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Medical Records

Consent to treatment form Required for all surgical operations and nonroutine diagnostic or therapeutic procedures performed in the medical office. the form must be signed by the patient and provides written evidence that the patient agreed to the procedure(s) listed on the form.
Release of Medical Information Required to release information that is not part of medical treatment, payment, and healthcare operations
Electronic Medical Record Is a computericzed record of the important health information regarding a patient, including the care of that individual and the progress of the patient's condition.
What does EMR software do? Allows for the creation, storage, organization, editing, and retrieval of medical records on a computer.
Advantages to EMR Speed, productivity, efficiency, and accessibility
EMR disadvantages Initial cost, time investment, and occupational tasks that need to be performed before an EMR program becomes an option
Source-oriented medical record Organized into sections based on the department, facility, or other source that generated the information. Each section of a source-oriented medical record is separated form the others by a chart divider labeled with the title of its respective section.
Documents in a problem-oriented record Organized by the patient's specific health problems and include a database, a problem list, a plan of action for each problem, and progress notes.
What do progress notes for a problem-oriented record include? Four categories: Subjective data, objective data, assessment, and plan (SOAP)
Charting The process of making written entries about a patient int he medical record. The medical record is a legal document, and the information must be charted completely and accurately as possible, while following established charting guidelines.
Consultation Report A narrative report of an opinion about a patient' condition by a practitioner other than the attending physician
Diagnosis dia-: Thorough; complete -gnosis: Knowledge The scientific method of determining and identifying a patient's condition
Diagnostic Procedure dia- :Thorough; complete -gnos/o: knowledge -ic: pertaining to A procedure performed to assist in the diagnosis, management, or treatment of a patient's condition.
Discharge summary sheet A brief summary of the significant events of a patient's hospitalization.
Health History Report A collection of subjective data about a patient
Home healthcare The provision of medical and non-medical care in a patient's home or place of residence
Physical Examination Report A report of the objective findings from the physician's assessment of each body system
Prognosis Pro-: before -gnosis: knowledge The probable course and outcome of a disease and the prospect for the patient's recovery
Hematology Examination and analysis of blood for the detection of abnormalities and includes such areas as blood cell counts, cellular morphology, clotting ability of the blood, and identification of cell types.
Clinical Chemistry Detecting the presence of chemical substances and determining the amount of these substances in body fluids, excreta, and tissues (e.g. blood, urine, cerebrospinal fluid). The largest area in the clinical chemistry is blood chemistry.
Immunology Studying antigen-antibody reactions to assess the presence of a substance or to determine the presence of a disease
Urinalysis The physical, chemical, and microscopic analysis of urine.
Microbiology Deals with the identification of pathogens in specimens taken from the body (e.g. urine, blood, throat, sputum, wound, urethral, vaginal, cerebrospinal).
Parasitology Deals with the detection of disease-producing human parasites or eggs in specimens taken from the body (e.g. stool, vaginal, blood).
Cytology Deals with the detection of abnormal cells
Health History Consists of the following components: identification data, chief complaint, present illness, past history, family history, social history, and review of systems.
When is a health history form filled out? For each new patient, and subsequent office visits (in the form of progress notes) provide information regarding changes in the patient's illness or treatment.
Progress Notes Update the medical record with new information each time the patient visits or telephones the medical office.
Types of progress notes charted by the medical assistant Pt sx, med. procedures, administration, changes in, or refill of, meds, specimen collections, diagnostic procedures, and lab tests ordered, results of lab tests, instructions given regarding medical care, missed or canceled appointments , telephone calls
Informed Consent Consent given by a pt for a procedure after they have been informed of their condition, the purpose of the procedure, and have been given an explanation of risks involved, alternative treatments, the likely outcome, and the risks of declining or delaying
Histology Deals with the detection of diseased tissues
Patient Registration Record Must be completed by all new patients and consists of demographic and billing information
What is a Health History form used for? (along the physical exam and lab and diagnostic tests) it is used to determine the pt's general state of health, to arrive at a diagnosis and prescribe treatment, and to observe any change in a pt's illness after treatment has been instituted
Physical exam report A summary of the findings from the physicians assessment of each part of the pt's body
Medication record Consists of detailed information relating to a pt's meds and includes one or more of the following categories: Rx (prescription) meds, OTC (over-the-counter) meds, and meds administered at the medical office
Consultation Report A narrative report of a specialist's opinion about a pt's condition and is based on a review of the pt's med record and an exam of the pt
Home health care Provides medical and non-medical care in a pt's home or place of residence to minimize the effect of disease or disability
Diagnostic Procedure Report Consists of a narrative description and interpretation of a diagnostic procedure and includes the following reports: ECG, Holter monitor, Sigmoidoscopy, colonoscopy, spirometry, radiology, and diagnostic imaging.
Therapeutic Service Report Documents the assessments and treatments designed to restore a pt's ability to function, such as physical therapy, occupational therapy, and speech therapy.
Laboratory Report A report of the analysis or examination of body specimens. Its purpose is to relay the results of lab tests to the physician to assist him or her in diagnosing and treating disease
Hospital Documents Prepared by the attending physician and include the history and physical exam of a hospitalized pt, operative report, discharge summary report, pathology report, and emergency department report
Created by: Dott
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