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Clinical Chapter 1
The Medical Record
| Term | Definition |
|---|---|
| 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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