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Clinical Chapter 1

The Medical Record

TermDefinition
Functions of a Medical Record - documents the results of treatment and the patient's progress - serves as a legal document - efficient and effective method for communicating in the medical office
What does HIPAA stand for? What is its purpose? Health Insurance Portability and Accountability Act -To provide patients with a better control over the use and disclosure of their health information.
General categories of information that are included on a patient registration record - Patient's demographic - Billing information
Uses of the health history - To determine the patient's general state of health - To arrive at a diagnosis and to prescribe treatment - To document any changes in a patient's state of health
Categories of medication that may be included in a medication record - Prescription medications - Over the counter medications - Medications administered at the Medical Office
Components of a Medical Record - Administrative/clinical documents - Laboratory - Diagnostic procedures - Therapeutic services - Hospital documents - Consent documents
Administrative Documents - Registration forms - Correspondence
Clinical Documents - Health history - Physical examination - Progress notes - Medication and immunization records - Consultation/home health reports
Laboratory Documents - Hematology - Chemistry - Serology - Urinalysis - Microbiology - Cytology - Parasiology
Diagnostic Procedures - Holter monitor reports - Sigmoidoscopy - Colonoscopy - Spirometry - Imaging (x-rays, CT scans, MRI) - EKG's
Therapeutic Services - Physical therapy - Occupational therapy - Speech therapy
Hospital Documents - History and physical - Operative report - Discharge Summary - Pathology report - ER report
Consent Documents - Consent to treatment - Consent to release medical reports
Medical Record preparation (supplies) - File folders - Labels - Chart dividers
Charting (progress notes) - What do we chart? - Patient symptoms - Procedures - Administration of medications - Specimen collection - Results of lab tests - Diagnostic procedures - Instructions given to a patient regarding care
Created by: Rachel_m
 

 



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