1 powerpoint ® to accompany chapter 9 second edition ramutkowski booth pugh thompson whicker...

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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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larityBe precise and use accepted medical terminology when describing a patient’s condition.

The Six Cs of Charting

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lient’s wordsBe sure to record the client’s exact words and do not rephrase their statements.

The Six Cs of Charting

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oncisenessBe as brief and to the point as possible. Use medical abbreviations to save time.

The Six Cs of Charting

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hronological orderDate entries in the order they occur. This shows consistency with accurate documentation.

The Six Cs of Charting

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onfidentialityAll information in patient record must be kept confidential to protect patient privacy.

The Six Cs of Charting

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ompletenessFill out all forms in the patient record completely so others will understand your notations and entries.

The Six Cs of Charting

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Types of Medical Records

(POMR) makes it easier to track specific illnesses

Consists of: Data base Problem list Educational, diagnostic and

treatment plan Progress notes

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.

Problem-Oriented Medical Records

Source-Oriented Medical Records

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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