CHAPTER 2

INTRODUCTION TO HEALTH RECORDS

INTRODUCTION TO HEALTH RECORDS

• Health records can be found in a paper chart or an electronic

health record (EHR)

• Health records contain information about the patient

• Previous illnesses and treatments

• Current medical problems

• History of family illnesses

• Current medications

• The health record contains the data that will determine the

patient’s care plan

INTRODUCTION TO HEALTH RECORDS

• Medical notes share a consistent, logical organization

• Chapter 2 focuses on the organization of medical documents

• Health information Career Map from the American Health Information Management Association

THE SOAP METHOD• SOAP is an acronym for the different types of

information documented by health care providers

S = subjective: what the patient says

O = objective: what the tests reveal

A = assessment: the analysis of the subjective and objective

information; performed by the health care provider

P = plan: course of action for the patient

TYPES OF HEALTH RECORDS

• Medical records vary in length and content

TYPES OF HEALTH RECORDS• Example Note #1: Clinic Note

TYPES OF HEALTH RECORDS• Example Note #2: Consult Note

TYPES OF HEALTH RECORDS• Example Note #3: Emergency Department

Note

TYPES OF HEALTH RECORDS• Example Note #4: Admission Summary

TYPES OF HEALTH RECORDS• Example Note #5: Discharge Summary

TYPES OF HEALTH RECORDS

• Example Note #6: Operative Report

• Example Note #7: Daily Hospital Note/ Progress Note

• Radiology Report

• Pathology Report

TYPES OF HEALTH RECORDS

• Example Note #10: Prescription

COMMON TERMS ON HEALTH RECORDS• Subjective

• These are the problems that the patient states he/she has

• Those problems are then translated into medical terms

• This is so that you can correctly communicate the problems to all health care providers

COMMON TERMS ON HEALTH RECORDS

General subjective terms:

• symptom

• noncontributory

• acute vs. chronic

• abrupt

• progressive vs. exacerbation

• febrile vs. afebrile

COMMON TERMS ON HEALTH RECORDS• General objective

terms:

• Things that are seen:• alert

• oriented

• Things that are heard:

• auscultation

• percussion

• Things that are felt:• Palpation

• Descriptions of what is observed:

• unremarkable

• marked

COMMON TERMS ON HEALTH RECORDS

General assessment terms:

• impression

• diagnosis

• differential diagnosis

• etiology vs. idiopathic

• benign vs. malignant

• remission

COMMON TERMS ON HEALTH RECORDS

General assessment terms (cont.):

• morbidity

• mortality

• prognosis

• localized vs. systemic/generalized

• pathogen

• lesion

• sequelae

COMMON TERMS ON HEALTH RECORDS

General plan terms:

• disposition

• observation

• reassurance

• supportive care

• Palliative

COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation

COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation

COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation

COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation

COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation

COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation

A FEW COMMON ABBREVIATIONS

Areas of the Health Care Facility

pre-op, OR, PACU, post-op

ICU – intensive care unit: CCU, SICU, PICU, NICU

ER, ED, and ECU

L&D

A FEW MORE ABBREVIATIONSCommon on Health Records

• H&P – the history and physical

• CC – the patient’s chief complaint

• HPI – history of present illness

• ROS – review of systems

• PE – physical exam

• PCP – primary care provider

And there are many more you will need to

know!

HEALTH RECORDS AND HEALTH INFORMATION MANAGEMENT

• There is substantially more to a Career in Health Information Management than Health Records

• HIM careermap

• HIM professional video

• HIM professional 2 video

• HIM professional 3 video