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The Medical Record

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Chapter 4 The Medical Record * * * * * * * * * * Sample Prescription Military Time Corrections Careful clarification of an error when making an entry in a medical ... – PowerPoint PPT presentation

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Title: The Medical Record


1
The Medical Record
  • Chapter 4

2
History and Physical H P
Figure 4.1 page 58
  • Document of medical history and findings from
    physical examination
  • Includes
  • Subjective Information Historyobtained from
    patient including his/her personal perceptions
  • Objective Information Physicalfacts and
    observations made by an examiner

3
History (Hx)
  • Record of the patients personal medical history
    including past injuries, illnesses, operations,
    defects, and habits
  • Includes chief complaint (CC), history of
    present illness (HPI), past history (PH), family
    history (FH), occupational history (OH) and
    review of systems (ROS)

4
History (Hx) Abbreviations
  • CC Chief Complaint or c/o complains
    ofBrief description of why patient is seeking
    care
  • PI or HPI Present Illness/History of Present
    IllnessNotation of duration and severity of
    complaintHow bad is it? How long have they had
    it?
  • Sx symptomEvidence of illness that the patient
    reports

5
History (Hx) Abbreviations
(continued)
  • PH, PMH Past History, Past Medical
    HistoryNotation of surgeries, injuries, physical
    defects, medications, allergies
  • UCHD usual childhood diseases
  • NKA no known allergies
  • NKDA no known drug allergies

6
History (Hx) Abbreviations
(continued)
  • FH Family HistoryNotes about the state of
    health of immediate family members
  • Example FH father, age 58, mother, age 54,
    brother, age 32, all LW
  • AW alive and well
  • LW living and well

7
History (Hx) Abbreviations
(continued)
  • SH Social Historyrecreational interests,
    hobbies, use of tobacco/drugs
  • OH Occupational Historywork habits that may
    involve work related risks
  • ROS or SR Review of Systems, Systems
    Reviewquestions related to function of the body
    systems
  • HEENT head, eyes, ears, nose, throat

8
Physical Exam (Px or PE)
  • Document of physical examination of a patient
    including notations of positive and negative
    findings
  • Includes results of diagnostic testing
  • Sign objective evidence of disease

9
Physical Exam Abbreviations
  • HEENT head, eyes, ears, nose, throat
  • PERRLA pupils equal, round and reactive to
    light and accommodation
  • NAD no acute distress, no appreciable disease
  • WNL within normal limits

10
History and Physical
  • Assessment (A) identification of a disease or
    condition after evaluation of all subjective and
    objective information
  • Impression (IMP)
  • Diagnosis (Dx)
  • Rule out (R/O) a differential diagnosis noted
    when one or more diagnoses are suspect requires
    further testing to verify or eliminate each
    possibility

11
History and Physical
(continued)
  • PLAN,RECOMMENDATION, orDISPOSITION
  • outline of the treatment plan designed to remedy
    the patients condition, which includes
    instructions to the patient, orders for
    medications, diagnostic tests, or therapies

12
Problem Oriented Medical Record (POMR)
  • Health record with focus on patients problem
  • Information organized for access at a glance
  • Documents thought processes of provider
  • Consists of four sections
  • Database
  • Problem list
  • Initial plan
  • Progress notes

13
Problem Oriented Medical Record (POMR)
(continued)
14
SOAP Notes
  • Progress notes made after the initial history and
    physical is recorded. The letters represent the
    order in which progress is noted
  • S subjective that which the patient describes
  • O objective observable information, such as
    test results, blood pressure readings, etc.
  • A assessment progress and evaluation of
    the effectiveness of the plan
  • P plan decision to proceed or alter strategy

15
Common Hospital Records
  • History and Physical
  • Physicians orders
  • Diagnostic tests/laboratory reports
  • Nurses notes
  • Physicians progress notes
  • Consultation Report
  • Operative Report
  • Pathology report
  • Anesthesiologists report

16
Common Patient Care Abbreviations
  • Use only those acceptable to workplace
  • emergency facility ER, ECU
  • place to recover after surgery PAR, PACU
  • registered bed patient IP
  • care before surgery preop
  • patient pt
  • well developed, well nourished WDWN
  • bathroom privileges BRP

17
Common Patient Care Abbreviations
(continued)
  • difficulty breathing SOB
  • treatment Tx, Tr
  • temperature, pulse, T, P, R, BP respiration,
    blood pressure VS or vital signs
  • increase ?
  • decrease ?
  • degree or hour
  • pound or number sign

18
Error Prone Abbreviations and Symbols
  • Medical errors caused by illegible entries and
    misinterpretations have led health care agencies,
    such as the Joint Commission on Accreditation of
    Healthcare Organizations (JCAHO), to require that
    medical facilities publish lists of authorized
    abbreviations for use by all personnel, including
    a list of those unacceptable.

19
Error Prone Abbreviations and Symbols
(continued)
  • q. d every daymistaken for q.i.d when the
    period after the q is sloppily written to look
    like an i
  • spell out daily
  • q.o.d. every other daymistaken for q.d when the
    o is mistaken for a period
  • spell out every other day

20
Error Prone Abbreviations and Symbols
(continued)
  • DC, D/C discharge, discontinuemistaken for
    discontinue when followed by medications
    prescribed at the time of discharge
  • spell out discontinue or discharge
  • gt, lt greater than, less thanmistaken for each
    other
  • spell out

21
Error Prone Abbreviations and Symbols
(continued)
  • AS, AD, AU left ear, right ear, both earsOS,
    OD, OU left eye, right eye, both eyesmistaken
    for each other
  • spell out
  • SC or SQ subcutaneousmistaken for SL
    (sublingual), or 5 every.
  • spell out "subcutaneously or use Sub-Q

22
Diagnostic Imaging Modalities
  • IONIZING IMAGING a process that changes the
    electrical charge of atoms with a possible effect
    on body cells. Overexposure can have harmful side
    effects, e.g. cancer
  • RADIOGRAPHY (X-RAY)
  • COMPUTED TOMOGRAPHY OR COMPUTED AXIAL
    TOMOGRAPHY
  • NUCLEAR MEDICINE IMAGING OR RADIONUCLIDE ORGAN
    IMAGING

23
Diagnostic Imaging Modalities
(continued)
  • NON-IONIZING IMAGING a process that presents no
    apparent risk
  • MAGNETIC RESONANCE IMAGING
  • SONOGRAPHY

24
Common Terms Related to Disease
  • acute vs chronic
  • benign vs malignant
  • localized vs systemic
  • exacerbation vs remission
  • progressive
  • recurrent
  • degenerative

25
Common Terms Related to Disease
(continued)
  • symptom (subjective)
  • sign (objective)
  • diagnosis (through knowing)
  • syndrome (running together)
  • prognosis (before knowing)
  • etiology (study of cause)
  • idiopathic (disease of individual)
  • sequela

26
Common Terms Related to Disease
(continued)
  • good vs malaise
  • febrile vs afebrile
  • gross
  • marked
  • equivocal
  • noncontributory
  • unremarkable
  • morbidity
  • mortality

27
Pharmaceutical Abbreviations and Symbols
  • Metric
  • cc (cubic centimeter)
  • cm (centimeter)
  • g or gm (gram)
  • kg (kilogram)
  • L (liter)
  • mg (milligram)
  • ml, ML (milliliter) Note 1 cc 1 mL
  • mm (millimeter)
  • cu, mm (cubic millimeter)

28
Pharmaceutical Abbreviations and Symbols
(continued)
  • Apothecary
  • fl oz (fluid ounce)
  • gr (grain)
  • gt (drop)
  • gtt (drops)
  • dr (dram)
  • oz (ounce)
  • lb or (pound)
  • qt (quart)

29
Medication Administration Drug Forms
  • Solid and Semisolid Forms
  • Tablet (tab)
  • Capsule (cap)
  • Suppository (suppos)
  • Liquid Forms
  • Fluid
  • Parenteral (ID, Sub-Q, IM, IV)
  • Cream, lotion, ointment
  • Other delivery systems
  • Transdermal
  • Implant

30
Parenteral Drug Administration
31
The Prescription
  • Physicians written direction for dispensing or
    administering a medication for a patient
  • Must be written in a specific format
  • Rx
  • Symbol at beginning of prescription
  • Stands for recipe

32
Drug Names
  • Chemical name assigned to drug at the time it
    is formulated
  • Generic name the official, nonproprietary name
    given a drug
  • Trade or brand the manufacturer's name for a
    drug

33
Drug Names
(continued)
  • For example
  • Chemical name 1-3-(6,7-dihydro-1-methyl-7-oxo-
    3-propyl-1H-pyrazolo4,3-pyrimidin-5-yl)-4-ethoxy
    phenylsulfonyl-4-methylpiperazine citrate
  • Generic name sildenafil
  • Trade or Brand name Viagra

34
Sample Prescription
35
Military Time
36
Corrections
  • Careful clarification of an error when making an
    entry in a medical record is essential.
  • Include
  • Date
  • The abbreviation corr
  • Initials of person making corrections
  • Do not use correction fluid!

37
Proper Correction of a Medical Record
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