Date post: | 07-May-2015 |
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The Medical Record
The Medical Scribe’s Role
The medical record is an important part of the patient’s care in the clinic or emergency room.
The information a scribe records on the chart could affect how the patient is managed currently or in the future.
The Medical Record
To communicate relevant information to other medical personnel.
It is a legal document that can be presented in a court of law.
Functions of the Medical Record
A physician may be asked to testify in cases of:◦Rape◦Homicide◦Assault◦Child abuse◦Civil procedures involving personal injury
The method used in charting the patient’s stay through the clinic/ED must follow a logical progression.
The most common method is to consider the chart to have four generalized sections:◦Subjective◦Objective◦Assessment◦Plan
SOAP
The Subjective portion includes: ◦Chief Complaint (CC)◦History of Present Illness (HPI)◦Review of Systems (ROS)◦Past Medical History (PMHx)◦Family History (FHx)◦Social History (SHx)
Subjective
The Subjective section pertains to any information that the patient and/or family states.
This information is dependent upon the patient’s condition, beliefs, personality, etc.
This section will contain the patient’s story in his/her own words.
Subjective
Chief Complaint◦The main reason the patient has come to the clinic/ED.
◦Every chart must have a Chief Complaint.◦A short statement in the first sentence of the HPI identifying why the patient has come to the clinic/ED.
◦Should be in the patient’s own words (if possible).
SubjectiveChief Complaint (CC)
History of Present Illness (HPI)◦Explains the Chief Complaint.◦Describes why the patient is in the clinic/ED and lists any pertinent positives and negatives.
◦This should be in a narrative paragraph consisting of 4-5 sentences depending on the severity of the patient’s condition.
◦The HPI is a chronological description of the development of the patient’s present illness from the first sign/symptom or from the previous encounter to the present.
SubjectiveHistory of Present Illness (HPI)
8 dimensions of HPI - directly related to Chief Complaint◦Location◦Quality◦Severity◦Duration◦Timing◦Context ◦Modifying factors◦Associated signs and symptoms
SubjectiveHistory of Present Illness (HPI)
Location◦A place on the body Examples: R flank, midsternal chest, etc.
Quality ◦Description of the complaint Constant, dull, crampy, intermittent, etc.
Severity◦How bad is it? ◦Usually on a scale of 1 to 10 Examples: Acute, mild/moderate/severe,
7/10, 3 pads in the last hour, etc.
SubjectiveHistory of Present Illness (HPI)
Duration◦How long do the episodes last? Examples: 30 seconds each, 5 years, etc.
Timing◦When did it start? Examples: 3:00 AM, this afternoon, etc.
Context◦What were you doing when it happened? Examples: Running laps, just ate 7 doughnuts, awoken from sleep, etc.
SubjectiveHistory of Present Illness (HPI)
Modifying factors◦What makes it better or worse? Examples: Worse with activity, improve with nitroglycerin, increased pain with movement.
Associated signs and symptoms◦Any other symptoms Examples: If CC is chest pain, associated with diaphoresis and N/V.
SubjectiveHistory of Present Illness (HPI)
A review of the patient’s past medical, social history, and family medical history.
Depending on the circumstances or encounter, the patient’s Chief Complaint could be an indication of a complication of, or a result of, a preexisting condition or the patient’s past medical history.
SubjectivePast Medical, Social, and Family History
Past Medical History (PMHx)◦Includes injuries, chronic illnesses, and surgeries.
Social History (SHx)◦Identifies behavioral risks such as tobacco alcohol, or drug use.
Family History (FHx)◦Includes relevant past family medical information.
SubjectivePast Medical, Social, and Family History
Past Medical History (PMHx)◦ Hypertension (HTN), coronary artery disease
(CAD), chronic obstructive pulmonary disease (COPD), diabetes (DM), coronary artery bypass graft (CABG), cancer (Ca).
Past Surgical History ◦ A subcategory under PMHx.
Social History (SHx)◦ Tobacco use (Tob), alcohol use (EtOH),
intravenous drug use (IVDA), living situation (lives alone, lives with others, nursing home, or lives at home with parents).
Family History (FHx)◦ Includes genetic traits, DM, Ca, cardiac disease,
etc.
SubjectivePast Medical, Social, and Family History
Common ROS:◦ General◦ Eyes◦ ENT◦ CVS◦ Resp◦ GI◦ GU
SubjectiveReview of Systems (ROS)
Identifies any recent symptoms the patient may have other than the current illness.
A Review of Systems is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.
SubjectiveReview of Systems (ROS)
General Symptoms ◦ e.g. diaphoresis, cold symptoms, fever, chills.
Eyes◦ e.g. Visual changes, blindness, ophthalmoplegia, blurry, eye pain,
discharge. Ear, Nose, Throat, Mouth
◦ e.g. dysphagia, tinnitus, epistaxis, rhinorrhea. Cardiovascular
◦ e.g. palpitations, edema, cyanosis, dyspnea on exertion, CP. Respiratory
◦ e.g. SOB/dyspnea, wheezing, cough. Gastrointestinal
◦ e.g. dysmenorrhea, dyspareunia, dysuria, vaginal bleeding. Musculoskeletal
◦ e.g. arthralgia, myalgia.
SubjectiveReview of Systems (ROS)
Skin/Breast◦e.g. rashes, hives, discoloration, pallor,
mastectomy. Neurological
◦e.g. H/A, dizziness, LOC, numbness, paresthesia.
Psychiatric◦e.g. suicidal, depressed.
Endocrine◦e.g. cold intolerance, heat intolerance,
polydipsia, polyuria. Hematologic
◦e.g. active bleeding, easy bruising.
SubjectiveReview of Systems (ROS)
EXCEPTIONS: ◦ If a patient is unable to provide any information
due to severity of illness, inebriation, intubation, unconscious, etc., you may check the “Unable to obtain HPI/ROS/PMFHSH secondary to pt’s condition.
◦Be careful when using this caveat, and only use it if it really applies (HPI, Past Medical/Social/Family History, and ROS only).
◦Ask the physician for clarification when needed. ◦Speaking another language is not an exception.◦Physical exam must be documented.
SubjectiveReview of Systems (ROS)
The Objective portion includes:◦Physical Exam◦Medical Decision-Making Elements
Objective
The Objective section contains information that is obtained through observation and testing and is independent of an individual’s interpretation.
Objective
Physical Examination (PEx)◦Information is more medically-oriented ◦Information elicited through observation, palpitation, percussion, and auscultation.
Medical Decision Making (MDM)◦Documented under “Progress Notes” and contains Differential Diagnosis, Progress notes, attending note.
Objective
Differential Diagnosis (DDx)◦Lists the different conditions that testing will rule out.
Progress Notes◦Any new subjective information provided by the patient and any new or changed findings upon reexamination of the patient.
Objective
Example:Re-eval at 1532 – Pt states she is improved. Nausea resolved. PEx: Abd soft, NT/ND, nl active BS. Pt will be discharged and f/u with PMD advised within 24 hours.
ObjectiveProgress Notes
Attending Note◦Recorded when a physician oversees a resident case.
◦This will follow the SOAP format. ◦Example:
A) Attending Note: Reviewed and agree c Hx.B) PEx – GI: abd soft, NT, CVS: RRR s MGR. RESP: Lungs CTA.C) A: UTI vs. Kidney stoneD) P: Labs, CT abd/pelvis r/o stone
Objective
The Assessment portion includes:◦Diagnosis: The physician’s impression of the patient after combining the information in both the Subjective & Objective sections.
Assessment
The Plan consists of:◦How the physician manages the patient’s care after the final diagnosis has been identified and can include:
Admission◦Ensure that the chart has been coded to the appropriate level and enter admission information.
Discharge Instructions◦Lists the various treatments, medications prescribed, work status, precautions, and followup care the patient needs.
Plan
Level 1: Visits requiring very minor care. This level is seldom used in the ED but would be used in a clinic setting.◦ Removal of sutures from a well-healed, uncomplicated laceration.◦ Tetanus toxoid immunization; Depo-Provera injection; hormone injections.◦ Several uncomplicated insect bites.
Level 2: Diagnosis reached without the aid of any labs or x-rays. ◦ Painful sunburn with blister formation on the back in an otherwise healthy
patient.◦ Child presenting with impetigo localized to the face.◦ Minor traumatic injury of an extremity with localized pain, swelling, and bruising.◦ Red, swollen cystic lesion on patient’s back in an otherwise healthy patient.◦ Rash on both legs after exposure to poison ivy.◦ Inflamed sclerae and purulent discharge from both eyes without pain, visual
disturbance, or history of foreign body in either eye in an otherwise healthy patient.
Five E/M Coding Levels
Level 3: Visits requiring minor lab work such as CBC, U/A, or a few x-rays.◦ Well-appearing child who has a fever, diarrhea, and
abdominal cramps and is tolerating oral fluid.◦ Inversion ankle injury, patient is unable to bear
weight on the injured foot and ankle. ◦ Acute pain associated with a suspected foreign body
in the painful eye.◦ Blunt head injury with local swelling and bruising
without subsequent confusion, loss of consciousness, or memory deficit in an otherwise young and healthy adult.
Level 4: Visits requiring extensive lab workup or CT scan.◦ Child sustaining a head injury (falling off bicycle)
with brief loss of consciousness.◦ Elderly patient who has fallen and complaining of
pain in the right hip with inability to ambulate. ◦ Flank pain and hematuria without fever.◦ Lower abdominal pain and a vaginal discharge.
Five E/M Coding Levels
Level 5: Visits requiring admission into the hospital, critical care patients.◦ Complicated overdose requiring aggressive
management to prevent side effects from the ingested materials.
◦ New onset of palpitations/tachycardia requiring IV drugs.
◦ Active upper gastrointestinal bleeding.◦ Motor vehicle accident with intraabdominal injuries or
multiple extremity injuries.◦ Acute onset of chest pain compatible with symptoms
of cardiac ischemia and/or pulmonary embolus.◦ Sudden onset of “the worst headache of my life” with
associated meningismus, nausea, and vomiting.◦ New onset of a cerebral vascular accident.◦ Acute febrile illness in an adult, associated with
shortness of breath and an altered level of alertness.
Five E/M Coding Levels
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