The Medical Record and Health History LO #1-2

What is the crucial part of a medical practice?

medical records

What does the written record of important information about a pt include?

the care of pt and progress of pt condition

What do medical records use info as a basis for when regarding decisions?

pt care and tx

What do medical records include in regards to functions?

document results of tx and pt progress

Medical records are an effective and efficient way to do what?

communicate info to authorized personnel

Good documentation protects who?

provider and medical staff

What does an incomplete medical record show?

pt didn't recieve quality care

Info in a medical record is strictly ___, must not be ____ by or ____ with anyone except _____ or _____ involved with pt.

confidential, read, discussed, provider, staff

A medical record consist of numerous documents with specific what?

functions or purpose

What are the categories of medical record documents?

administrative, clinical, laboratory, diagnostic, therapeutic, hospital, consent

Administrative medical records include info necessary for what managment of office?

effecient

What do administrative medical records include?

pt registration record, notice of privacy practices and acknowledgement, correspondence

Clinical medical records include a variety of ___ & ____, assisting Dr in ____ & ____ of pt.

records, reports, care, tx

What do clinical medical records include?

health history report, physical exam report, progress note, medication record, consultation report, home health care report

Laboratory reports are the report of analysis or exams of what?

body specimens

Laboratory reports relay results of ____ to Dr to assist in ___ & ____ disease.

laboratory, diagnosing, treating

What is included in diagnostic medical records?

hematology report, clinical chemistry report, immunology report, urinalysis report, microbiology report, parasitology report, cytology report, histology report

Diagnostic procedure reports type of procedure performed to assist in ____, ____, or ___ of pt's condition.

diagnosis, managment, tx

Diagnostic procedure reports consist of ___ description & ____ of dx procedure.

narrative, interpretation

What type of procedures are apart of diagnostic reports?

electrocardiogram report, holter monitor report, colonoscopy report, spirometry report, radiology report, diagnostic imaging report

Therapeutic service reports document ___ & ___ designed to restore pt's ability to function.

assessments, tx

Therapeutic service reports consist of what?

physical therapy report, occupational therapy report, speech therapy report

Hospital documents assist Dr in ___ pt's hospital visit & providing ___ care.

reviewing, follow-up

Hospital documents are prepared by Dr ___ for care of pt @ hospital.

responsible

Hospital documents include what?

history and physical report, operative report, discharge summary report, pathology report, emergency department report

Consent documents are legal documents to perform certain ____ or release ___ contained in record.

procedures, information

What do consents documents consist of?

consent to tx form, release of medical info form