  • Diagnostic Procedure Report Narrative
    description and interpretation of a diagnostic
    procedure
  • Diagnostic procedure A type of procedure
    performed to assist in diagnosis, management, or
    treatment of a patient's condition.
  • Performed by physician, MA, or specially trained
    technician
  • Interpretation of results made by physician
  • Physician completes a written report

35
Diagnostic Procedure Documents, cont.
  • Examples of diagnostic procedure reports
  • Electrocardiogram report
  • Holter monitor report
  • Sigmoidoscopy report
  • Colonoscopy report
  • Spirometry report
  • Radiology report
  • Diagnostic imaging report

36
Radiology Report
Modified from Diehl MO, Fordney MT Medical
keyboarding, typing, and transcribing, ed 4,
Philadelphia, 1997, Saunders.
37
Diagnostic Imaging Report (CT Scan)
38
Therapeutic Service Documents
  1. Therapeutic Service Report Documents the
    assessments and treatment designed to restore a
    patients ability to function

39
Therapeutic Service Documents, cont.
  • Example of therapeutic services
  • Physical therapy Use os physical agents to
    restore function and promote healing following an
    illness or injury
  • Therapeutic exercise
  • Thermal modalities
  • Cold
  • Hydrotherapy
  • Electrical stimulation
  • Massage

40
Therapeutic Service Documents, cont.
  • Occupational therapy Helps the patient learn
    new skills to adapt to a disabling condition
  • Enables patient to perform activities of daily
    living
  • Achieve as much independence as possible
  • Speech therapy Treatment for the correction of
    a speech impairment resulting from
  • Birth
  • Disease
  • Injury

41
Hospital Documents
  • Prepared by the physician responsible for care of
    the patient in the hospital
  • Known as the attending physician
  • May be
  • Patients regular physician
  • A different physician (e.g., emergency room
    physician)

42
Hospital Documents, cont.
  • Dictated by attending physician and transcribed
    at the hospital
  • Original kept on file at hospital
  • Copy sent to patients physician
  • Assists patients physician in
  • Reviewing patients hospital visit
  • Providing follow-up care

43
History and Physical Report
  • Inpatient Patient who has been admitted to
    hospital for at least one overnight stay
  • Health history and physical examination must be
    performed on all inpatients
  • Exception
  • If history and physical examination are performed
    at medical office 1 week before admission
  • Can be used instead

44
History and Physical Report, cont.
  • If reliable health history cannot be obtained
    from patient
  • Obtained from a person able to relay the facts
  • Consists of a narrative report of
  • Health history
  • Physical examination
  • Physicians medical impressions

45
History and Physical Report, cont.
  1. Purpose of health history document patients
    current complaints and symptoms
  2. Purpose of physical examination assess patients
    current health status

46
History and Physical Report, cont.
  • Medical impressions Conclusions drawn from
    interpretation of data
  • Other terms used
  • Provisional diagnosis
  • Tentative diagnosis
  • Physician interprets data from health history and
    physical examination
  • Draws conclusions (medical impressions) as to
    patients state of health

47
Hospital History and Physical Examination Report
48
Operative Report
  1. Must be completed on all patients who have had a
    surgical procedure
  2. Purpose describes the surgical procedure
  3. Completed and signed by surgeon performing
    operation

49
Operative Report, cont.
  • Includes
  • Patient identification information
  • Date of surgery
  • Preoperative diagnosis
  • Name of surgical procedure
  • Full description of findings

50
Operative Report, cont.
  1. Description of technique and procedures used
  2. Ligatures and sutures used
  3. Number of packs, drains, and sponges used
  4. Description of specimens removed
  5. Condition of patient after completion of surgery
  6. Postoperative diagnosis
  7. Name of surgeon

51
Operative Report, cont.
52
Discharge Summary Report
  • Summary of the significant events of a patients
    hospitalization
  • Includes
  • Concise account of patients illness
  • Course of treatment
  • Response to treatment
  • Patients condition at time of discharge

53
Discharge Summary Report, cont.
  • Purpose is to document information needed by
  • Patients family physician for continuity of
    future care
  • Respond to authorized requests for information
    regarding patients hospitalization
  • Completed and signed by attending physician

54
Discharge Summary Report, cont.
Modified from Diehl MO, Fordney MT Medical
transcription techniques and procedures, ed 5,
Philadelphia, 2003, Saunders.
55
Pathology Report
  • Macroscopic and microscopic description of tissue
    removed during
  • Surgery
  • Diagnostic procedure
  • Includes a diagnosis of the patients condition
  • Pathologist examines tissue completes and signs
    report

56
Pathology Report, cont.
Modified from Diehl MO, Fordney MT Medical
transcription techniques and procedures, ed 5,
Philadelphia, 2003, Saunders.
57
Emergency Department Report
  1. Record of significant information obtained during
    an emergency department visit
  2. Prepared and signed by emergency department
    physician
  3. Copy sent to patients physician so follow-up
    care can be provided

58
Emergency Department Report, cont.
  • Includes
  • Date of service
  • Patients identification information
  • Nature of illness or injury
  • Laboratory or diagnostic test results

59
Emergency Department Report, cont.
  1. Procedures performed
  2. Treatment rendered
  3. Diagnosis
  4. Condition of patient at discharge
  5. Instructions regarding follow-up care

60
Emergency Department Report, cont.
61
Consent Documents
  • Required to
  • Perform certain procedures
  • Release information contained in patients
    medical record
  • Types
  • Consent to treatment form
  • Release of medical information form

62
Consent to Treatment Form
  • Required for
  • All surgical operations
  • Nonroutine therapeutic and diagnostic procedures
  • Example of diagnostic procedure Sigmoidoscopy

63
Consent to Treatment Form, cont.
  1. Signed by patient or legally authorized
    representative
  2. Purpose provides written evidence that patient
    agrees to procedure(s) listed on form

64
Consent to Treatment Form, cont.
  • Informed consent patient has received the
    following information before giving consent
  • Nature of patients condition
  • Nature and purpose of recommended procedure
  • Risks involved
  • Alternative treatment or procedures available
  • Prognosis likely outcome of the procedure
  • Risks of declining or delaying procedure

65
Consent to Treatment Form, cont.
  • Must be in terms patient can understand
  • Patient must be given opportunity to ask
    questions
  • Form should not be signed until patient has been
    provided with all necessary information

66
Consent to Treatment Form, cont.
  • Patients signature must be witnessed
  • Witnessing a signature
  • Means MA verified the patients identity and
    watched patient sign form
  • Does not mean MA is attesting to accuracy of
    information on form

67
Witnessing the patients signature
68
Consent to Treatment Form
69
Release of MedicalInformation Form
  • Not required for medical treatment, payment, and
    health care operations (TPO)
  • a. Stipulated by HIPAA
  • Required for purposes that are not part of TPO
  • a. Example Patient moving to another
    state and transferring medical records
  • 3. Must be signed by patient (or parent/guardian)

70
Release of MedicalInformation Form, cont.
  • Includes
  • Patient full name and address
  • Medical practice releasing info
  • Individual or facility to receive info
  • Info to be released
  • Purpose or need for info
  • Method of release

71
Release of MedicalInformation Form, cont.
  • Signature of patient (or legal representative)
  • Date signed
  • Expiration date of form
  • May be faxed or mailed if patient is unable to
    come to office

72
Release of MedicalInformation Form, cont.
73
Medical Record Formats
  • PPR paper-based patient record
  • Most of record is paper-based
  • Some patient data stored on computer
  • Example Patient registration information
  • c. Formats
  • Source-oriented record
  • Problem-oriented record
  • EMR electronic medical record
  • Entire medical record is stored in computer

74
Source-Oriented Record
  1. Used most often in the medical office
  2. Organized into sections based on department,
    facility, or other source that generated
    information (e.g., laboratory)

75
Source-Oriented Record, cont.
  1. Separated by chart dividers color-coded tabs
    labeled with title of section

76
Source-Oriented Record, cont.
  • Within each section Documents arranged
    according to date
  • Most recent document placed on top or in front of
    the others
  • Known as reverse chronological order

77
Source-Oriented Record, cont.
  • Titles of sections
  • History and Physical
  • Progress Notes
  • Medications
  • Laboratory Reports
  • Electrocardiogram
  • X-Ray Reports
  • Consultations

78
Source-Oriented Record, cont.
  1. Rehabilitation Therapy
  2. Home Health Care
  3. Hospital Reports
  4. Insurance
  5. Consents
  6. Correspondence
  7. Miscellaneous

79
Problem-Oriented Record (POR, POMR)
  1. Organized according to patients health problems
  2. Advantage Patients problems can be defined and
    followed individually

80
Problem-Oriented Record (POR, POMR), cont.
  • POR developed in four stages
  • Database Consists of a collection of subjective
    and objective data
  • Includes
  • Health history report
  • Physical examination report
  • Results of baseline laboratory and diagnostic
    tests

81
Problem-Oriented Record (POR, POMR), cont.
  • Problem list Consists of a list of patients
    problems
  • Problem Any patient condition that requires
    observation, diagnosis, management or patient
    education
  • Includes
  • Medical problems
  • Psychologic problems
  • Social problems
  • Each problem in the list is numbered and titled
  • Serves as a table of contents for the record

82
Problem-Oriented Record (POR, POMR), cont.
  • Plan Plan of action for each problem
  • May include plans for
  • Laboratory tests
  • Diagnostic tests
  • Medical treatment
  • Surgical treatment
  • Therapy
  • Patient education
  • Each plan begins with the problem number followed
    by the plan of action

83
Problem-Oriented Record(POR, POMR), cont.
  • Progress notes Follow-up for each problem
  • Begins with the number of the problem
  • Includes
  • Subjective data Data obtained from the patient
  • Objective data Data obtained by observation,
    physical examination, laboratory and diagnostic
    tests, etc.

84
Problem-Oriented Record (POR, POMR), cont.
  • Assessment Physicians interpretation of the
    current condition based on the subjective and
    objective data
  • Plan Proposed treatment for the patient
  • Acronym SOAP

Soaping Writing progress notes using the SOAP
format
  • Advantages of using SOAP format
  • Can deal with each problem clearly
  • Can analyze data in an orderly manner

85
POR SOAP Progress Notes
Courtesy of and modified from Briggs, Des Moines,
Iowa.
86
Preparing a Medical Record for a New Patient
  • Method of preparation depends on
  • Format used to organize record
  • Filing system
  • Type of storage equipment

87
Preparing a Medical Record for a New Patient,
cont.
  • Most medical offices use
  • Source-oriented format
  • Alphabetic filing system
  • Shelf filing units

88
Medical Record Supplies
  • File Folder protective cover that holds medical
    documents
  • Metal fasteners often used to hold documents in
    folder

89
Medical Record Supplies, cont.
  • Tab projection extending from a folder
  • Identifies contents
  • Located on side or top
  • Full cut tab tab extending across entire side or
    top
  • Full cut side tab often used in medical office
  • Indentions on full cut tabs indicate placement
    of labels
  • Ensures that labels on every record is affixed at
    same place

90
Medical Record Supplies, cont.
  • Folder labels identifies the medical record
  • Most common types used
  • Name labels
  • Alphabetic color-coded labels
  • Color-coded year labels

91
Affixing labels to the chart
92
Medical Record Supplies, cont.
  • Chart Dividers identifies each section of
    medical record by subject
  • Color-coded tab with subject title attached

93
Taking a Health History
  • A collection of data obtained by interviewing a
    patient and/or having patient complete a
    preprinted form
  • a. Reviewed for completeness by MA
  • 2. Thorough history taken on a new patient
  • 3. Subsequent visits information is obtained
    regarding changes in the patients illness or
    treatment (progress notes)

94
Taking a Health History, cont.
  • 4. Quiet, comfortable room encourages patient to
    communicate
  • 5. Showing interest and concern reduces patient
    apprehension
  • Facilitates collection of data

95
Components of the Health History
  • Health history is taken before the physical
    examination
  • Provides physician opportunity to compare
    findings
  • Identification data basic patient data
  • Completed by patient

96
Components of the Health History, cont.
  • Chief Complaint (CC)
  • Patients reason for seeking care
  • Symptom causing the patient the most trouble
  • Foundation for present illness and review of
    systems
  • MA usually responsible for obtaining and
    recording CC
  • Recorded on a preprinted lined form

97
Components of the Health History, cont.
  • Guidelines for obtaining and recording CC
  • Use open-ended questions
  • Example What seems to be the problem?
  • Limit CC to one or two symptoms
  • Should refer to a specific rather than a vague
    symptom
  • Record CC concisely and briefly in patients own
    words as much as possible
  • Include duration of symptom
  • Do not use names of diseases or diagnostic terms

98
Components of the Health History, cont.
  • Examples
  • Correct Burning during urination that has
    lasted for 2 days.
  • Incorrect Ear pain and fever. (Duration of
    symptom is not listed)

99
Components of the Health History, cont.
  • Present Illness (PI)
  • Expansion of CC
  • Full description of patients current illness
  • MA often completes asks patient questions
  • Recorded on same form as CC
  • MA asks patient questions
  • To obtain a detailed description of the CC
  • Requires skill and practice in asking proper
    questions

100
Components of the Health History, cont.
  • Past History
  • Past medical status of patient
  • Assists physician in providing optimal care
  • Patient completes this section checklist form
  • MA should assist if needed

101
Components of the Health History, cont.
  1. Includes
  • Major illness
  • Childhood diseases
  • Unusual infections
  • Accidents and injuries
  • Hospitalizations and operations
  • Previous medical tests
  • Immunizations
  • Allergies
  • Current medications

102
Past History
103
Components of the Health History, cont.
  • Family History
  • Review of health status of patients blood
    relatives
  • Focuses on familial diseases
  • Familial disease a disease that occurs in blood
    relatives more frequently than would be expected
    by chance

104
Components of the Health History, cont.
  • -Examples
  • (1) Hypertension
  • (2) Heart disease
  • (3) Allergies
  • (4) Diabetes mellitus

105
Components of the Health History, cont.
  • Patient completes this section
  • Includes following info on each blood relative
  • State of health
  • Presence of any significant disease
  • If deceased cause of death

106
Family History
107
Components of the Health History, cont.
  • Social History
  • Information on patients lifestyle Health
    habits and living environment
  • Purpose Lifestyle may have impact on patients
    condition
  • If a major lifestyle adjustment is necessary
    (e.g., smoking cessation)
  • Support services may be recommended
  • Completed by patient

108
Components of the Health History, cont.
  • Includes
  • Education
  • Occupation (past and present)
  • Living environment
  • Diet

109
Components of the Health History, cont.
  • Includes, cont.
  • Personal history
  • Exercise
  • Sleep patterns
  • Use of tobacco, alcohol, drugs
  • Travel to foreign countries

110
Social History
111
Components of the Health History, cont.
  • Review of Systems (ROS)
  • Systematic review of each body system
  • Purpose detect any symptoms that have not yet
    been revealed
  • Physician completes this section
  • Asks a series of detailed and direct questions
    related to each body system
  • Assists physician in determining type and extent
    of physical examination required

112
Review of Systems
113
Charting in the Medical Record
  • Charting The process of making written entries
    about a patient in the medical record
  • Performed by personnel directly involved with
    health care of patient
  • Legal document Important to chart information
    completely and accurately

114
Charting in the Medical Record, cont.
Charting Guidelines
  • Check name on chart before making an entry
  • If document in wrong chart
  • Procedure may be excluded from correct patients
    record
  • From a legal standpoint A procedure not
    documented was not performed

115
Charting in the Medical Record, cont.
  • Use black ink
  • Provides permanent record
  • Easier to reproduce (e.g., information needed by
    insurance company, patient referral)
  • Write legibly

116
Charting in the Medical Record, cont.
  • Chart information accurately using clear and
    concise phrases as follows
  • Be brief but complete
  • Avoid vagueness and duplication of information
  • Do not need to include patients name in entry
  • Entire record centers on one patient
  • Assumed that info refers to that patient

117
Charting in the Medical Record, cont.
  • Begin each phrase with a capital letter and end
    with period
  • Begin each new entry on a separate line
  • Include date and time on all entries
  • Use standard abbreviations, medical terms, and
    symbols
  • Save time and space
  • First check office policy for terms used in
    office
  • Spell correctly
  • Use dictionary if necessary

118
Charting in the Medical Record, cont.
  • Chart immediately after performing a procedure
  • If delay may not remember certain aspects of
    procedure
  • Never chart in advance
  • Individual performing procedure should be the one
    to chart it
  • Do not chart for someone else
  • Each entry should be signed by person making it
  • Include first initial, full last name, and
    credentials

119
Charting in the Medical Record, cont.
  • Never erase or obliterate an entry
  • Reduces credibility if involved in litigation
  • To correct an error
  • Draw a single line through incorrect information
  • Write the word error above incorrect data
  • Include date, first initial, last name, and
    credentials
  • Insert correct information next to error

120
Correcting a charting error
121
Charting Progress Notes
  1. Updates medical record with new information each
    time patient visits office
  2. Documents patients health status, care, and
    treatment
  3. Provides communication among office personnel
  4. Serves as legal document
  5. Preprinted lined sheets used known as progress
    note sheets

122
Charting Patient Symptoms
  • Symptom Any change in the body or its
    functioning that indicates the presence of
    disease
  • Subjective symptom A symptom that is felt by the
    patient and cannot be observed by another person
    (pain, pruritus, vertigo, nausea)
  • Objective symptom A symptom that can be observed
    by another person (rash, coughing, cyanosis)

123
Charting Patient Symptoms, cont.
  • Taking patient symptoms consists of
  • Obtaining chief complaint
  • Obtaining additional information about CC

124
Other Activities That MustBe Charted
  • Procedures
  • MA frequently charts procedures performed on the
    patient (e.g., vital signs)
  • Include Date, time, type of procedure, outcome,
    patient reaction

125
Other Activities That MustBe Charted, cont.
  • Administration of Medication
  • Important responsibility
  • Include Date, time, name of medication, dosage
    given, route of administration, injection site,
    any significant observations or patient reactions

126
Administration of Medication
127
Other Activities That MustBe Charted, cont.
  • Specimen Collection
  • Include Date, time of collection, type of
    specimen, area of body where specimen was
    obtained
  • If specimen sent to outside laboratory chart
    test(s) requested, date specimen sent, where sent
  • Provides data if test results are not back yet

128
Specimen Collection
129
Other Activities That MustBe Charted, cont.
  • Diagnostic Procedures and Laboratory Tests
  • Include Date, time, type of procedure/test(s)
    ordered, scheduling date, where procedure/test(s)
    being performed
  • Purpose of charting
  • If patient does not undergo test ordered
    documented proof exists that test was ordered
  • Refreshes physicians memory that tests were
    ordered (if results not yet back from laboratory)

130
Diagnostic Procedure and Laboratory Test
131
Other Activities That MustBe Charted, cont.
  • Results of Laboratory Tests
  • STAT tests or critical findings may be telephoned
  • Must record results on a report form
  • Laboratory tests performed in office must be
    charted
  • Include date, time, name of test, and test
    results

132
Test Results
133
Other Activities That MustBe Charted, cont.
  • Patient Instructions
  • May need to relay instructions to patient
    regarding medical care (e.g., wound care)
  • Important to chart this information date, time,
    and type of instructions relayed to patient

134
Other Activities That MustBe Charted, cont.
  • Preprinted instruction sheet may be used
  • Patient signs form to indicate has
    read/understands instructions
  • MA witnesses the signature
  • Filed in chart copy given to patient
  • Legally protects physician If patient does not
    follow instructions and causes harm to a body part

135
Patient Instruction Sheet
136
Patient Instructions
137
Other Activities That MustBe Charted, cont.
  • Other areas of charting
  • Missed or canceled appointments
  • Telephone calls from patients
  • Medication refills
  • Changes in medication dosage by physician

138
Telephone Call and Missed Appointment
139
POSTTEST
True or False
  1. The purpose of HIPAA is to provide patients with
    more control over the use and disclosure of
    their health information.
  2. The health history provides subjective data about
    a patient to assist the physician in arriving at
    a diagnosis.
  3. Physical therapy helps a patient with a
    disability learn new skills to perform the
    activities of daily living.
  4. A copy of the patients emergency room report is
    sent to the patients family physician.
  5. When a medical assistant witnesses a patients
    signature on a form, it means that the medical
    assistant is verifying that the patient
    understands the information on the form.

140
POSTTEST, cont.
True or False
  1. SOAP is the acronym for the format used to
    organize POR progress notes.
  2. The chief complaint is the symptom causing the
    patient the most trouble.
  3. The purpose of progress notes is to update the
    medical record with new information.
  4. The patients name must be included at the
    beginning of each entry charted in the patients
    medical record.
  5. A decrease in the amount of water in the body is
    known as edema.
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