Exam 2 - Health Record Content and Documentation

All key information to how the health record matters

1.      Know the difference between unit number, serial unit numbering, serial numbering and straight numeric.

paper record

physical document that contains written or printed information 

• Authentication is accomplished by handwritten signature or initials in ink.

electronic record

is any information created, stored, or transmitted in digital form rather than on paper.

• These records are used across industries to improve efficiency, accessibility, and security.

  • EHRs in healthcare, bank statements, legal documents 

hybrid record

refers to a system that combines both paper-based and electronic records within an organization.

• It’s common during transitions from traditional documentation to digital systems, especially in healthcare, education, and government.

• EHRs for prescriptions and lab results for older patients 

1.      Know the different types of data-primary, secondary, etc.

1.      Know the difference between qualitative and quantitative analysis and their challenges

1.      Understand SOAP

1.      Know when a history and physical needs to be in a patient’s chart

Understand medical staff bylaws

• The internal standards are developed by the medical staff and approved by the board of trustees or governing body in healthcare facilities.

• Basically, making sure that all time limits and established rules and regulations are being reached and followed.

What is a longtidunal record?

• Birth to death record

  • A record complied about an individual that contains health records from various encounters and from numerous healthcare delivery systems

• Reduces risks end errors

  • Helps to prevent medical errors because information on allergies, drug interactions, surgeries, and past medical problems can be made available before treatment decisions are made.

Know Standard Time frames for completion of patient records

1.      understand what the purpose of utilization review is

1.      Know what ASTM is

1.      Know the delinquency rate for Joint Commission over a 12 month.

1.      Identify some advantages of electronic records compared to paper

1.      identify another name for demographics