Ch 9 maintaining office medical records – Flashcards
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Documentation
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is the recording of information in a patient's medical record; that includes detailed notes about each contact with the patient and about the treatment plan, patient progress and treatment outcomes.
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Electronic Health Record EHR
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is an electrically stored patient record. Info related to past, present or future physical & mental health or condition of an individual which resides in an electronic system. This contains information from all of the doctors involved in the patients care. Patients need to sign a consent form. Not all doctors participate. Global.
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Electronic Medical Record EMR
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is an electronically stored patient record. A digital version of a paper chart that contains all of the patient's medical history from one practice (doctor office, clinic or hospital) in-house network
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Individual Identifiable Health Information IIHI
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is any part of an individual's health information, including demographic information, collected from an individual that is received by a covered entity, for example a health care provider.
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Informed Consent Forms
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are forms that verify that a patient understands the offered treatment and its possible outcomes or side effects. Refers to the idea that the patient fully understands the treatment and its side effects and the outcome of not doing the treatment and any alternative options. You cannot force a patient to sign the form.
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Noncompliant
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is the term used to describe a patient who does not follow the medical advice given.
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Objective O in SOAP
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pertains to data that is readily apparent and measurable, such as vital signs, fever, test results, or physical examination findings. A Sign.
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Patient Charts or Records
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are a compilation of important information about a patient's medical history and present condition.
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Problem-Oriented Medical Record POMR
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is a system for keeping patients charts. Information in a POMR includes database information about the patient and patient's condition, the problem list, the diagnostic and treatment plan and progress notes.
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Sign
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is an objective or external factor, such as blood pressure, rash, or swelling that can be seen or felt by a physician or measured by an instrument.
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SOAP
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is an approach to medical records documentation that documents information in the following order S - subjective data, O - objective data, A - assessment, P - plan of action.
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Subjective S in SOAP
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Pertains to data that is obtained from conversation with a person or patient. A Symptom; Things we can't see; for example pain or headache.
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Symptom
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Is a subjective or internal condition felt by a patient, such as pain, headache or nausea or another indication that generally cannot be seen or felt by the doctor or measured by instruments.
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Transcription
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Is the transforming of spoken notes into accurate written form.
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Transfer
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Means to give something, such as information, to another party outside the doctor's office.
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Research with regards to Patient Information
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You are allowed to release information for research without patient consent except for patient's name, address, phone number, birthdate and social security number.
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Assessment A in SOAP
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The diagnosis or impression of a patient's problem. DX1, DX2 and DX3; differential diagnosis; DX1 is the most probable.
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Plan of Action P in SOAP
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Treatment options; instructions; referrals; medications; chosen treatment; tests; patient education and follow-up.
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Which element of SOAP charting describes the data that comes directly from the patient?
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S Subjective
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What does the abbreviation PT mean?
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Physical therapy
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The six C's of charting include
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Client's words; Clarity; Completeness; Conciseness; Chronological order; and Confidentiality
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Client's words
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Record patient's exact words rather than your interpretation of them. Do not rephrase patient's words. One of the six C's of charting.
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Clarity
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Use precise descriptions and accepted medical terminology when describing patient's condition. One of the six C's of charting.
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Completeness
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Fill out completely all of the forms used in patient's record. Provide complete information that is readily understandable to others whenever you make any notation in the patient chart. One of the six C's of charting.
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Conciseness
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Be brief and to the point. Abbreviations and specific terminology can often save time and space when recording information. One of the six C's of charting.
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Chronological order
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All entries in patient's records must be dated to show the order in which they are made. This is critical in case of a legal question. One of the six C's of charting
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Confidentiality
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All the information in patient's records and forms. One of the six C's of charting
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Conventional or Source-Oriented Record
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In this approach, patient information is arranged according to who supplied the data-the patient, doctor, specialist, or someone else. These records describe all problems and treatments on the same form in simple chronological order.
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Problem-Oriented Medical Record POMR
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This approach makes it easier for the physician to keep track of a patient's progress.
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The information in a POMR includes the
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Database. Problem list. Educational. Diagnostic. Treatment plan.
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Electronic Health Record EHR
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This contains information from all of the doctors involved in the patients care. Patients need to sign a consent form. Not all doctors participate. Global.
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Electronic Health Record EHR
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is an electrically stored patient record. Info related to past, present or future physical & mental health or condition of an individual which resides in an electronic system.
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Informed Consent Forms
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are forms that verify that a patient understands the offered treatment and its possible outcomes or side effects.
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Informed Consent Forms
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Refers to the idea that the patient fully understands the treatment and its side effects and the outcome of not doing the treatment and any alternative options. You cannot force a patient to sign the form.
