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Documents health information of patients Resource for treatment planning Mechanism of ____communication____ among health care providers Serves as a __legal document_ _for a patient's healthcare information Since it is a legal document must careful in what you write in the chart

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Function of the Medical Chart

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paper electronic-saves space

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Types of Medical Charts

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Storage: 3-ring binder Hard cover protects paper Sheets of paper can be easily manipulated Can be used multiple times Organization Separated into logical sections by __tabbed______ dividers Each tab is labeled with section heading

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Characteristics of Paper Chart

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Patient information is entered into a computer software program that is available throughout the hospital Information separated into sections like a paper chart Advantages over paper charts Eliminates problems with _illegible___ writing Easy to access data from previous admissions Software may interface with labs, diagnostics, etc. Software may offer physician order entry

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Characteristics of Electronic Chart

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Each facility has policies for medical chart use _Flagging_ Process used to identify patient order status Used to communicate what should be done next to ensure completion of patient orders Types Color-coordinated to communicate importance level of orders Binder _positioning__ or placement

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Using a Medical Chart: Flagging

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Extension of the medical chart Contains _daily_ information that is frequently updated or referenced Frees up medical chart for use Information filed in the medical chart at end of day Used for day to day type of information blood pressure, glucose if diabetic, temperature, so you do not have to carry the entire chart.

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Using a Medical Chart:Clipboards or Clip Charts

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Nursing Station Patient Bedside Rolling Chart Rack Outside Patient's Room

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Typical Locations to Find a Medical Patient Chart

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Chart ALWAYS travels with the _patient Patient goes to operating room - operating room Patient is on the floor - on the floor -For long periods of hospitalization Chart is _thinned_ - infrequently used information is removed Removed information is still stored on patient floor

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Where can the chart always be found?

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Admitting data _Physician orders_ Graphic charts (flow sheets) Nursing notes Laboratory data Diagnostic procedures Operating room procedures History and _Physical_______ Progress notes _Medication Administration Report (MAR) Miscellaneous

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Sections of the Patient Medical Chart

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-Standardized forms forms generally used -Located at the front of chart -Contains biographical data including: Name DOB Marital status Gender Emergency contact Financial status Insurance information Guarantor Provides data to billing department __Date______ and __Time______ of admission Name of admitting physician Admitting diagnosis/problem Admitting service

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What information does the Admitting Data contain?

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Consent Forms Documents risks and benefits of a specific action that takes place during admission Types include: Medical treatment Tests/procedures Investigational treatment/drugs Release of information Photographs, videotapes, film of patient Health Insurance Portability and Accountability Act (HIPAA) forms Even the smallest amount of risks. All types of FORMS are going to be in admitting data.

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Besides information, what else must be filed under admitting data?

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Physician Orders

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What comes after Admitting data?

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__Directives______ for patient treatment Types of orders Written _Verbal_______ Telephone

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What are physician orders and what types are there?

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Graphic Charts.

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What follows physician orders?

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Also known as _flowsheets_______ Standardized forms that simplify data collection and retrieval Quantitative records of _repetitive monitoring activities Arranged to easily visualize __trends______ and _patterns Can be standardized to specific nursing units or patients receiving special therapy

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What are graphic charts also known as and what information do the contain?

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Vital signs Intake and output ADLs Blood glucose Insulin doses Intravenous fluids Blood products Neurologic checks

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Name examples what information can be obtained from graphic charts.

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Nursing notes.

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What is the section of the patient's chart after graphic charts?

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Used to document _observations_______ and patient care _activities_______ Builds on info from _graphic charts_ Can be separate section or integrated in physician's progress notes Nursing Notes can be separate or will be part of the progress notes.

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What are nursing notes exactly?

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Physical functioning (are they moving) Behavior/mental status (memory) Clinical signs/symptoms Nursing interventions: PRN medications administered Risk assessments Pain assessments or interventions Documentation of care ANY AS NEEDED MEDICATIONS THAT WERE GIVEN!!!! Patient _education_______ Nursing consults Nursing care plans Nursing admission data _Discharge__ planning

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What information can be found in nursing notes?

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Laboratory Data

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What section of the chart follows nursing notes?

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Lab test results are usually contained in one section Most facilities will have a _computer_______ -based lab system Patient's most recent values will be reported in the computer; review this source _first. Lab tests results in the chart typically appear in summary form and are updated daily _Abnormal_ lab values highlighted with * L = low H = high Look at _trends__ when assessing lab data Look at _clinical_ situation of patient Never make a decision just on one value such as WBC high from one test/day.

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What information can be found in Laboratory Data?

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Hematology Urinalysis Type and screen Chemistry Microbiology Arterial blood tests

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What types of test categories are there in Laboratory Data?

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Diagnostic Procedures/Consults

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What section follows Laboratory Data?

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Presented in standardized format -Typed narrative -Diagram -Graph Results may first be available on computer -Common procedures X-rays ECGs EEGs CT scans MRI Arteriograms Invasive hemodynamic monitoring

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What is contained in diagnostic procedures and consults?

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Operating Room Procedures

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What section follows diagnostic procedures and consults?

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Contain information of a patient's _operation___ Presented in a typed narrative, graphic, or diagrammatic format

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What does the Operation Room Procedures section contain?

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History and Physical a.k.a. the admission note

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What section is found after Operation Room Procedures?

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Also called the _admission____ note Information about the patient's past and present medical history and physical examination findings Medications current taking, symptoms Includes _initial_____ impressions or diagnosis of the patient's medical complaint _SOAP_______ format or variation

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What info is found in the History and Physical?

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Why they are here? Medications, symptoms, ONLY PLACE YOU WILL FIND SOCIAL HISTORY!!!

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What info is only found in History and Physicial?

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S-Subjective-info the patient provides O-Objective-observable information (test results, BP readings) A-Assesment-patient's progress and evaluation of the plan's effectveness; and any newfound problems or diagnosis is noted here P- Plan- decision to proceed or to alter the plan strategy

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Define SOAP.

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Progress Notes

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What section follows History and Physicial?

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Provide running commentary of the patient's _condition_______ Document patient's _response___ to treatment from admission to discharge Who provided care to the patient What was done for the patient Where, why, how the patient responded Sometimes nursing notes are combined WHO PROVIDED THE CARE? WHY DID SOMETHING HAPPEN? This is where the WHY comes into play. Nurses notes sometimes in here.

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What information is found in the Progress Notes?

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WHO PROVIDED THE CARE? WHY DID SOMETHING HAPPEN? This is where the WHY comes into play. Nurses notes sometimes in here.

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What information is only found in the Progress Notes?

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Dated Timed _Signed_______ Handwritten, dictated, or typed Outline or narrative format Documentation of errors Single cross out with _error__ written above Includes person's initials and date

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What the characteristics of a properly written Progress Note?

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Filed in forward or reverse _chronological_ order Pharmacists contribute to progress notes Admission medication history Discharge medication counseling Provision of drug information Recommendations to modify therapeutic regimens Reverse order. The newest day on top. Oldest day on the bottom of stack.

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How are the Progress Notes organized?

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Medication Administration Record (MAR)

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What section is located after Progress Notes?

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Medication administration not documented on MAR _Physician____ administration - progress notes Medications given during code - code sheet Perioperative orders - anesthesia or _operating___ records

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What is listed in MAR section?

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Miscellaneous

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What section is after the MAR?

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Contains information that is not included in other sections Examples include Ambulance reports Records from outside hospitals _Discharge___ orders Documentation of patient's valuables

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What information is found in Miscellaneous?

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Healthcare providers within the hospital Administrative personnel of facility Patients (have to sign form) Legal Educational Research Audit You should only use the chart if needed.

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Who should use the chart?

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Healthcare_______ professionals Physicians Nurse practitioners Physician assistants Pharmacists Nurses Dieticians Physical therapists Respiratory therapists Administrative_______ personnel Hospital administrators Medical records personnel Ward clerks __Patients______ For outpatient provider For insurance purposes

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List the people who fall under these categories to use the chart.

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__Legal______ use Used as _evidence__ in legal action or suit Why it is important to document ALL interventions correctly Malpractice suits may be filed for various reasons Poor judgment of standard of care Medication or treatment errors Negligence Adverse drug effects _Educational_______ use Students receive valuable instruction from "real life" patient charts Important to remove all patient identifiers and obtain appropriate permission for use _Research_____ use Charts can provide clinical and health statistics research Important to obtain IRB and HIPAA approvals prior to commencement of research

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Outside the hospital, who else would need to use the chart?

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Health Insurance _Portability_ and _Accountability_ Act Created a national standard to protect individuals' medical records and other health information Sets forth requirements for all healthcare professionals concerning protected health information

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What does HIPPA stand for and what did it implement?

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Medical information is only useful when it is properly understood and accurately interpreted Use most recent data available Use similar types of information to help assess patient Know where new data can be found Assess the whole picture before arriving at a conclusion

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What information and steps should you use when assesing a patient?

Patient Medical Chart

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