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medical record

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should be kept confidential and in a secured, locked location. should never leave medical facility in which it originated. patients have a right to access information in the record

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disadvantages to paper medical records

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only one person at a time can use it, it can be easily lost, record can be in a different area of facility when needed

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advantages to computer medical records

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more then one person can use at a time, information can be accessed in a variety of locations, can be accessed in another city or state, complete information is available in emergency situations

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types of medical records

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paper, computer, source oriented, problem oriented

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source oriented medical record

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one sheet of paper per visit, seperate sections for lab reports, x-rays, radiology reports, etc. in reverse chronological order.

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problem oriented medical record

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number of visits per sheet, divides record into four bases: data base, problem list (diagnoses), treatment plan, progress notes, when to comeback.

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database (in problem oriented record)

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numbered and titled list of every problem includes: chief complaints, present illness, patient profile, review of symptoms, physical examination, lab reports

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progress notes (in problem oriented record)

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continually added to the record, must list each patient visit, instructions, prescriptions, and telephone calls should be noted, always initial

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SOAP

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treatment plan approach, S: subjective impressions, O: objective clinical evidence, A: assessment or diagnosis, P: plans for further studies-treatment-or management

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treatment plan (in problem oriented record)

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management, additional workups needed, therapy, each plan is titled and numbered respect to the problem

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CHEDDAR

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cheif complain, history, examination, details, drugs and doses, assessment, return visit

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contents of complete case history

answer

patients full name, name if a child, sex, date of birth, marital status, spouses name, number of children, s s #, driver licence #, address and phone, email, occupation and employer, business address and phone, insurance info, spouses employment info, source of refferal

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obtaining the patient history

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by patient questionnaire,MA or physician asking questions,

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personal and medical history

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by patient questionnaire, info about past illnesses or surguries, explains injuries or physical defects, daily health habits, allergies, living wills

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MA role when taking patient history

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make sure in a private place, ask details about condition and symptoms,

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patients history

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family history: physical condition of patients family, past illnesses of patients family, causes of death of patients family social history: patients lifestyle, alchohol, tobacco and drug use, marital info, psycological or emotional info.

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patients chief complaint

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nature and duration of pain,when patient noticed symptoms, patients opinion to possible cause, remedies they may have tried, whether it has happened before, if so what treatment.

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objective information

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often called signs, are gained from physicians examination, lab and radiology reports, diagnosis, treatment prescribed, progress notes, condition at the time of termination of treatment.

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authentication

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for a chart to be admissible in court, the person dictating or wrtting the entries must be able to attest that they are true and correct at time they were written by initialing enteries in the medical record

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making additions to the record

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place most recent info on top, physicians should read and initial reports before they get filed.

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lab reports

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often on different colored paper for easy reference,

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radiology reports

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usually typed on standard size paper, place in reverse chronological order, usually in a seperate section

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making corrections to medical records

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never use white out, erasers, or any other obliteration methods, do not hide errors, if errors could affect the health and well being of the patient bring it to the physicians attention.

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correcting paper or electronic error

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three steps paper chart: draw a line thru the error insert the correction above or after the error, in the margin write \"correction\" and initial. if an error is made when typing, simply backspace and put correct info, if it is discovered later, make an additional entry with correct info. do not delete or change previous entries.

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keep records current

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the patients health is jeopardized when current, accurate records are not available to the physician.

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prescriptions

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all prescriptions must be noted in the medical record, including refills.like a check, number of pills must be written both ways #20 and twenty tabs by mouth three times daily

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DEA

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drug enforcement authorization

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classifications of records in the physicians office

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active files, inactive files, closed files

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active files

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patients currently recieving treatment

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inactive files

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patients who have not been seen for about 6 months to a year

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closed files

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patients who have died, moved away, or discontinued treatment

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purging

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transferring medical records from active to inactive or closed

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retention and destruction of medical record

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most physicians keep medical records for at least 10 years,records for minor patients should be kept for at least 3 years after legal age, use your stickers on patient files.keep records on deceased patients for at least 2 years

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releasing medical records

answer

requests must be made in writing for release of records, patients must sign an authorization, release only records that are specified on the form. court or military wants originals. must keep a copy for your records

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types of filing systems

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drawer, shelf, rotary circular, lateral, compactable, automated, card

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filing supplies

answer

divider guides, OUTguides, OUTfolders, files and folders, labels

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color coding

answer

almost all offices use some sort of color coded filing systems, numeric color coding provides a high degree of patient confidentiality

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filing procedures and methods

answer

conditioning, releasing, indexing and coding, sorting, storing and filing, alphabetic, numeric, alphanumeric, subject

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indexing rules

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last name first, then first name, then middle name or initial, terms of seniority are used only to distinguish from another identical name

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transitory or temporary files

answer

useful when seeing patients from another geographical area who are not expected to return

chapter 14 paper medical record

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