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clinical (2)

chapter 13 medical record

What is the purpose of Medical Records Maintain pt.'s health information
A complete & accurate medical record is a combo of: pt.'s medical history, known family history pt.'s personal history, pt.'s personal history, social habits, med/allergies, occupational exposures, test performed.
pt.'s personal info includes: Demographic info, age, ethnicity, occupation, insurance info
Charting: a process that lays out a chronological account of the pt.'s reports, evaluation, prescribed treatment & need for f/u
legal document medical record that also serves as a legal document
legal document supports pt.'s account of injury
legal document defense for the provider against legal action
chart belongs to.... the practice
all interactions w/ the pt.'s are documented
when documenting use_______ ink black
if errors are made, cross out w/ a single line through it
write correction where? above or next to it and then initial
H.I.P.A.A means Health, Insurance, Portability, accountability, Act of 1996
H.I.P.A.A maintains the privacy of pt.'s health info
privacy officer duties are.. to keep track of who has access to PHI (Protect Health Information)
H.I.P.A.A applies to... medical records, computers, conversations, financial info
pt.'s flies are arranged in... orderly fashion in sections
Progress notes go on what side of record on the right, w/ labs and physicals
demographics go on what side od record on the left, w/ authorization, forms, meds list and immunizations
when filing the most current info it goes.. on the top
subject data is info supplied by the pt.
chief complaint is pt.'s own words for the reason for visit
objective data is info obtained by the doctor or MA by exam
pt.'s 1st visit must provide demographic info
demographics refers to... d/o/b, marital status, phone#'s
always ask pt. if they have... allergies and what meds they are on or have taken
step 1 of pt.'s screening call pt. from waiting room by full name
step 2 of pt.'s screening introduce your name and title
step 3 of pt.'s screening take a seat in chair/exam table
step 4 of pt.'s screening ask pt. for CC
how do you help pt. with CC ask questions.(how long, where, how bad)
step 5 of pt.'s screening ask about meds/allergies
once completed step 6 is? review the cc with pt.
step 7 of pt.'s screening ask if they have questions, notify when MD will be in
Imaging procedures include: MRI,CT Scan, x-rays, ultra sound
lab info consists of.... blood work, urinalysis, pathology/cytology
lab results are either positive or negative (abnormal) (normal)
labs w/ critical values should be... highlighted, noted, & presented to the provider
meds are documented in the medication section of the chart
complete medication entries include prescriber, med name, dose, site, time, observation period, pt.'s response to meds
copies of RX are also placed in the chart
P.O.M.R stands for Problem Oriented Medical Record
P.O.M.R organized according to the pt.'s health problems
S.O.A.P stands for subjective objective assessment plan
H.P.I.P history physical impression plan
C.H.E.D.D.A.R chief complaint history examination details drugs & dosage assessment return
filling medical steps Inspection, Indexing, Coding, Sorting, Storing
filling systems alphabetic, numerical, Chronolgical
Tickler file f/u method for a particular date. can be expanding file. offices have pt. fill out a card as a reminder. tickler must be check every day.
purging means to cleaning out.
HIPPA requires all medical records be kept for 6 years
records of the deceased are kept for... 2 years
Created by: bpstears