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PowerPoint® to accompanyChapter 9
Second Edition
Ramutkowski Booth Pugh Thompson Whicker
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
Medical AssistingChapter 9
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Objectives9-1 Explain the purpose of compiling patient medical
records.9-2 Describe the contents of patient record forms.9-3 Describe how to create and maintain a patient
record.9-4 Identify and describe common approaches to
documenting information in medical records.
Maintaining Patient Records
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Maintaining Patient Records
9-5 Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records.
9-6 Discuss tips for performing accurate transcription.9-7 Explain how to correct a medical record.9-8 Explain how to update a medical record.9-9 Identify when and how a medical record may be
released.
Objectives (cont.)
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Maintaining Patient Records
Patient Records
Also known as chartscontaining:
• Past and present medical conditions• Communications between health team members
• Name & address• Insurance coverage• Occupation• Medical treatment plan• Health-care needs• Response to care• Lab and radiology reports
The chart is a legal document, and can play a role in patient and staff education. It may also be used for quality control and research.
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Importance of Patient RecordsLegal Guidelines forPatient Records As a general rule, if
information is not documented there’s no proof it was ever done.
Charts are used in court.
Standards for Records Complete, accurate and
well-documented records can serve as convincing evidence that the doctor provided appropriate care.
Incomplete, inaccurate, altered or illegible records may imply poor standards.
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Importance of Patient Records
Additional Uses of Patient Records
Patient Education Quality of Treatment
Research
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Contents of Patient ChartsStandard Chart Information Patient Registration Form
Date of current visit Demographic data (age, date of birth, SS#,
address, telephone number, marital status, etc.) Medical insurance information Emergency contact person Family medical history List of medical problems
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Past Medical History Illnesses, surgeries, allergies and current
medications Family medical history Social history (use of drugs and alcohol, cigarette
smoker, etc) Occupational history Statement of current patient complaint recorded
in patient’s own words
Contents of Patient ChartsStandard Chart Information (cont.)
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Physical Examination Results Containing results of a general physical exam
Results of Laboratory and other Tests Results from lab tests performed on patient
Records from other Physicians or Hospitals Include along with these records a copy of the
patient consent authorizing release of information
Contents of Patient ChartsStandard Chart Information (cont.)
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Doctor’s Diagnosis and Treatment Plan Lists doctor’s diagnosis, medications prescribed
and overall treatment plan Operative Reports, Follow-Up Visits, and
Telephone Calls A continuous record of all care provided to the
patient while under the doctor’s care Also document calls made to and from the patient
Contents of Patient ChartsStandard Chart Information (cont.)
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Informed Consent Forms Signed consent forms show that the patient
understands procedure, outcomes and options Patient may still change their mind even after
signing the consent form Hospital Discharge Summary Forms
Includes information summarizing the patient’s hospitalization
Follow-Up care after discharge is also included and the physician signs it
Contents of Patient ChartsStandard Chart Information (cont.)
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Correspondence With or About the Patient All written correspondences regarding the patient
should be included Be sure to record date each was received on the
actual form
Contents of Patient ChartsStandard Chart Information (cont.)
Information Received by Fax
Request an original copy, if not available make a photocopy of the fax.
Dating and Initialing
Be sure to date and place your initials on everything you place in the chart.
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Initiating and MaintainingPatient Records
Initial Interview
Completing MedicalHistory Forms
Documenting Patient Statements
Documenting TestResults
Examination Preparation & Vital Signs
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Follow-Up Duties Transcribe notes the doctor dictates Post results of laboratory and examinations
on summary sheet Record all telephone communication with
the client Record all medical or discharge
instructions given to the client
Initiating and MaintainingPatient Records (cont.)
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Apply Your KnowledgeThe medical assistant is obtaining the initial information from a patient. The patient informs the medical assistant that he/she has used intravenous drugs for the past 3 years. Which section of the chart will this be recorded in?
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The medical assistant is obtaining the initial information from a patient. The patient informs the medical assistant that he/she has used intravenous drugs for the past 3 years. Which section of the chart will this be recorded in?
This should be recorded in the past medical history section. More specifically under the social history section.
Apply Your Knowledge -AnswerAnswer
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lient’s wordsBe sure to record the client’s exact words and do not rephrase their statements.
larityBe precise and use accepted medical terminology when describing a patient’s condition.
ompletenessFill out all forms in the patient record completely so others will understand your notations and entries.
oncisenessBe as brief and to the point as possible. Use medical abbreviations to save time.
hronological orderDate entries in the order they occur. This shows consistency with accurate documentation.
onfidentialityAll information in patient record must be kept confidential to protect patient privacy.
The Six Cs of Charting
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Types of Medical RecordsSource-Oriented Medical Records
Problem-Oriented Medical Records
Also called conventional Information is arranged
according to who supplied the data
Problems and treatments are described on the same form
Presents some difficulty with tracking progress of specific events.
(POMR) makes it easier to track specific illnesses
Consists of: Data base Problem list Educational, diagnostic and
treatment plan Progress notes
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SOAP Documentation Incorporated with POMR Utilizes an orderly series of steps for dealing
with any medical case Lists the following:
Patient symptoms Diagnosis Suggested treatment
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ubjective data
bjective data
ssessment
lan
Subjective data is information the patient tells you about their symptoms.
Objective data is data observed by the physician during the examination.
Assessment is the impression of the patient’s problem that leads to a diagnosis.
Plan of action consists of the treatment plan to correct the illness or problem.
SOAP Documentation
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Appearance, Timeliness, andAccuracy of Records
• Use a good quality pen, black ink preferably.• Make all writing legible.• Never use white out in charts.
• Record all findings as soon as they are available
• For late entries, record both original date and current date
• Record date and time of telephone calls and
information discussed
• Check information carefully• Double check accuracy of information• Make sure most recent information is recorded• Follow correct procedure for
correcting errors
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Professional Attitude and Tone Maintain a professional tone with your
writing by: Recording patient comments in their own words Not recording your personal, subjective
comments, judgments, opinions or speculations
You may call attention to a problem by attaching a note to the chart but do not make such comments part of the chart.
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Computer Records Advantages
Can be accessed by more than one person at-a-time
Can be used in teleconferences Useful for tickler files
Security Concerns Protecting patient confidentiality is a major area
of concern
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Medical Transcription Transcription means transforming spoken
words into written format. Dictated information is part of the medical
record and must be kept confidential. Always date and initial each transcription
page. Strive for ultimate accuracy and completeness
of transcribed information.
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Transcribing Recorded Dictation Organize your work area Adjust transcription machine speed, tone and volume as
needed Listen initially to entire recording before transcribing and
document areas with difficult interpretations Listen to voice tones to determine correct punctuation Never try to guess at meanings Re-read for accuracy and correct spelling and punctuation Physicians should initial all transcribed doctor’s notes
Medical Transcription (cont.)
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Transcribing Direct Dictation Use a writing pad and good pen that will not
smear Use incomplete sentences and phrases to keep up
with physicians pace Use abbreviations Ask for clarification immediately if something is
unclear Read the dictation back to verify accuracy
Medical Transcription (cont.)
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Medical Transcription (cont.)
Transcription Aids
TranscriptionReference Books
MedicalTerminology Books
SecretarialBooks
Medical ReferenceBooks
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Label the following items as either (S) “subjective” or (O)“objective”.
headache
vomiting
nausea
chest pain
respirations = 22 and non-labored
skin color
Apply Your Knowledge
or
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headache
vomiting
Label the following items as either (S) “subjective” or (O)“objective”.
chest pain
nausea
respirations = 22 and non-labored
skin color
Apply Your Knowledge -AnswerAnswer
headache
vomiting
nausea
chest pain
skin color
respirations = 22 and non-labored
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Correcting and Updating Patient Records Medical records in legal terms are regarded as
“due course” meaning information is to be entered at the time of occurrence and not “conveniently” later.
Use care with corrections because it is more difficult to explain a chart that has been altered after something was documented.
Date and initial each addition to the medical record.
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Release of Records Procedures for Releasing Records
Obtain a signed and newly dated release form authorizing the transfer of their information, and place in file.
Make photocopies of original materials. Copy and send only documents covered in the release
authorization. Special Cases
Divorce and death Confidentiality
Children age 18 in many states are to be treated as adults and their parents do not have the right to see their records without authorization.
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Apply Your KnowledgeThe medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another physician’s office. What would you do in this situation?
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The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another fax number. What would you do in this situation?It is difficult to know the actual originator of a fax transmittal and to verify the signature. The safest solution would be not to release any information ever via fax.
Apply Your Knowledge -AnswerAnswer
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End of Chapter