Medical Records Documentation – Flashcards

Administrative and clinical

Administrative

Administrative Data

Medical, Nursing and Ancillary

History and Physical Examination (H&P), Progress Notes, Operative Reports, Physician Orders, Discharge Summary (DS)

Nursing documents ; reports

Laboratory Reports Pathology Reports Radiography Reports EKG Reports Physical Therapy Reports Dietary Reports Social Services Reports

Sufficient information to clearly identify the patient such as: patient name, health record number, date of birth and gender

IM 7.2 The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.

authorization for routine care- things like physical examination, routine laboratory tests and general medical care authorization for release of information needed to process claim for reimbursement release of liability for any personal items or valuable the patient keeps in hospital. financial agreement - patient responsibility for bill. Format - Sometimes printed on the back of the Admission/Discharge Record (face sheet) or may be a separate form. Responsibility - Usually Admissions/Registration staff obtain the patient's signature at the time of admission. Other - Also Known As (AKA) Conditions of Admission

Date and time of the order, signature of the physician who order the treatment and who picked up the order

Content - A summary of the patient's hospitalization that typically includes: Reason for hospitalization Hospital Course - chronological narrative of significant findings from exams and tests Procedures performed and treatments Patient's response Condition on discharge - in non-ambiguous terms. Statements like "improved" or "better" are discouraged. The physician should document how the patient is improved. Discharge instructions: In terms of follow up, activity level, diet, medication, etc. Final diagnoses are almost always listed in the discharge summary. The discharge summary function as an information to other caregivers and facilitates continuity of care. For patients discharged to ambulatory (outpatient) care, the clinical resume summarizes previously levels of care.

Joint Commission - Requires: Medical History including the chief complaint; details of the present illness; relevant past, social, and family histories (appropriate to the patient's age); and a review of body systems. required usually within 24 hours of admission and always before surgery is performed. if recorded within 30 days prior to admission to the hospital, a legible copy may be included in the health record and any interim changes recorded at time of admission. if patient readmitted within 30 days for same or related condition, an interval H&P explaining changed may be used. Medicare COP - 482.24 (c)(2) All records must document the following, as appropriate: (i)"Evidence of a physical examination, including a health history, performed no more than 7 days prior to admission or within 48 hours after admission." Other - The facilities Medical Staff Rules and Regulations will state which individuals (such as medical students, interns, etc.) require countersigning of reports by the

Joint Commission - Verbal orders of authorized individuals are accepted and transcribed by qualified personnel who are identified by title or category in the medical staff rules and regulations. Each verbal order is dated and is identified by the names of the individuals who gave and received it. The record documents who implemented it. Individuals who receive verbal orders are qualified to do so and are authorized by the medical staff to do so as identified by title or category of personnel. Medicare COP 428.24 Medical Record Services (c)Standard: Content of record (1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. (i) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner, except as noted in paragraph (c)(1)(ii) of this section. (ii) For the 5 year period following January 26, 2007, all orders, including verbal orders, must be dated, timed, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient as specified under § 482.12(c) and authorized to write orders by hospital policy in accordance with State law. (iii) All verbal orders must be authenticated based upon Federal and State law. If there is no State law that designates a specific timeframe for the authentication of verbal orders, verbal orders must be authenticated within 48 hours. Other - Medical staff can define in the Rules and Regulation those categories of verbal orders that pose a potential hazard to patient. These must be signed by practitioner within a specified period of time, usually 24 hours. An example of an order that might pose a potential hazard is an order for the use of restraints or an order for particular classes of drugs such as chemotherapy drugs. Standing orders - These are a standard set of orders for a particular type of patient, such as post-PTCA or patient undergoing a stent procedure. In CPOE systems, these might be templated that the physician can pull up. In either case the standing orders must be customized for the specific patient.  Standing orders must be signed and dated by a physician with modifications made for the particular patient. Admitting orders are one type of order for which standing orders may be used. For example, a specific physician must have a standing orders for the admission of his/her patients.

Joint Commission - requires "progress notes made by the medical staff and other authorized individuals" Medicare COP - 4482.24 (c)(2) All records must document the following, as appropriate: (iii) Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. (iv) Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs Other - Medical Staff Rules and Regulations may specify the required frequency of progress notes. Some hospitals used interdisciplinary or integrated progress notes in which the notes of all healthcare professionals are integrated chronologically with the physician's progress notes.

Joint Commission - requires that the medical record include any "consultation reports". (Note: not all patients receive consultations). Medicare COP - 482.24 (c)(2) All records must document the following, as appropriate: (iii) Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient.

Joint Commission - A concise clinical resume included in the medical record at discharge provides important information to other caregivers and facilitates continuity of care. For patients discharged to ambulatory (outpatient) care, the clinical resume summarizes previously levels of care. The discharge summary contains the following information. The reason for hospitalization Significant findings Procedures performed and treatment rendered The patient's condition at discharge Instructions to the patient and family, if any For normal newborns with uncomplicated deliveries, or for patients hospitalized for less than 48 hours with only minor problems, a progress note may substitute for the clinical resume. The medical improves the quality of healthcare by insuring that the best information is available to make any healthcare decision. Health information management professionals manage healthcare data and information resources. The profession encompasses services in planning, collecting, aggregating, analyzing, and disseminating individual patient and aggregate clinical data. It serves the healthcare industry including: patient care organizations, payers, research and policy agencies, and other healthcare-related industries. defines what problems and interventions may be considered minor. The progress note may be handwritten. It documents the patient's condition at discharge, discharge instructions, and follow up care required. When a patient is transferred within the same organization from one level of care to another (for example, from the hospital to residential care), and the caregivers change, a transfer summary may be substituted for the clinical resume. A transfer summary briefly describes the patient's condition at time of transfer, and the reason for the transfer. When the caregivers remain the same, a progress note may suffice. Medicare COP - 428.24 Medical Record Services (c)Standard: Content of record within 30 days following discharge. (2) All records must document the following, as appropriate: (vii) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care. (viii) Final diagnosis with completion of medical records within 30 days following discharge.

A category of healthcare information systems that supports human resources management, financial management, executive decision support, and other business-related functions.

A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decision in the event the patient is incapable of communicating his or her preferences.

Written documentation of the findings from a postmortem pathological examination.

System that identify the right patient and right drug to be given at the right time, in the right dose, and via the right route

Nurses Notes, Flow charts, Graphic Vital Sign Records, Intake and Output records(I&O) Nurses Notes contain; Documentation that reflects the patient's condition and progress in objective, behavioral terms.

Is an important communication tool that allows the physician to see what has happened to the patient in his/her absence. They provide proof that the physician's orders were carried out and documentation of the patient's response.

It should contain the patient identification information, the name of the test, test date, time in and out of laboratory, test result. The report should also indicate the pathologist in charge of the laboratory. Reports usually also contain the normal value range for each test when appropriate. Often results that are out-of-range are marked in some way such as with an asterisk to call attention to the result. When results are performed by a technologist rather than automatic results reporting by a computer and laboratory equipment, the technologist performing the test is indicated (often with the use of initials or code number). Certain special tests may not be performed by the hospital and are sent out to another lab. These results become part of the patient's medical record and must contain the name of the laboratory performing the test.

Content - This is a report of the interpretation of diagnostic x-rays ordered by the patient's physician. Content includes patient identification information, x-ray number, name of x-ray procedure performed, date performed, reason for x-ray examination, as well as the interpretation and authentication by the radiologist. Interpretation typically includes a description of findings and an impression.

These are the reports of findings of various tests performed on body materials, fluids and tissues.

This is a report of the interpretation of diagnostic x-Rays ordered by the physician

Content - Most anesthesia forms used by hospitals contain areas to document pre-anesthesia evaluations and pre-anesthesia medications (such as valium or other medications used to relax the patient)as well as the administration of anesthetics, medications (including type, route, amount), fluids and blood products during the procedure and the monitoring of the patient's status. An anesthesia record is not required for the administration of local anesthetics.

There is always a specific anesthesia form which contains an area for graphing of vital signs during the operative procedure. Some hospitals do not use a separate recovery room record and may therefore expand the anesthesia record to include required post-anesthesia documentation such as the patient's assessment upon discharge from the recovery room.

Operative reports include pre-operative and post-operative diagnosis, the names of surgeons and assistants, reason for the procedure, procedure(s) performed, a description of the procedure and the surgical findings, anesthesia used, a description of unusual events or complications and the condition of the patient upon completion (and often before and during the procedure).

This report contains a description of gross (macroscopic)findings of specimens received. A description of microscopic findings may also be performed. Additionally the report gives a pathological diagnosis based upon the findings.

Joint Commission - Nursing documentation contributes to many of Joint Commission's documentation requirements including: progress notes made by the medical staff and other authorized individuals clinical observations the patient's response to care discharge instructions to the patient and family Some specific requirements that nursing documentation needs to comply with or contributes to meeting the standard are: Nursing assessment must be completed within 24 hours of admission Patients' learning needs, abilities, preferences and readiness to learn is assessed. The assessment considers cultural beliefs, religious beliefs, barriers to learning (i.e., emotional, physical, cognitive) When called for by the age of the patient and the length of stay, school-age children are given the opportunity to continue their schooling. The patient is educated about the safe and effective use of medications The patient is educated about diet and nutrition, including potential drug-food interactions The patient is educated about rehabilitation techniques. The patient is educated about personal hygiene and grooming. The following is assessed for each patient: physical status, psychological status, social status Need for discharge planning is determined. Monitoring of a medication's effect on the patient includes an assessment based on collective observations, including the patient's own perceptions of its effect. Medicare COP - A registered nurse must supervise and evaluate the nursing care for each patient. The medical record must contain information to justify admission and continued care. All records must document the following, as appropriate: (vi) All practitioners' orders, nursingnotes, reports of treatment, medication records, radiology, and laboratory reports,and vital signs and other information necessary to monitor the patient'scondition. 482.43 Condition of participation:Discharge planning. The hospital must have in effect a discharge planning process that applies to all patients. The hospital's policies and procedures must be specified in writing. (a) Standard: Identification of patients in need of discharge planning. The hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. (b) Standard: Discharge planning evaluation. (1) The hospital must provide a discharge planning evaluation to the patients identified in paragraph (a) of this section, and to other patients upon the patient's request, the request of a person acting on the patient's behalf,or the request of the physician. (2) A registered nurse, social worker,or other appropriately qualified personnel must develop, or supervise the development of, the evaluation. (3) The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post- hospital services and of the availability of the services. (4) The discharge planning evaluation must include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. (5) The hospital personnel must complete the evaluation on a timely basis so that appropriate arrangements for post-hospital care are made before discharge,and to avoid unnecessary delays in discharge. (6) The hospital must include the discharge planning evaluation in the patient'smedical record for use in establishing an appropriate discharge plan and must discuss the results of the evaluation with the patient or individual acting on his or her behalf. (c) Standard: Discharge plan. (1) A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, a discharge plan if the discharge planning evaluation indicates a need for a discharge plan.

Patients in restraints are monitored at a minimum, every two hours. Each episode of restraint use is documented in the patient's medical record, consistent with organization policy(ies) and procedure(s). Nurses

Joint Commission - record contains "all diagnostic and therapeutic procedures and test results". Medicare COP - 482.24 Condition of participation: Medical record services. (c) Standard: Content of record. "(2) All records must document the following, as appropriate: (vi) All practitioners' orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient's condition."

Nursing assessment must be completed within 24 hours of admission

Written documentation of the findings from a postmortem pathological examination.

Contains the findings of macroscopic and microscopic examinations of the body after death. The autopsy report contains a summary of patient's history and treatment, a report of gross and microscopic findings and the provisional and final diagnoses.

Format - The report is dictated by the pathologist and then transcribed. Responsibility - The pathologist performing the autopsy is responsible for dictating and authenticating the transcribed report. Authorization for the autopsy must be obtained from the patient's family unless the case is a coroner's case (more about this in your legal aspects and health statistics courses).

Joint Commission - "When an autopsy is performed, provisional anatomic diagnoses are recorded in the medical record within three days, and the complete protocol is included in the record within 60 days, unless the medical staff establishes exceptions for special studies." Note: Some of the microscopic tests used in autopsy reports such as toxicology testing take a considerable amount of time to perform, therefore it is not unusual for the final autopsy report to be completed in 6-8 weeks. "The medical staff shall attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest. The mechanism for documenting permission to perform an autopsy must be defined. There must be a system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed." Other - AKA post mortem examination or necropsy.

Joint commission "A preanesthesia assessment is performed for each patient before anesthesia induction". "Each patient's physiologic status is monitored during anesthesia". Medicare COP - 482.52 Condition of participation: Anesthesia services. -(b) Standard: Delivery of services. Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of preanesthesia and post anesthesia responsibilities. The policies must ensure that the following are provided for each patient: (1) A preanesthesia evaluation by an individual qualified to administer anesthesia under paragraph (a) of this section performed within 48 hours prior to surgery. (2) An intraoperative anesthesia record.

This is a report of the interpretation of diagnostic x-rays ordered by the patient's physician.

Content includes patient identification information, x-ray number, name of x-ray procedure performed, date performed, reason for x-ray examination, as well as the interpretation and authentication by the radiologist. Interpretation typically includes a description of findings and an impression.

Format - X-ray films are reviewed and interpreted by a Radiologist who dictates the interpretation. This dictation is typically transcribed by a medical transcriptionist. Voice recognition technology is being used by some Radiology Departments to transcribe the interpretation. Some hospitals use a format in which the upper portion of the report form serves as the request from the ordering physician and the lower portion is radiologist's report of findings and impression.

The radiologist

Joint Commission - "... the medical record contains very specific data including all diagnostic and therapeutic procedures and test results" Other - AKA X-ray report. The films and a copy of the report are filed in the Radiology Department. The results of other imaging examinations such as MRIs and ultrasounds contain similar content and format. Therapeutic radiology (radiation used for the treatment of cancer) consists of a summary of radiotherapy (use of cobalt, radium and radioactive isotopes)given. At the end of the treatment series it is signed by radiologist and made a part of the medical record.

These are the reports of findings of various tests performed on body materials, fluids and tissues.

the report should contain patient identification information,the name of the test, test date, time in and out of laboratory, test result. The report should also indicate the pathologist in charge of the laboratory. Reports usually also contain the normal value range for each test when appropriate. Often results that are out-of-range are marked in some way such as with an asterisk to call attention to the result. When results are performed by a technologist rather than automatic results reporting by a computer and laboratory equipment, the technologist performing the test is indicated (often with the use of initials or code number). Certain special tests may not be performed by the hospital and are sent out to another lab. These results become part of the patient's medical record and must contain the name of the laboratory performing the test.

The reports are often in a "cumulative" format. Cumulative reports contain all results from the current episode of care. In cumulative reports, every time a new result is added the entire report is re-generated. When a new cumulative report is added to the medical record, any previous cumulative report should be removed. (It is important that these reports that have been removed be disposed of properly). Anyone purging the record of reports needs to be careful to look at the report date to ensure that the latest cumulative report is kept. Often immediately after discharge when all results are in, a final cumulative report is generated. This report is usually marked at "final" or "discharge" report or is printed on a different color paper. All others are then removed from the record. Results are typically grouped according to the type of test such as hematology, microbiology, urinalysis, chemistry, blood bank, serology, etc.

All tests must be ordered by the patient's physician(s).

Joint Commission - "... the medical record contains very specific data including all diagnostic and therapeutic procedures and test results" Medicare COP -... Other - Medical staff rules and regulations may require certain tests such as CBC and UA for all patients unless specified otherwise by the physician.

EKG (electrocardiogram) reports are reports of the electrical activity of the heart. The report, in addition to patient identification includes a tracing as well as measurements and an interpretation

EKG tracing are printed either directly on strips which are then mounted on a mounting sheet or are printed directly on a full-sheet of paper. The latter is more common now. Most EKG machines are now capable of printing a machine-interpretation of the results. These machine interpretations must be confirmed by a cardiologist

Must be ordered by the physician. Tracing is "read" and authenticated by a cardiologist.

Therapists notes regarding assessment and treatment plans designed to restore function. Notes include a plan of care, documentation of objective and goal-oriented services and the patient's response to treatment.

May be either forms that are filled in or an appropriately labeled record for therapist notes.

These services must be ordered by the physician. Therapists must authenticate their own notes.

Joint Commission - requires the medical record contain: clinical observations any referrals and communications made to external or internal care providers and to community agencies. the patient's response to care progress notes made by the medical staff and other authorized individuals "When warranted by the patient's need, functional status is assessed." "A functional assessment is performed for each patient referred for rehabilitation services." Medicare COP - 482.56 Condition of participation: Rehabilitation services. (b) Standard: Delivery of services. Services must be furnished in accordance with a written plan of treatment. Services must be given in accordance with orders of practitioners who are authorized by the medical staff to order the services, and the orders must be incorporated in the patient's record.

documentation of evaluations and treatments performed by respiratory therapists either for treatment of acute or chronic respiratory conditions or the prevention of respiratory conditions. Services may be treatments such as breathing exercises, ventilator support, therapeutic percussion (the pounding on the chest that is frequently done for cystic fibrosis patients) or specialized testing such as pulmonary function tests. Documentation would include the type of treatment or test, frequency, duration, type and dose of any medications used, oxygen concentrations administered, machines used. Documentation should include patient assessments and response to therapy.

Joint Commission - Same as requirements for Rehabilitation Services Medicare COP - 482.57 Condition of participation:Respiratory care services. (b) Standard: Delivery of Services.Services must be delivered in accordance with medical staff directives. (1) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing. (2) If blood gases or other laboratory tests are performed in the respiratory care unit, the unit must meet the applicable requirements for laboratory services specified in § 482.27. (3) Services must be provided only on, and in accordance with, the orders of a doctor of medicine or osteopathy.

Includes documentation of the background and social information of the patient, as well as social problems such as family or personal problems identified by the patient or family such as problems with housing or access to healthcare services. Social service notes typically include a plan of action, progress notes and a discharge note.

Joint Commission - "when appropriate the patient is educated about available community resources." Medicare COP - 482.43 Condition of participation:Discharge planning. The hospital must have in effect a discharge planning process that applies to all patients. The hospital's policies and procedures must be specified in writing. (a) Standard: Identification of patients in need of discharge planning. The hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. (b) Standard: Discharge planning evaluation. (1) The hospital must provide a discharge planning evaluation to the patients identified in paragraph (a) o f this section, and to other patients upon the patient's request, the request of a person acting on the patient's behalf,or the request of the physician. (2) A registered nurse, social worker,or other appropriately qualified personnel must develop, or supervise the development of, the evaluation. (3) The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post- hospital services and of the availability of the services. (4) The discharge planning evaluation must include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. (5) The hospital personnel must complete the evaluation on a timely basis so that appropriate arrangements for post-hospital care are made before discharge,and to avoid unnecessary delays in discharge. (c) Standard: Discharge plan. (1) A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, a discharge plan if the discharge planning evaluation indicates a need for a discharge plan.

information about the patient's nutritional status and nutritional treatment. Dietitian's documentation may include confirmation of diet orders, diet history, nutritional assessment, nutritional consultations with the patients, periodic assessments of nutrient intake and food tolerance, nutritional care discharge plan, diet instructions.

Format - Nutritional assessment forms and narrative nutritional progress notes. Responsibility - Qualified dietitians document and authenticate entries.

Joint Commission - "When warranted by the patient's need, nutritional status is assessed." "When appropriate, the patient is educated about diet and nutrition, including potential drug-food interactions." "... authorized individuals prescribe or order food and nutritional products in a timely manner". Medicare COP - 482.28 Condition of participation:Food and dietetic services. (b) Standard: Diets. Menus must meet the needs of the patients. (1) Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the patients. (2) Nutritional needs must be met in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the patients.

1. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectivenes of the clinical services being provided to a patient. 2. A process that integrates and coordinates patient care over time and across multiple sites and providers, especially in complex and high-cost cases 3. The process of developing a specific care plan foa a patient that seres as a communication tool to improve quality of care and reduce cost.

A tool designated to coordinate multidisciplinary care planning for specific diagnoses and treatments.

Is one of many forms to document data during the operative procedure. Is a Nurses Worksheet used to record the opening and closing counts of instruments and materials used during the operative episode. Counts of items used during the procedures are compared to closing counts to ensure that no materials or instruments are inadvertently left inside the patient.

Contains documentation of all drugs ordered and administered including the date, time, name of drug, dose, route (orally, topically, injection, inhalation, infusion, etc), and who administered the drug. Documentation of missed doses and the reason is also documented.

the initials of the person administering the dosage are entered. At the bottom of the page, a legend is generally made to identify the full name and credentials corresponding to each set of initials used. It can be computer generated. Three columns mark the three nursing shifts. Times for administration are indicated in the column for the appropriate shift, followed by a line.

Joint Commission - "... the medical record contains: every medication ordered or prescribed for an inpatient every medication dispensed to an ambulatory patient or an inpatient on discharge every dose of medication administered and any adverse drug reaction" Medicare COP 482.23 Condition of participation:Nursing services.(c) Standard: Preparation and administration of drugs. Drugs and biologicals must be prepared and administered in accordance with Federal and State Laws, the orders of the practitioner orpractitioners responsible for the patient'scare as specified under482.12(c), and accepted standards ofpractice. (1) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. (2) With the exception of influenza and pneumococcal polysaccharide vaccines,which may be administered per physician-approved hospital policy after an assessment of contraindications, orders for drugs and biologicals must be documented and signed by a practitioner who is authorized to write orders by hospital policy and in accordance with State law, and who is responsible for the care of the patient as specified under 482.12(c). (i) If verbal orders are used, they are to be used infrequently. (ii) When verbal orders are used, they must only be accepted by persons who are authorized to do so by hospital policy and procedures consistent withFederal and State law.

usually includes checklists of things required prior to surgery such as a H&P, informed consent, results of ordered lab work. The record may also be used to record a pre-operative nursing assessment and pre-procedure medications.

pre-operative forms are used, content usually includes checklists of things required prior to surgery such as a H&P, informed consent, results of ordered lab work. The record may also be used to record a pre-operative nursing assessment and pre-procedure medications.

Generally forms contain a combination of checklist items and fill-in documentation.

Joint commission "Before surgery, the patient's physical examination and medical history, any indicated diagnostic tests, and a preoperative diagnosis are completed and recorded in the patient's medical record." Medicare COP "(1) There must be a complete history and physical work-up in the chart of every patient prior to surgery, except in emergencies. If this has been dictated, but not yet recorded in the patient's chart, there must be a statement to that effect and an admission note in the chart by the practitioner who admitted the patient.

This report documents all pre-operative and intra-operative medications, as well as monitoring of vital signs during the procedure and all anesthetic procedures.

must be completed within 24 hours of admission

Joint commission and Medicare COP requires to write and authenticate Operative reports IMEDiTELLY after surgery

physicians should write a comprehensive operative note in the medical record for continuity of care purposes.

A type of health record or documentation that describes the results of a microscopic and macroscopic evaluation of a specimen removed or expelled during a surgical procedure.

The report is almost always dictated by the pathologist and then transcribed.

The pathologist is responsible for authenticating the report.

A standardized tool used to evaluate the patient's condition after admission to, and at discharge from, the healthcare facility.

A type of health record documentation used by nurses to document the patient's reaction to anesthesia and condition after surgery aka Recovery Room Report

Includes documentation of the patient's level of consciousness when entering and leaving unit, as well as vitals signs and the status of infusions, dressings, tubes, catheters and drains.

May be either a separate form or may be combined with the anesthesia record.

Generally is completed by the nursing staff and signed by the nurse in charge of the unit but may be signed by the physician or both the nurse and the physician. A post-anesthesia note signed by the anesthesiologist/nurse anesthetist is required within 24 hours after the surgery.

AKA Post-Anesthesia Record or Recovery Room Record.

"Postoperative documentation records the patient's vital signs and level of consciousness; medications (including intravenous fluids), blood, and blood components; any unusual events or postoperative complications; and management of such events." "Postoperative documentation records the patient's discharge from the postanesthesia care area by the responsible licensed independent practitioner or according to discharge criteria." "Compliance with discharge criteria is full documented in the medical record" "Postoperative documentation records the name of the licensed independent practitioner responsible for discharge." Joint Commission also requires at least one post-anesthesia visit describing presence or absence of post-anesthesia complications within 24 hours of the surgery. This is documentation beyond that of the operative and recovery room documentation. It might be recorded by a number of individuals such as the attending physician, surgeon or anesthesiologist. This note can be documented in a variety of locations such as in the progress notes, recovery room record or anesthesia record. Medicare COP - 482.52 Condition of participation: Anesthesia services. -(b) Standard: Delivery of services. "(3) With respect to inpatients, a postanesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia as specified in paragraph (a) of this section within 48 hours after surgery. (4) With respect to outpatients, a postanesthesia evaluation for proper anesthesia recovery performed in accordance with policies and procedures approved by the medical staff."

The specific goals in the treatment of an individual patient, amended as the patient's condition requires, and the assessment of the outcomes of care; servers as the primary source for ongoing documentation of the resident's care, condition and needs.

: the skill, good judgment, and polite behavior that is expected from a person who is trained to do a job well

improves the quality of healthcare by insuring that the best information is available to make any healthcare decision. Health information management professionals manage healthcare data and information resources. The profession encompasses services in planning, collecting, aggregating, analyzing, and disseminating individual patient and aggregate clinical data. It serves the healthcare industry including: patient care organizations, payers, research and policy agencies, and other healthcare-related industries.

Contextual norms are the acceptable behaviors and attitudes of the professionals who work in a particular environment. Often, these behaviors are supportive of safe work practices and contribute to effective teamwork as well.

our appearance contributes to how people perceive you as a professional. Appropriate dress and grooming are also important components of being a professional in the healthcare environment. As part of professional demeanor, good grooming and appropriate dress communicate to others that you respect yourself, them, and the organization. They also contribute to your being treated with respect by your co-workers.

is the activity of protecting your personal information.

Privacy is your right to keep things to yourself, your ability not to have to disclose private things about yourself.

is your right to keep things about you from being disclosed to other people. So you vest confidentiality in a physician and a healthcare system and by doing that expect them to not disclose information about yourself to others, to keep it confidential.

Protected Health Information (PHI) protects a patient's health information in any form including paper, electronic or oral form.

HIPAA, a federal law passed in 1996 included administrative simplification requirements to 1) standardize electronic submission of administrative and financial transactions and 2) to protect the security and privacy of transmitted information.

the state law is more stringent the state law related to the reporting of disease/injury, child abuse, birth, or death or when it relates to public health surveillance, investigation or intervention the state law requires a health plan to report or provide access to information for the purpose of audits, program monitoring evaluation or licensing or certification of facilities or individuals the state has received approval from DHHS for an exception

all medical records and other individually identifiable health information in any form or medium Health information is defined as any information, whether oral or recorded in any form or medium, that: Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.

The standards apply to covered entities which are defined as health plans healthcare clearinghouses providers

ARRA has several provisions that extend HIPAA privacy, security, and administrative requirements to business associates (BAs). In addition there are new provisions for HIPAA-covered entities and BAs, as well as provisions for those not considered HIPAA-covered. Breach requirements (identification and notification) are established both for HIPAA-covered entities and non-HIPAA-covered entities, essentially any organization holding personal health information. Restrictions are further established on the sales of health information. A new accounting requirement is established for disclosure related to treatment, payment, and operations. New access requirements are established for individuals related to healthcare information in electronic format. New conditions are instituted for marketing and fund raising functions. Personal health record information with non-HIPAA entities is now protected. Use of de-identified data and minimum necessary data will be addressed. Enforcement is improved and penalties are increased.

For use or disclosure of information for treatment, payment, and healthcare operations most be obtained before treatment is provided.

Is required for the use or disclosure of protected health record for purposes other than treatment, payments or operations. E.g psychotherapy notes.

Medical ethics is using reason and logic to deal with situations concerning life, death, and the continuum between the two. It also deals with regulating the behavior of the health care professional

Is the repository of all data of an individual's health status, it contains the who, what, where, when, why, and how-all the relevant facts of the patient's illnesses, care, and treatment

Communication; among various health care professionals serving the patient Basis for planning; individuals care Documentary evidence; of the course of the patient's illness & treatment Evaluation of quality of care; rendered to the patient Protecting legal interest of the patient, hospital, physician Research and evaluation; providing the clinical data used in research and education Administration; necessary for accreditation, licensing, planning etc Billing and reimbursement; serves as an information for developing sustaining the billing and claim for payment of healthcare services

A personal use of the medical record occurs whenever the identity of the individual is revealed or important to the use of the medical record e.g request of the patient's inmunization record by a school. An impersonal use of the medical record is an instant when the identity of the patient is not revealed or not necessary for the intented use.

For example the statistical, research and historical and the name of the patient is not important.

The Patient The provider The healthcare Delivery system

Physician has the major or final responsibility for individual medical record

Governing board has a GENERAL responsibility, has the final management responsibilities e.g selection of an efficient staff.

Hospital Administrator (CEO) is responsible to provide health information management department that is equipped and staffed, also enforces Medical Record regulations/policies/standards within the hospital and HIM department

They review record rules, regulations policies, and standards is responsible for the maintenance, and completion and clinical pertinence.

Assume responsibility for the health record is maintained, stored, and able for retrieval, confidentiality, data, security integrity, access, performing coding, classification managing paper and non paper patient information and organization.

Data is non-interpreted items represent the basic facts about people measurements, conditions etcetera e.g text Information represent meaning e.g reports, graphs

Assist the physician in diagnosing and threatening the patient

The challenging when it comes to locating all components of a health record, are costly due to duplicate processes and maintenance.

Further maturation needed in some technologies, standards most be developed, tested. Exchange of health care data.

Quality of care for patients in every healthcare environment

Current ; past illnesses, know drug allergies, current medication date, time, and method of admission, and current condition, symptoms, vital signs, weight.

Therapeutic services, discharge order, ancillary medical services, special orders, nurses notes, MAR

Present illness ( history of present illness)

For normal newborns with uncomplicated deliveries, or for patients hospitalized for less than 48 hours with only minor problems, a progress note may substitute for the clinical resume.

They should be completed with in 30 days of discharge.

Operative Report

If the physician or nurse is not involved in the patient's evaluation or treatment or in the administrative function such as quality improvement involving the medical record, then he/she is not entitled to see the record.

Source oriented: conventional is the most common format, is arranged by department, e.g all progress notes are together Advantages; easy to compare related tests, individual Pages can be located. Disadvantages; difficult to identify the nature of the patient's most recent treatment. Integrated: the record is arranged in strict chronological order. Advantages; allows healthcare professionals to see a progression of the patient's care. Disadvantages; comparing of tests is more difficult role, Problem-oriented; emphasizes following the course of treatment for a particular problem from start to finish. Has 4 parts database, problem list, initial plans, progress note(soap) Disadvantages; time consuming

Nurses progress note

Within 48 hrs after surgery

JC requires at least one post-anesthesia visit describing presence or absence of post-anesthesia complications within 24hrs of surgery.

Nurses progress note

Face sheet & Discharge summary

Intra-operatives reports

Attending physician

Progress notes of POMR

The difference between ROS and IBS is that the review of systems is the symptoms the patient is experiencing, and the Inventory of systems is the assessment of the patient's condition, through physical examination by a physician or other authorized healthcare practitioner.

As per Medicare COP a registered nurse, social worker, or other appropriately qualified personnel most develop or supervise the development of the evaluation

Yes, joint commission is up to 30 days prior admission.