Chapter 2: The Patient’s Medical Record OBJECTIVES: 1. Apply a given list of prefixes and suffixes. 2. Describe directional terms and joint movements. 3. Define the 4 methods of examination. 4. State 5 essential components of documentation for a patient encounter. 5. Explain the SOAP method of dictation. 6. Identify a given list of abbreviations. 7. Differentiate between a given list of sound-alike words. 8. Apply guidelines to transcription.
Transcript
Chapter 2:
The Patient’s Medical Record
OBJECTIVES:
1. Apply a given list of prefixes and suffixes.
2. Describe directional terms and joint movements.
3. Define the 4 methods of examination.
4. State 5 essential components of documentation for a patient
encounter.
5. Explain the SOAP method of dictation.
6. Identify a given list of abbreviations.
7. Differentiate between a given list of sound-alike words.
8. Apply guidelines to transcription.
Prefixes and Suffixes
Prefixes Meaning Prefixes Meaning Prefixes Meaning
a, an without, lack of endo within neo new
ab away from epi on, upon peri around
ad toward eu good, well poly many
ante before ex outside post alter, behind
anti against hemi half pre before
bi twice, double hyper above, excessive retro behind
bio life hypo under, deficient semi half
contra against inter between sub under
de away from intra within super/supra upper, excessive
dextro toward the right iso equal tel (e) distance
dys abnormal, pain macro large trans across
ecto outside micro small
Diagnostic Suffixes/Symptomatic Suffixes
Suffixes Meaning Suffixes Meaning Suffixes Meaning
In the anatomical position, the body is erect, eyes looking forward, arms hanging down at sides with palms facing forward, legs parallel with toes pointing forward. A plane is an imaginary line passing though the body at different places and dividing it for anatomical purposes. These planes are as follows:
Sagittal – dividing into unequal right and left sides
Midsagittal – dividing into equal right and left sides
Frontal (coronal) dividing into anterior (ventral) and posterior (dorsal) sections
Transverse (horizontal)- dividing into superior (upper) and inferior (lower) sections.
Other directional terms
frequently used in
patient documentation:
Term Meaning
anterior/ventral toward the front
posterior/dorsal toward the back
horizontal/transverse across
vertical up and down
inferior below
superior above
medial middle
lateral side
proximal nearer to point of origin
distal away from point of origin
supine lying face up
prone lying face down
superficial near the outside
deep near the inside
symmetric equal
asymmetric unequal
STYLE TIP:A plain x-ray means that the
x-ray was done without contrast. It should not be
confused with the anatomical plane.)
Types of Movements
Term Meaning
abduction moves away from the body
adduction moves toward the midline of the body
circumduction (of the shoulders and hips) allows movement in a circle
extension increases the size of an angle
flexion decreases the size of an angle
eversion turns outward
inverstion turns inward
pronation (of the forearm) places the palm down
supination (of the forearm) places the palm up
recumbent lying down, reclining
rotation moves the head from side to side
Common Movement of the Joints
Common Movement of the Joints
Common Movement of the Joints
Common Movement of the Joints
Methods of Examination
Four principal diagnostic means of examining a patient are as follows:
Observation/inspection. The examiner observes the general appearance including
hygiene and grooming, general state of health, posture, mannerisms, and obvious
deformities of the patient.
Percussion. Tapping (percussion) with the fingers or small hammer (plessor) produces
sounds that help to determine size, position, or density of an underlying organ
(viscera).
Palpation. Palpation refers to the sense of touch and may be used to feel for organs, masses, or infiltrate of a body part and determine the condition of an underlying
organ.
Auscultation. By listening to sound, usually with a stethoscope, the examiner may
determine sounds in the heart, lungs, or abdomen.
Each patient encounter notation begins with a statement about why the
patient is seeking the physician’s advice. The reason for the visit may be stated
as a symptom or sign and may be referred to as the chief complaint (CC),
problem, or subjective.
Complete Physical Examination Format:
History of Present Illness (HPI) or Subjective is an information given by the patient. It includes a description of symptoms and when they began, associated factors and remedies tried.
Past History or Past Medical History (PMH) may include information about the patient’s history or medications; immunizations; education; social, family, medical, surgical, psychiatric, obstetrical, gynecological, dental, diet, and work history. Habits including alcohol and substance abuse may be a separate subsection.
Allergies to medications or to other substances should be listed.
Current medications should include all medications that the patient is using at the time of this encounter.
Review of systems includes a review in which the physician asks specific questions about the functioning of each body system.
Physical Examination (PE) or Objective provides an examination record. Laboratory and x-ray findings are also considered objective information, although they may be placed in a separate paragraph entitled Diagnostic Studies.
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Complete Physical Examination (cont.) Mental status provides a general description of the patient’s emotions,
perceptual disturbance, thought process, orientation, memory, impulse
control, judgment, insight, and reliability.
Diagnosis, assessment, impression, or conclusion provides the examining
physician’s interpretation of the information. A diagnosis may be rule out,
suspected, provisional, or probable, and additional studies will be planned.
Plan, disposition, treatment, or recommendations include instructions to the patient, additional diagnostic procedures to be performed, medications
prescribed, and so forth.
Clinical Data Information about a patient’s condition (clinical data) is entered or noted
each time the patient visits the office or is seen by a healthcare provided in another location such as hospital or nursing home. The documentation should include the date of visit, data pertaining to the visit, and the name of the person who examined the patient. The patient medical record is also called chart or file – is an accumulation of all data pertaining to that patient. The patient medical record may include the following:
History and physical examination (H & P)
Chart notes made by the physician, nurse, or healthcare provider
Laboratory or x-ray reports
Special procedure reports (gastroscopy, colposcopy, ER visits, outpatient surgical procedures, etc.)
Correspondence
Forms used for a specific purpose, such as immunization records, developmental and growth records of children, pre-employment physicals, preoperative physicals, disability reports, and burn or injury diagrams.
Headings and Formats
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST HISTORY OR PAST MEDICAL
HISTORY
ALLERGIES
MEDICATIONS
REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
GENERAL
VITAL SIGNS
SKIN
HEENT
NECK
CHEST
LUNGS
HEART
ABDOMEN
PELVIC
RECTAL
MUSCULOSKELETAL
NEUROLOGIC
DIAGNOSIS
PLAN
Sequence of headings for complete history and physical
exam may be as follows:
Headings and Formats (cont.)
Headings are capitalized and on individual lines at the left margin. Their
information should start directly below the heading, but leave a blank line
before a new main heading.
Example:
CHIEF COMPLAINT
The patient is seen today for a follow-up for a sore throat.
HISTORY OF PRESENT ILLNESS
The patient was treated 10 days for a sore throat.
Two lines below the signature information, insert the dictator’s and the
transcriptionist’s initials at the left margin. These initials can be in all capitals
or all lower cased and are separated by a colon (:) or a virgule (/).
RG:KB or rg:kb RG/KB or rg/kb
Headings and Formats (cont.) The date and time of dictation and transcription are also usually included in
the signature block. Insert this information 2 lines below the initials at the left margin. Some medical facilities include the places of dictation (D) and transcription (T).
Robert Gatzs, MDChief of Staff
RB:KB
D: 10/20/20___, Chicago, ILT: 10/21/20___, Niles, IL
Enter the word continued on the bottom of the page if the transcribed document continues onto a new page. Each new page should have the patient’s name, page number and the medical record number, and the type and date of the report at the left margin.
