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Medical Office 2

Medical Records and Documentation

importance of patient medical records records are legal documents that give a complete, concise, chronological history of a patient’s past medical history, current medical issues, treatment plan, and treatment outcome
documents that constitute a patient medical record. patient registration form, medical history form, physical exam form, laboratory and other test results, records from physicians or hospitals, physician diagnosis and treatment plan, operative reports, hospital discharge summaries
SOMR documents in the medical record in strict chronological order
POMR files the same documents according to numbered problems found on the patient problem list.
SOAP notes organize medical record documentation according to subjective, objective, assessment, and plan
CHEDDAR chief complaint, history, exam, details, drugs, assessment, and return visit plan.
6 Cs of charting clarity, completeness, conciseness, chronological order, and confidentiality
Documenting in chart Personal thoughts and observations should never be a permanent part of the patient medical record.
written request for release of medical records express written permission from the patient must be received. Only release records that are expressly requested and authorized by the patient.
Noncompliant term used to describe a patient who does not follow the medical advice he or she receives. also used as a physician’s defense in a malpractice suit if it can be proven
respondeat superior Latin: "let the master answer"
Uses of Patient Records Patient Education > Quality of Care > Research
Quality of Care records are frequently used to evaluate the care and treatment a facility or physician provides
Research Carefully kept records are valuable sources of data about patient responses, behavior, symptoms, side effects, and outcomes.
demographic information Date of current (first) visit •Patient’s legal name and physical address •Phone numbers •Patient’s date of birth •Medical insurance •Emergency contact •Primary care physician
Patient Medical History second part of the registration process, contains the patient’s past medical history, serves as the base document for the patient’s medical record
Physical Examination Form review of systems is an “inventory” of the body obtained by the healthcare provider through a series of questions. The purpose of this review is to identify any signs or symptoms the patient is experiencing
Results of Laboratory and Other Tests findings from tests performed in the office and those received from other physicians, hospitals, independent laboratories, or other outside sources
Documents from Other Sources Incoming records from other sources also must be entered and stored in the patient’s medical record
Diagnosis and Treatment Plan plan may include treatment options, the final treatment plan, instructions to the patient, and any medications prescribed.
Telephone Calls patient contacts by the office staff should be recorded in the patient’s medical record.
Hospital Discharge Summaries summary generally includes information that summarizes the reason the patient entered the hospital; tests, procedures, and operations performed in the hospital; medications administered to the patient; and the disposition (outcome) of the case
Consent Forms “informed,” the patient must understand the treatment offered and the possible outcomes or side effects of the treatment. documents must be witnessed
Correspondence About the Patient Each piece should be marked or stamped with the date the medical office received the document.
The right to notice of privacy practices Patients must receive a written notice of privacy practices on their first visit to a healthcare provider. signed form must be carefully filed in the patient’s medical record
The right to limit or request restriction on their PHI and its use and disclosure patients can limit how your office uses their medical information and how much of that information is shared, date range required for that information should be released, nothing more.
“Need to Know” general rule only the minimal amount of patient information should be released to meet the current needs of the patient.
The right to confidential communications must make a reasonable effort to communicate with the patient in a confidential manner as the patient requests.
The right to inspect and obtain a copy of their PHI patients have a right to request and receive a copy of their own medical records. It is considered an acceptable practice to act on a request within 30 days of the request and to charge a reasonable fee
The right to request an amendment to their PHI All requests for amendment and response must be carefully documented and filed in the medical chart.
The right to know if their PHI has been disclosed and why always record the date of the disclosure, the name and address of the person receiving the PHI, a brief summary of the information released, and the purpose of the disclosure.
Progress Notes always includes—in chronological order—the patient’s condition, complaints, problems, treatment, and responses to care.
Medical Transcription As with all parts of the medical record, they are part of the patient’s continuing (and confidential) case history and often include findings, treatment stages, prognoses, and final outcomes
Timeliness records should be kept up-to-date and be readily available when any healthcare professional needs to see them
Accuracy physician must be able to trust the accuracy of the information in the medical records
Created by: baybro9933