| 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 |
