Ch. 21 The Health Record

Paper-based records include…

• Patient medical care information

• Patient registration information

• Patient scheduling information

• Billing information

Electronic medical records (EMR)

computerized records of patient health information, including patient care, treatment outcomes, and details about patient conditions. EMRs are often linked to other patient-related administrative services, such as billing and claims, which facilitates easily accessible information.

Electronic health records (EHR)

EHRs can be easily shared among healthcare organizations and serve as a compilation of subjective and objective data, including health history reports, physical examination reports, and laboratory and diagnostic tests.

Difficulties with paper health records

Misfiling, difficult to share, handwriting, storage space, viewed by one person at a time

Benefits of EHR

Shared easily, clarity of info, viewed by multiple people simultaneously, less space, less maintenance, less errors

Problem-oriented medical records (POMR)

include documents that are organized according to patients’ health problems. The benefit of using POMRs is that each patient's problem can be stated and followed individually.

4 stages of POMR development

1. Establishing a database

2. Compiling a detailed patient problem list

3. Creating a plan of action for each problem

4. Following each problem with suitable progress notes

Database

Stores information on both subjective and objective data that includes health history report, physical examination report, and results of baseline laboratory and diagnostic tests.

Problem list

Lists problems categorized as a diagnosis, a physiologic finding, a symptom, or an abnormal test result.

Plan

Begins with a heading that identifies the number of the problem, based on the problem list. It is followed by a plan of action that is appropriate for the patient problem.

Progress notes

Used to record information about the patient and the patient’s services during the appointment, including how the patient feels, what the provider observes, what the assessment or examination concludes, and what kind of plan of action is necessary for the patient to take.

Source-oriented medical records (SOMR)

consist of documents organized into sections, depending on the department, facility, or other source that generated the information (e.g., radiology, laboratory, hospital, or consultant).

Patient’s social history

• Patient’s lifestyle, including hobbies

• Patient’s drinking habits

• Patient’s smoking habits

• Drug use and marital life

Personal and medical history

• Any past illnesses or surgery the patient has had

• Physical defects, whether congenital or acquired

• Patient’s daily health habits

Personal demographics

• Patient’s full name, parents, gender, DOB

• Marital status, name of the spouse, and number of children

• Home address, telephone number, and e-mail address

• Occupation and name of the employer

• Business address and telephone number

• Information about healthcare insurance

• Social Security Number and copy of a government-issued ID

Patient’s chief complaint

• The type of pain, if any

• When the patient first noticed the symptoms

• The patient’s view about the possible causes of the problem

• If the patient has had the same or a similar condition in the past

• Treatments the patient may have tried before seeing the provider and if they helped with symptoms

Vital signs and measurements

• Temperature

• Pulse

• Pulse oximetry

• Respiration

• Blood pressure

• Height

• Weight

Labs and radiology reports

Diagnostic or lab test requests and results

Diagnoses

• Past history

• Examination findings

• Supplementary tests, if any

Treatment prescribed and progress notes

• Recommended treatment for the patient

• List of prescribed or over-the-counter medications and any vitamin supplements

• Instructions given to the patient related to care and treatment

• Progress notes describing the patient’s condition and treatment outcomes

Condition at the time of termination of treatment

• The patient’s condition at the time the treatment ends

• If the patient’s symptoms have resolved

• If the patient is physically or emotionally comfortable

• If the patient is terminated due to noncompliance

Documentation on progress notes method (SOAP)

• Subjective data (S)

• Objective data (O)

• Assessment (A)

• Plan of action (P)

Subjective contents

the patient’s personal demographics, chief complaint, health, family, and social history.

Objective contents

diagnosis, treatment prescribed and progress notes, vital signs and anthropometric measurements, and condition at the time of termination of treatment.

Provisional vs differential diagnosis

a differential diagnosis weighs the probability of one disease against the probability of another as the disease-causing agent.