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Medical Record

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A patient's is a handwritten or typewritten recording of information that documents facts & events during the administration of patient care.

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The principle reasons for maintaining medical records are:

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1) To aid in the diagnosis & treatment of a patient 2) to provide written document of directed patient area 3) to verify service were medically necessary 4) to assist in the research of disease & injuries so other patients may benefit from previous patient care 5) to substantiate procedure & diagnosis code selection for appropriate reimbursement 6) comply with federal & state laws & 7) to defend the physician in the event of a lawsuit

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A good medical record is a

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Key to quality care.

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It assist with accessing

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Patient's conditions, provides others with critical information, furnishes statistical information, & protects against liability suits.

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The day has arrived when medical record information is available through

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Data retrieval systems that provide computer readouts so that traditional patient charts can be updated constantly.

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Paper-Based Medical Record System:

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Costly to manage, move, & store; many people feel secure with a hard copy of information in hand, but paper records are more vulnerable to a variety of security threats such as tampering, theft, & loss; there is no easy way to search for clinical data in a paper-based system.

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Electronic Medical Record System

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EMR

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EMR offers

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Fast, secure, & centralized access to health care data that can be viewed from home, satellite office, & hospital sites (such as the ER or intensive care unit)

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Benefits of an EMR system include the ability

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Track pt histories, prescription drugs, consultations, & a variety of data. Detect inconsistencies in diagnoses. Monitor quality assurance standards. Deliver prompt reports. Achieve timely billing & reimbursement. Decrease the errors & miscommunication. Reduce handwritten notes. Make information more accessible. Eliminate searching charts for clinical data.

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Problem-Oriented Record System

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POMR or POR

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POMR developed by

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Dr. Lawrence Weed

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POMR

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Modified per individual discipline. Includes progress notes, flow sheets, charts, or graphs to quickly find info & perform comparative evaluations.

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Flow sheet

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?

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POMR advantages:

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It helps physicians retrieve info.quickly & handle large or workloads; permit evaluation of physician's reasoning in assessing pts conditions; less reliance on physician memory so errors are reduced; or receives more efficient, continuous care.

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POMR disadvantage:

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It takes time to develop the problem list, it takes time to do necessary repetitious recording.

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Source-Oriented Record System

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SOR

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SOR

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Arranged according to sections (history & physician, progress notes, lab, radiology, surgical operations, etc...,)

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SOR advantage:

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May use color tabs for quick, easy location of info; sequenced in chronological order w/most recent on top (reverse chronological)

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SOR disadvantage:

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Lack an overall picture of pt's health or problem b/c documentation of issues filed in different sections.

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Integrated Record System

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Files all documents in chronological order w/out regard to their sources. Comparing information can be difficult because it is scattered throughout the record.

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4 basic ways information can be entered into the medical record:

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1)Physician hand enters data 2) Physician dictates 3) Physician keys data 4) MA enters data

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Physician hand enters data

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?

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Physicians dictates

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?

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Physicians keys data

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?

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Medical Assistant enters data

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?

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Record keeper in charge of

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Oversee medical record system & file clerks, documentation requirement, coding, internal audits, processing authorization requests for records, & obtaining pt records from other facilities.

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Attending Physician:

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Refers to the medical staff members who is legally responsible for the care & Tx given to a pt.

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Consulting Physician:

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Is a provider whose opinion or advise regarding evaluations &/or management of a specific problem is requested by another physician.

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Ordering Physicians:

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Is the individual directing the selection, preparation, administration of tests, medication, or Tx.

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Referring Physician:

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Is a provider who sends the pt for testing or Tx. It may also be the provider who transfers the management of a pt to another physician.

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Treating or Performing Physicians:

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Is the provider who renders a service to a pt.

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Each document must be

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Authenticated by signature.

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Manuel Signature:

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Handwritten or typed entries made during the continuing care of the pt should be signed by the treating or attending physician.

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Electronic Signature:

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Refers to a method of authenticating documents by the insertion of a facsimile of a person's actual handwritten signature or typed name that is affixed electronically at the end of a document.

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Digital Signature:

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Is secure because it can't be forged or altered w/out detection, & if the content of the signed document is altered, the signature is invalidated. To authenticate portions f the medical record using, an individual has computer access & uses an identification encryption system such as letters or #s (alphanumeric computer key entries), an electronic writing, or a biometric system (voice print, hand or fingerprint transmissions, facial, iris, or retinal scans).

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SOAP format:

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S=subjective O=objective A=assessment P=plan

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Subjective:

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Statements about how the pt feels & symptoms experienced. This would include comments by the pt about the history of present illness, responses to review of systems, & statement about past, the family, & social history.

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Objective:

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Data from laboratory reports, x-rays, other diagnostic tests, & physical findings on examinations by the physicians. All data are seen (inspection & observation), heard (resuscitation), felt (palpitations), or measured as in diagnostic testing

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Assessment:

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Analysis of the subjective & objective portions of the chart note used to attain a diagnosis.

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Plan:

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Therapeutic treatment plan & instructions to the patient by the physician. This includes further testing, medications, return visit, & outlook or prognosis of the case.

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Measurements

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Reimbursement is affected by the size or area documented & subsequently reported on insurance claims

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Burns are listed by:

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Type (e.g., chemical), depth (first, second, or third degree), site (face, arm, leg, trunk), percentage of total body surface (TBS) affected.

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Correcting a medical record

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Never erase or use correction fluid on handwritten or typed entries. If a corrections need to be made on pt' s medical record, draw a single line through the incorrect entry so it remains readable. If there is adequate room above or below the original entry, insert the correct information there. Otherwise it may be inserted in the margin or after the conclusion of the note. The person making the correction writes \"Corr\", the date, & his or her initials in the margins of the page. If the correction inserted is @ the end of the chart note, the person making the correction enters the date, writes or types \"correction to chart note of date of note being corrected\", enter the correction, & initials or signs at the end of the notation. When the physician discovers an error, such as a progress note that has been inserted into the wrong record or is missing, it must be added as an addendum or corrected in the specific manner. When making a correction on a computerized document, maintain the original entry in the electronic file.

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Patient Information Form

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Used to obtain demographic & insurance information. It is primarily a business record but also helps acquaint the physician w/the pt' s personal data & becomes part of the medical record.

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The level of E/M are bases on 4 types of history:

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Problem focused (PF), expanded problem focused (EPF), detailed (D), & comprehensive (C).

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Patient Medical Record

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When a pt comes in the w/a complaint of symptoms describing how they feel, this is called subjected information; that is, it can't be measured & May be viewed differently by each individual. The history of the present illness is based on this subjective information. It is drawn from the pt' s own words about the CC & their response to questions asked. Depending on the specialty of the physician & the subjective symptoms, the medical history may vary.

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Chief Complaint (CC)

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Is a concise statement, usually in the pt' s own words, describing the symptoms, problem, condition, or other factors that is the reason for the encounter. The symptoms is any indication of the disease or disorder that is perceived or experienced by the pt. If more than one, list them in order of importance. Complaints can also be objective; if a pt c/o something that can seen, felt, heard or measured (e.g., rash or a bump), it is objective info.

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History Of Present Illness (HPI)

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The CC is followed by a detailed account of how the pt was injured or when they 1st notice the illness. Is a chronological description of the development of the pt' s present illness from the first sign or symptom or from the previous encounter to the present. It includes the following elements: location, quality, severity, duration, timing, context, modifying factors, & associated signs & symptoms. When a symptom is demonstrable to an observer upon examination, it is an objective symptom, or, more generally a sign. If the pt has been treated by another physician for the same or similar problem, this will be discussed, along w/the possible diagnosis & treatment prescribed.

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Past History (PH)

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Is a personal history, including usual childhood diseases (UCHD), previous illnesses, physical defects, operations, accidents or injuries, treatments, medications, drug reactions, immunizations, & allergies. Medications include listing drugs the pt has taken recently or is currently taking. Allergies include any reactions the pt may have to drugs, food, or the environment. Allergies should be underlined in red in the medical record & placed on the front of the chart, bodly visible. Some medical practices list allergies at the top of each page in the pt's progress notes. Because new allergies may appear as individuals age, questions should be asked to verify allergies each time a pt is seen for an appointment.

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Family History (FH)

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Is a review of medical events in the pt's family, including diseases that may be hereditary or place the pt at risk. Notations are made regarding whether the mother & father are living & well (M & F, I & w), age at death, cause of death, & similar informatition for siblings & grandparents. The place & circumstances of the pt's birth might also be noteworthy

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Social History (SH)

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Is an ageappropriate review of past & current activities & occupational history (OH), habits, diet, alcohol, drugs, tobacco, marital history (MH), exercise, & recreational interest. Sexual activity & #s of sexual partnerss are also noted.

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Review Of System (ROS)

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Or systemic review (SR), is an inventory of body obtained through a serious of oral questions seeking to identify signs or symptoms the pt might be experiencing or has experienced that may reveal information related to the present illness. Should be confused w/the examination of body systems, which will folllow. Begins at the top of the body & continues down through each body system as a questions are asked about previous medical problems. the physician may use a check-off sheet or dictate data w/subheadings. The MA must be able to recognize the body part & divide the information as it is dictated.

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Constitutional Symptoms

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Physical makeup of a body, which includes the methods the body uses to function, actions of metabolic processes, manner & degree of reactions ot stimuli, & power of resistance to disease organisms.

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Eyes

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Assessment of the pt's perceptiopn of their vision functions. Symptoms & conditions concerning the eye & ocular adnexa are evaluated. These may include ision difficulties & problems such as lazy or wandering eye; glaucoma; scotoma; conjunctivitis; trachoma; pain; discharge; redness; limitation of visual fields; us of glasses, contact lens, or intraocular lenses; bluring; double vision; seeing spots or rings around lights; watering; itching; abnormal sensitivity to light; infections; tear duct problem; etc.......;

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Ears, Nose, Throat (ENT)

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Because of the intercommunication between hte structures of the upper respiratory tract, the ears, nose, mouth, & throat are often reviewed.together. Ears-Includes testing of the hearing & conditions such as hearing loss, discharge, dizziness, syncope, tinnitus (ringing in ears), & pain Nose-Includes the sense of smell & conditions such as discharges, colds, allergies, chronic sinus congestion, & epistaxis (nosebleed) Mouth & Throat-Includes conditions of teeth, dental hygience, dentures, thyroid gland, movemetn of the neck, position of the trachea, & problemss such as tender gums, sensitive tongue, difficulty swallowing, hoarseness, sore throat, postnasal drip, & choking

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Cardiovascualar (CV)

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Systems that includes the heart & blood vessels. Symptoms include chest pain, angina, tachycardia, bradycardia, heart murmurs, palpitations, heart attacks, pitting or pedal edema, cool extremities, varicose veins, HBP, hypotnsion, etc.......,

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Respiratiory

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Exchange of oxygen is the main function of the lungs & respiratory system. Symptoms may include comments on dyspnea, orthopnea, twopillow orthopnea, hemoptysis, & paroxysmal nocturnal dyspnea (PND)

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Gastrointestinal (GT)

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System that mechanically & chemically breaks food down to molecular size for absorption into the bloodstream to be used by the cells. The liver & gallbladder are also included in this system. Symptoms include comments on appepitite, indigestion, melena, icterus, jaundice, anorexia, n/v, hematemisis, flatus, borborygmus, flatulence, coffee-ground vomitus, stool color (black tarry or clay-colored), hematochezia, diarrhea, obstipation, dysphagia, change in weight or diet, change of bowel habits & constipation.

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Genitourinary (GU)

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Review of organs w/urinary & reproductive functions. Symptoms include comments on urinary flow, incontinence, stress incontinence, burning & frequency during urination, dysuria, pyuria, nocturea, hematuria, oliguria, enuresis, STD, urgency or hesitancy during during urination, dribbling, discharge, lumbar pain, & stones.

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Musculoskeletal (MS)

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System composed of the muscles, bones, & joints. Symptoms include pain, strains, sprains, stiffness, painful or swollen joints, limitation of movement, dislocations, fractures, & arthritis.

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Integumentary (Skin & Breast)

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Systems that pertains

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Neurological

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?

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Psychiatric

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?

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Endocrine

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?

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Hematologic/Lymphatic

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?

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Allergic/Immunologic

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?

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During the PE, the physician goes through 4 basic procedures:

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1. Inspection or observation of the pt's physical characterists & body parts 2. Palpation or touching & feeling, various parts & organs of the body 3. Percussion or striking parts of the body w/short, sharp blows, during which attention is fixed on the resistance of the tissues under the fingers & on the sound elicited to determine tissue size, density, & locations 4. Auscultation or listening to sounds of the internal parts of the body w/the aid of a stethoscope.

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The level of E/M services are based on 4 types of examination:

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1. Problem Focused (PF): a limited examination of the affected body area or organ. 2. Expanded problem focused (EPF): A limited examination ofhte affect body area or organ system & other symptomatic or related body areas or organs systems 3. Detailed (D): An extended detail examination of the affected body area or organ system & other symptomatic or related body areas or organ system 4. Comprehensive (C): a general multisystem examination or complete examination & other symptomatic or related body areas or organ system.

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The levels of E/M services recognize 4 types of medical decision making:

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Straightforward (SF), Low complexity (LC), Moderate complexity (MC), High complexity (HC)

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Management Option

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The # of diagnoses is based on the # & types of problems addressed during the visit, the complexity of establishing a diagnosis, & the management decision made by the doctor

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Diagnosis

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Is an impression, assessment, or final conclusion of the nature of the disease or illness based on history, physical examination findings, & sometimes, diagnostic tests such as x-rays, laboratory tests, or ECG.

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Treatment

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This is a recommended plan for the diagnosis

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Prognosis

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Is the probable outcome of the disease or injury & the prospect of recovery.

Chapter 9 Medical Records

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