Transcript Chapter One - cvadultcma

CHAPTER 1
THE MEDICAL RECORD
PRETEST
True or False
1. The medical record serves as a legal document.
2. The purpose of progress notes is to update the
medical record with new information.
3. The patient registration record consists of a list
of the problems associated with the patient's
illness.
4. All over-the-counter medications taken by the
patient should be charted on the medication
record form.
5. A consultation report is a narrative report of a
clinical opinion about a patient's condition by a
practitioner other than the primary physician.
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PRETEST, cont.
True or False
6. A report of the analysis of body specimens is
known as a diagnostic report.
7. Medical impressions are conclusions drawn from
an interpretation of data.
8. A consent to treatment form is required for
tuberculin skin testing.
9. Diabetes mellitus is an example of a familial
disease.
10. Pain is an example of an objective symptom.
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Content Outline
Introduction to the Medical Record
1. Medical record: Written record of important
information regarding a patient
a. Patient: An individual receiving medical care
2. Function
a. To make decisions regarding patient's care
and treatment
b. To document results of treatment and patient's
progress
c. Communicate information to authorized
personnel in medical office
d. Serves as a legal document
•
Law requires that patient's care and treatment be
documented
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Introduction to the Medical Record,
cont.
3. Good documentation
a. Works to legally protect the physician and
medical staff
4. Incomplete records
a. Can be used as evidence to show that
patient did not receive quality care
5. Information is strictly confidential
a. Must not be read or discussed by anyone
not involved in care of the patient
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Highlight on the HIPAA
Privacy Rule
1. HIPAA: Health Insurance Portability and
Accountability Act
2. HIPAA Privacy Rule: Federal law that
protects patient's privacy
a. Went into effect April 14, 2003
b. Purpose
•
Provide patients with more control over use and
disclosure of their health information (Known as
PHI: Protected health information)
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Highlight on the HIPAA
Privacy Rule, cont.
c. Who must comply: Anyone that uses,
stores, maintains or transmits health
information
•
•
•
Health care providers
Health plans
Health care clearinghouses (e.g., billing
services)
d. What is included in the HIPAA Privacy Rule
•
See Highlight on the HIPAA Privacy Rule
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Components of the Medical Record
1. Consists of numerous documents
a. Each document has a specific function
2. Preprinted forms are often used
3. Documents can be classified into
categories
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Medical Office Administrative
Documents
Contain information for efficient record keeping
of office
Patient Registration Record
1. Consists of demographic and billing
information
2. Must be completed by all new patients
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Patient Registration Record, cont.
3. Most offices enter this information into
the computer
a. Original placed in front of patient's chart
4. Information is used for a number of
computerized functions (e.g., scheduling
appointments, posting patient
transactions, processing patient
statements and insurance claims)
5. Original registration record
a. Placed in front of patient’s medical record
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Patient Registration Record, cont.
6. Includes:
a.
•
•
•
Demographic information
Full name
• Gender
Address
• Marital status
Phone (home
• Employer
and work)
• Date of birth
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Patient Registration Record, cont.
b. Billing information
•
•
•
•
•
•
Name of responsible party
Social Security number
Address of responsible party
Name of insured
Insurance company
Policy and group number
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Correspondence
1. May be received from:
a. Insurance companies
•
Example: Precertification authorization
b. Patient’s attorney
c. Patient
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Correspondence, cont.
2. May be sent from office:
a. Patient referral letter
b. Collection letter
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Medical Office Clinical Documents
Records and reports that assist physician in
care and treatment of patient
Health History Report
1. Subjective data about the patient
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Health History Report, cont.
2. Health history obtained by:
a. Having patient complete a preprinted form
b. Physician or MA during an interview
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Health History Report, cont.
3. Health history, physical examination,
and laboratory and diagnostic tests are
used to:
a. Determine patient's state of health
b. Arrive at a diagnosis
•
Diagnosis: The scientific method of determining
and identifying a patient's condition
c. Prescribe treatment
d. Document change in patient's illness after
treatment
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Health History Report, cont.
4. Thorough history obtained on each new
patient
5. Subsequent visits
a. Provides additional information regarding
changes in:
•
•
Patient's condition
Treatment
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Physical Examination Report
1. Physical examination: Assessment of
each part of patient's body
a. Purpose: Provides objective data about the
patient
•
Assists physician in determining patient's state
of health
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Physical Examination Report, cont.
2. Physical Examination Report:
a. A summary of the physician's findings from
each part of the body
b. Includes:
• General
appearance
• Head and neck
• Eyes
• Ears
• Nose
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Physical Examination Report, cont.
•
•
•
•
Mouth and pharynx
Arms and hands
Chest and lungs
Heart
•
•
•
•
Breasts
Abdomen
Genitalia and rectum
Legs and feet
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Progress Notes
1. Purpose
a. Update medical record with new
information when patient visits the office or
telephones
2. Must include:
a. Date and time
b. Signature and credentials of individual
making entry
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Medication Record
1. Detailed information on patient's
medications
2. Includes:
a. Prescription meds
b. Over-the-counter medications
c. Meds administered at medical office
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Medication Record, cont.
3. Types of forms
a. Prescription and Over-the-Counter
Medication Record Form
b. Medications Administration Record Form
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Medication Record, cont.
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Consultation Report
1. Narrative report of clinical opinion about a
patient's condition by a practitioner other
than primary physician (consultant)
2. Usually is usually a specialist (e.g.,
cardiologist)
3. Consultant's opinion is based on:
a. Review of patient's record
b. Examination of patient
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Consultation Report,cont.
Modified from Diehl MO, Fordney MT: Medical transcription: techniques and procedures, ed 5, Philadelphia, 2003, Saunders.
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Home Health Care Report
1. Home health care: The provision of
medical and nonmedical care in a
patient's home
2. Purpose
a. Minimize effect of disease or disability on
the patient by:
•
•
•
Promoting health
Maintaining health
Restoring health
3. Home health care must be ordered by
physician
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Home Health Care Report, cont.
4. Home health care professionals
a.
b.
c.
d.
e.
f.
g.
Nurses
Home health aides
Dietitians
Physical therapists
Occupational therapists
Speech therapists
Social workers
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Home Health Care Report, cont.
5. Home health services
a.
b.
c.
d.
e.
f.
g.
Cardiac
Infusion (IV) therapy
Respiratory therapy
Pain management
Diabetes management
Rehabilitation
Maternal-child care
6. Summary report sent to patient's
physician
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Home Health Care Report, cont.
Courtesy of and Modified from Briggs, Des Moines, Iowa.
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Laboratory Documents
1. Laboratory Report: A report of the
analysis or examination of body
specimens
2. Purpose
a. Relay results of laboratory tests to
physician to assist in diagnosis and
treatment of disease
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Laboratory Documents, cont.
3. Categories of Laboratory tests
a.
b.
c.
d.
e.
f.
g.
h.
Hematology
Clinical chemistry
Serology
Urinalysis
Microbiology
Parasitology
Cytology
Histology
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Diagnostic Procedure Documents
1. Diagnostic Procedure Report: Narrative
description and interpretation of a
diagnostic procedure
2. Diagnostic procedure: A type of
procedure performed to assist in
diagnosis, management, or treatment of
a patient's condition.
a. Performed by physician, MA, or specially
trained technician
b. Interpretation of results made by physician
c. Physician completes a written report
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Diagnostic Procedure Documents,
cont.
3. Examples of diagnostic procedure
reports
a.
b.
c.
d.
e.
f.
g.
Electrocardiogram report
Holter monitor report
Sigmoidoscopy report
Colonoscopy report
Spirometry report
Radiology report
Diagnostic imaging report
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Radiology Report
Modified from Diehl MO, Fordney MT: Medical keyboarding, typing, and transcribing, ed 4, Philadelphia, 1997, Saunders.
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Diagnostic Imaging Report
(CT Scan)
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Therapeutic Service Documents
1. Therapeutic Service Report: Documents
the assessments and treatment
designed to restore a patient’s ability to
function
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Therapeutic Service Documents,
cont.
2. Example of therapeutic services:
a. Physical therapy: Use os physical agents to
restore function and promote healing
following an illness or injury
• Therapeutic
exercise
• Thermal
modalities
• Cold
• Hydrotherapy
• Electrical stimulation
• Massage
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Therapeutic Service Documents,
cont.
b. Occupational therapy: Helps the patient
learn new skills to adapt to a disabling
condition
•
•
Enables patient to perform activities of daily
living
Achieve as much independence as possible
c. Speech therapy: Treatment for the
correction of a speech impairment resulting
from:
•
•
•
Birth
Disease
Injury
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Hospital Documents
1. Prepared by the physician responsible
for care of the patient in the hospital
a. Known as the attending physician
•
May be:
– Patient’s regular physician
– A different physician (e.g., emergency room
physician)
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Hospital Documents, cont.
2. Dictated by attending physician and
transcribed at the hospital
a. Original kept on file at hospital
b. Copy sent to patient’s physician
3. Assists patient’s physician in:
a. Reviewing patient’s hospital visit
b. Providing follow-up care
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History and Physical Report
1. Inpatient: Patient who has been admitted
to hospital for at least one overnight stay
2. Health history and physical examination
must be performed on all inpatients
a. Exception:
•
If history and physical examination are
performed at medical office 1 week before
admission
– Can be used instead
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History and Physical Report, cont.
3. If reliable health history cannot be
obtained from patient
a. Obtained from a person able to relay the
facts
4. Consists of a narrative report of:
a. Health history
b. Physical examination
c. Physician’s medical impressions
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History and Physical Report, cont.
5. Purpose of health history: document
patient’s current complaints and
symptoms
6. Purpose of physical examination: assess
patient’s current health status
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History and Physical Report, cont.
7. Medical impressions: Conclusions drawn
from interpretation of data
a. Other terms used:
•
•
Provisional diagnosis
Tentative diagnosis
b. Physician interprets data from health
history and physical examination
•
Draws conclusions (medical impressions) as to
patient’s state of health
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Hospital History and Physical
Examination Report
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Operative Report
1. Must be completed on all patients who
have had a surgical procedure
2. Purpose: describes the surgical
procedure
3. Completed and signed by surgeon
performing operation
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Operative Report, cont.
4. Includes:
a.
b.
c.
d.
e.
Patient identification information
Date of surgery
Preoperative diagnosis
Name of surgical procedure
Full description of findings
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Operative Report, cont.
f. Description of technique and procedures
used
g. Ligatures and sutures used
h. Number of packs, drains, and sponges used
i. Description of specimens removed
j. Condition of patient after completion of
surgery
k. Postoperative diagnosis
l. Name of surgeon
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Operative Report, cont.
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Discharge Summary Report
1. Summary of the significant events of a
patient’s hospitalization
2. Includes:
a.
b.
c.
d.
Concise account of patient’s illness
Course of treatment
Response to treatment
Patient’s condition at time of discharge
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Discharge Summary Report, cont.
3. Purpose is to document information
needed by:
a. Patient’s family physician for continuity of
future care
b. Respond to authorized requests for
information regarding patient’s
hospitalization
4. Completed and signed by attending
physician
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Discharge Summary Report, cont.
Modified from Diehl MO, Fordney MT: Medical transcription: techniques and procedures, ed 5, Philadelphia, 2003, Saunders.
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Pathology Report
1. Macroscopic and microscopic
description of tissue removed during:
a. Surgery
b. Diagnostic procedure
2. Includes a diagnosis of the patient’s
condition
3. Pathologist examines tissue; completes
and signs report
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Pathology Report, cont.
Modified from Diehl MO, Fordney MT: Medical transcription: techniques and procedures, ed 5, Philadelphia, 2003, Saunders.
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Emergency Department Report
1. Record of significant information
obtained during an emergency
department visit
2. Prepared and signed by emergency
department physician
3. Copy sent to patient’s physician so
follow-up care can be provided
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Emergency Department Report,
cont.
4. Includes:
a.
b.
c.
d.
Date of service
Patient’s identification information
Nature of illness or injury
Laboratory or diagnostic test results
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Emergency Department Report,
cont.
e.
f.
g.
h.
i.
Procedures performed
Treatment rendered
Diagnosis
Condition of patient at discharge
Instructions regarding follow-up care
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Emergency Department Report,
cont.
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Consent Documents
1. Required to:
a. Perform certain procedures
b. Release information contained in patient’s
medical record
2. Types
a. Consent to treatment form
b. Release of medical information form
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Consent to Treatment Form
1. Required for:
a. All surgical operations
b. Nonroutine therapeutic and diagnostic
procedures
2. Example of diagnostic procedure:
Sigmoidoscopy
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Consent to Treatment Form, cont.
2. Signed by patient
or legally
authorized
representative
3. Purpose: provides
written evidence
that patient
agrees to
procedure(s)
listed on form
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Consent to Treatment Form, cont.
4. Informed consent: patient has received
the following information before giving
consent:
a. Nature of patient’s condition
b. Nature and purpose of recommended
procedure
c. Risks involved
d. Alternative treatment or procedures
available
e. Prognosis: likely outcome of the procedure
f. Risks of declining or delaying procedure
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Consent to Treatment Form, cont.
5. Must be in terms patient can understand
6. Patient must be given opportunity to ask
questions
7. Form should not be signed until patient
has been provided with all necessary
information
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Consent to Treatment Form, cont.
8. Patient’s signature must be witnessed
a. Witnessing a signature
•
•
Means: MA verified the patient’s identity and
watched patient sign form
Does not mean: MA is attesting to accuracy of
information on form
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Witnessing the patient’s signature
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Consent to Treatment Form
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Release of Medical
Information Form
1. Not required for medical treatment,
payment, and health care operations
(TPO)
a. Stipulated by HIPAA
2. Required for purposes that are not part of
TPO
a. Example: Patient moving to another
state and transferring medical records
3. Must be signed by patient (or
parent/guardian)
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Release of Medical
Information Form, cont.
4. Includes:
a.
b.
c.
d.
e.
f.
Patient full name and address
Medical practice releasing info
Individual or facility to receive info
Info to be released
Purpose or need for info
Method of release
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Release of Medical
Information Form, cont.
g. Signature of patient (or legal
representative)
h. Date signed
i. Expiration date of form
5. May be faxed or mailed if patient is
unable to come to office
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Release of Medical
Information Form, cont.
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Medical Record Formats
1. PPR: paper-based patient record
a. Most of record is paper-based
b. Some patient data stored on computer
Example: Patient registration information
c. Formats
•
•
Source-oriented record
Problem-oriented record
2. EMR: electronic medical record
a. Entire medical record is stored in computer
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Source-Oriented Record
1. Used most often in the medical office
2. Organized into sections based on
department, facility, or other source that
generated information
(e.g., laboratory)
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Source-Oriented Record, cont.
3.Separated by chart dividers: color-coded
tabs labeled with title of section
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Source-Oriented Record, cont.
1. Within each section: Documents
arranged according to date
a. Most recent document placed on top or in
front of the others
•
Known as: reverse chronological order
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Source-Oriented Record, cont.
5. Titles of sections:
a.
b.
c.
d.
e.
f.
g.
History and Physical
Progress Notes
Medications
Laboratory Reports
Electrocardiogram
X-Ray Reports
Consultations
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Source-Oriented Record, cont.
h.
i.
j.
k.
l.
m.
n.
Rehabilitation Therapy
Home Health Care
Hospital Reports
Insurance
Consents
Correspondence
Miscellaneous
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Problem-Oriented Record
(POR, POMR)
1. Organized according to patient’s health
problems
2. Advantage: Patient’s problems can be
defined and followed individually
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Problem-Oriented Record
(POR, POMR), cont.
3. POR developed in four stages
a. Database: Consists of a collection of
subjective and objective data
•
Includes:
– Health history report
– Physical examination report
– Results of baseline laboratory and
diagnostic tests
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Problem-Oriented Record
(POR, POMR), cont.
b. Problem list: Consists of a list of patient’s
problems
•
•
•
Problem: Any patient condition that requires
observation, diagnosis, management or patient
education
Includes:
– Medical problems
– Psychologic problems
– Social problems
Each problem in the list is numbered and titled
– Serves as a table of contents for the record
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Problem-Oriented Record (POR,
POMR), cont.
c. Plan: Plan of action for each problem
•
•
May include plans for:
– Laboratory tests
– Diagnostic tests
– Medical treatment
– Surgical treatment
– Therapy
– Patient education
Each plan begins with the problem number
followed by the plan of action
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Problem-Oriented Record
(POR, POMR), cont.
d. Progress notes: Follow-up for each
problem
•
•
Begins with the number of the problem
Includes:
– Subjective data: Data obtained from the
patient
– Objective data: Data obtained by
observation, physical examination,
laboratory and diagnostic tests, etc.
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Problem-Oriented Record
(POR, POMR), cont.
– Assessment: Physician’s interpretation of
the current condition based on the
subjective and objective data
– Plan: Proposed treatment for the patient
» Acronym: SOAP
» Soaping : Writing progress notes using
the SOAP format
a) Advantages of using SOAP format:
• Can deal with each problem clearly
• Can analyze data in an orderly
manner
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POR SOAP Progress Notes
Courtesy of and modified from Briggs, Des Moines, Iowa.
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Preparing a Medical Record for a
New Patient
1. Method of preparation depends on:
a. Format used to organize record
b. Filing system
c. Type of storage equipment
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Preparing a Medical Record for a
New Patient, cont.
2. Most medical offices use:
a. Source-oriented format
b. Alphabetic filing system
c. Shelf filing units
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Medical Record Supplies
1. File Folder: protective cover that holds
medical documents
a. Metal fasteners: often used to hold
documents in folder
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Medical Record Supplies, cont.
b. Tab: projection extending from a folder
•
•
•
•
Identifies contents
Located on side or top
Full cut tab: tab extending across entire side or
top
– Full cut side tab: often used in medical
office
Indentions on full cut tabs: indicate placement of
labels
– Ensures that labels on every record is
affixed at same place
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Medical Record Supplies, cont.
2. Folder labels: identifies the medical
record
a. Most common types used:
•
•
•
Name labels
Alphabetic color-coded labels
Color-coded year labels
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Affixing labels to the chart
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Medical Record Supplies, cont.
3. Chart Dividers: identifies each section of
medical record by subject
a. Color-coded tab with subject title attached
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Taking a Health History
1. A collection of data obtained by
interviewing a patient and/or having
patient complete a preprinted form
a. Reviewed for completeness by MA
2. Thorough history taken on a new patient
3. Subsequent visits: information is
obtained regarding changes in the
patient’s illness or treatment (progress
notes)
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Taking a Health History, cont.
4. Quiet, comfortable room encourages
patient to communicate
5. Showing interest and concern reduces
patient apprehension
a. Facilitates collection of data
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Components of the Health History
1. Health history is taken before the
physical examination
a. Provides physician opportunity to compare
findings
2. Identification data: basic patient data
a. Completed by patient
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Components of the Health History,
cont.
3. Chief Complaint (CC):
a. Patient’s reason for seeking care
•
Symptom causing the patient the most trouble
b. Foundation for present illness and review of
systems
c. MA usually responsible for obtaining and
recording CC
d. Recorded on a preprinted lined form
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Components of the Health History,
cont.
e. Guidelines for obtaining and recording CC:
•
•
•
•
•
Use open-ended questions
– Example: What seems to be the problem?
Limit CC to one or two symptoms
– Should refer to a specific rather than a
vague symptom
Record CC concisely and briefly in patient’s own
words as much as possible
Include duration of symptom
Do not use names of diseases or diagnostic
terms
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Components of the Health History,
cont.
f.
Examples:
•
•
Correct: Burning during urination that has
lasted for 2 days.
Incorrect: Ear pain and fever. (Duration of
symptom is not listed)
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Components of the Health History,
cont.
4. Present Illness (PI)
a.
b.
c.
d.
e.
Expansion of CC
Full description of patient’s current illness
MA often completes; asks patient questions
Recorded on same form as CC
MA asks patient questions
•
To obtain a detailed description of the CC
f. Requires skill and practice in asking proper
questions
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Components of the Health History,
cont.
5. Past History
a. Past medical status of patient
b. Assists physician in providing optimal care
c. Patient completes this section; checklist
form
•
MA should assist if needed
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Components of the Health History,
cont.
d. Includes:
•
•
•
•
Major illness
Childhood diseases
Unusual infections
Accidents and
injuries
• Hospitalizations and
operations
•
•
•
•
Previous medical tests
Immunizations
Allergies
Current medications
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Past History
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Components of the Health History,
cont.
6. Family History
a. Review of health status of patient’s blood
relatives
b. Focuses on familial diseases
•
Familial disease: a disease that occurs in blood
relatives more frequently than would be
expected by chance
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Components of the Health History,
cont.
-Examples:
(1)
(2)
(3)
(4)
Hypertension
Heart disease
Allergies
Diabetes mellitus
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Components of the Health History,
cont.
•
•
Patient completes this section
Includes following info on each blood relative
– State of health
– Presence of any significant disease
– If deceased: cause of death
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Family History
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Components of the Health History,
cont.
7. Social History
a. Information on patient’s lifestyle: Health
habits and living environment
b. Purpose: Lifestyle may have impact on
patient’s condition
c. If a major lifestyle adjustment is necessary
(e.g., smoking cessation)
•
Support services may be recommended
d. Completed by patient
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Components of the Health History,
cont.
e. Includes:
•
•
•
•
Education
Occupation (past and present)
Living environment
Diet
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Components of the Health History,
cont.
e. Includes, cont.:
•
•
•
•
•
Personal history
Exercise
Sleep patterns
Use of tobacco, alcohol, drugs
Travel to foreign countries
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Social History
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Components of the Health History,
cont.
8. Review of Systems (ROS)
a. Systematic review of each body system
b. Purpose: detect any symptoms that have
not yet been revealed
c. Physician completes this section
•
Asks a series of detailed and direct questions
related to each body system
d. Assists physician in determining type and
extent of physical examination required
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Review of Systems
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Charting in the Medical Record
1. Charting: The process of making written
entries about a patient in the medical
record
a. Performed by personnel directly involved
with health care of patient
2. Legal document: Important to chart
information completely and accurately
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Charting in the Medical Record,
cont.
Charting Guidelines
1. Check name on chart before making an
entry
a. If document in wrong chart
•
•
Procedure may be excluded from correct
patient’s record
From a legal standpoint: A procedure not
documented was not performed
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Charting in the Medical Record,
cont.
2. Use black ink
a. Provides permanent record
b. Easier to reproduce (e.g., information
needed by insurance company, patient
referral)
3. Write legibly
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Charting in the Medical Record,
cont.
4. Chart information accurately using clear
and concise phrases as follows:
a. Be brief but complete
b. Avoid vagueness and duplication of
information
c. Do not need to include patient’s name in
entry
•
•
Entire record centers on one patient
Assumed that info refers to that patient
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Charting in the Medical Record,
cont.
d. Begin each phrase with a capital letter and
end with period
e. Begin each new entry on a separate line
f. Include date and time on all entries
g. Use standard abbreviations, medical terms,
and symbols:
•
•
Save time and space
First check office policy for terms used in office
h. Spell correctly
•
Use dictionary if necessary
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Charting in the Medical Record,
cont.
5. Chart immediately after performing a
procedure
a. If delay: may not remember certain aspects of
procedure
b. Never chart in advance
c. Individual performing procedure should be the one
to chart it
•
Do not chart for someone else
6. Each entry should be signed by person making
it
a. Include first initial, full last name, and credentials
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Charting in the Medical Record,
cont.
7. Never erase or obliterate an entry
a. Reduces credibility if involved in litigation
b. To correct an error:
•
•
•
•
Draw a single line through incorrect information
Write the word error above incorrect data
Include date, first initial, last name, and
credentials
Insert correct information next to error
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Correcting a charting error
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Charting Progress Notes
1. Updates medical record with new
information each time patient visits
office
2. Documents patient’s health status, care,
and treatment
3. Provides communication among office
personnel
4. Serves as legal document
5. Preprinted lined sheets used: known as
progress note sheets
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Charting Patient Symptoms
1. Symptom: Any change in the body or its
functioning that indicates the presence
of disease
a. Subjective symptom: A symptom that is felt
by the patient and cannot be observed by
another person (pain, pruritus, vertigo,
nausea)
b. Objective symptom: A symptom that can be
observed by another person (rash,
coughing, cyanosis)
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Charting Patient Symptoms, cont.
2. Taking patient symptoms consists of:
a. Obtaining chief complaint
b. Obtaining additional information about CC
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Other Activities That Must
Be Charted
1. Procedures
a. MA frequently charts procedures
performed on the patient (e.g., vital signs)
b. Include: Date, time, type of procedure,
outcome, patient reaction
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Other Activities That Must
Be Charted, cont.
2. Administration of Medication
a. Important responsibility
b. Include: Date, time, name of medication,
dosage given, route of administration,
injection site, any significant observations
or patient reactions
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Administration of Medication
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Other Activities That Must
Be Charted, cont.
3. Specimen Collection
a. Include: Date, time of collection, type of
specimen, area of body where specimen
was obtained
b. If specimen sent to outside laboratory:
chart test(s) requested, date specimen
sent, where sent
•
Provides data if test results are not back yet
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Specimen Collection
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Other Activities That Must
Be Charted, cont.
4. Diagnostic Procedures and Laboratory
Tests
a. Include: Date, time, type of
procedure/test(s) ordered, scheduling date,
where procedure/test(s) being performed
b. Purpose of charting:
•
•
If patient does not undergo test ordered:
documented proof exists that test was ordered
Refreshes physician’s memory that tests were
ordered (if results not yet back from laboratory)
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Diagnostic Procedure and
Laboratory Test
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Other Activities That Must
Be Charted, cont.
5. Results of Laboratory Tests
a. STAT tests or critical findings may be
telephoned
•
Must record results on a report form
b. Laboratory tests performed in office must
be charted
•
Include: date, time, name of test, and test
results
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Test Results
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Other Activities That Must
Be Charted, cont.
6. Patient Instructions
a. May need to relay instructions to patient
regarding medical care (e.g., wound care)
b. Important to chart this information: date,
time, and type of instructions relayed to
patient
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Other Activities That Must
Be Charted, cont.
c. Preprinted instruction sheet may be used:
•
•
•
•
Patient signs form to indicate has
read/understands instructions
MA witnesses the signature
Filed in chart; copy given to patient
Legally protects physician: If patient does not
follow instructions and causes harm to a body
part
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Patient Instruction Sheet
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135
Patient Instructions
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Other Activities That Must
Be Charted, cont.
7. Other areas of charting
a.
b.
c.
d.
Missed or canceled appointments
Telephone calls from patients
Medication refills
Changes in medication dosage by physician
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Telephone Call and Missed
Appointment
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POSTTEST
True or False
1.
2.
3.
4.
5.
The purpose of HIPAA is to provide patients with
more control over the use and disclosure of their
health information.
The health history provides subjective data about a
patient to assist the physician in arriving at a
diagnosis.
Physical therapy helps a patient with a disability learn
new skills to perform the activities of daily living.
A copy of the patient’s emergency room report is
sent to the patient’s family physician.
When a medical assistant witnesses a patient’s
signature on a form, it means that the medical
assistant is verifying that the patient understands the
information on the form.
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POSTTEST, CONT.
True or False
6. SOAP is the acronym for the format used to
organize POR progress notes.
7. The chief complaint is the symptom causing the
patient the most trouble.
8. The purpose of progress notes is to update the
medical record with new information.
9. The patient’s name must be included at the
beginning of each entry charted in the patient’s
medical record.
10. A decrease in the amount of water in the body is
known as edema.
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140