Abbreviations/terms

Admission sheet

Commonly used to gather information from the patient before the visit with the provider. Must be updated regularly, usually once a year.

Charting by exception format

An abbreviated documentation method that makes use of well-defined standards of practice and documents only significant or abnormal findings. Strictly a problem-oriented method of charting.

Familial

Diseases/traits that tend to run in specific families

Graphic(flow) sheet

A grid-like form used to record and monitor specific patient variables over time, such as vital signs and weight.

Military time

A 24-hour time cycle that counts the hours of the day from 00:00 to 23:59. Prevents confusion between AM and PM.

Narrative format

Oldest and least structured medical documentation style that is simply a paragraph indicating contact with patient, what was done for patient, and outcomes resulted. It is time-consuming to write and can be difficult to read.

Physician’s orders

Where precise and detailed documentation of any order of patient care lies. May include orders for medications, treatments, tests, and follow-up care.

Problem-oriented medical record(POMR)

Organizes information by the patient’s problem. Patient’s medical problem is on the first page of the record and assigned a number, and then all documentation about that issue is assigned the same number. When the issue no longer exists, an “X” is put next to the issue. It is sorted into sections, (1) problem list, (2) database, (3)treatment plan, and (4) progress notes. 

Progress notes

Record of each contact a provider has with the patient, whether in person or by phone, mail, or email which helps provide a snapshot of patient treatment, progress, and issues. In this section, the provider summarizes any findings from contact.

Soap Format

A documentation format made up of four parts: *s*ubjective data, *o*bjective data, *a*ssessment, *p*lan.

Source-oriented medical record(SOMR)

Groups information by type instead of problem

TPR

Temperature, pulse, respiration

BIP

Blood pressure

OD

Once a day

BID

Twice a day

TID

Three times a day

QID

Four times a day

IM

Intramuscular

SQ/SC

Subcutaneous

ID

Intradermal

PO

By mouth

NPO

Nothing by mouth

C/O

Complaint of

c(with line over it)

with

R/O

Rule out

CXR

Chest x-ray(to rule out pneumonia)

s/p

Status post fall

s(with line over it)

without

p(with line over it)

post

a(with line over it)

before

d/c

discontinue or discharge

q

every(as in hours)

Rx

Perscription

Tx

Treatment

Dx

Diagnosis

Pt

Patient

NKDA

No known drug allergies

LMP

Last menstrual period

What is primary purpose of medical documentation? What is the second main purpose?

The primary one is communication between healthcare providers so that all information is up-to-date. The other is describing a patient’s current medical condition and history.

What are all the purposes of medical documentation?

Education, communication, reimbursement, assessment, quality assurance, legal record, research,

ac

before meals

Why is medical documentation necessary?

Patients receive care from so many providers that they will never all be in the same room at once

Why is the permanent medical record important?

Having past and current medical records allows for clues to diagnosis and treatment plans

What can medical documentation provide evidence of?

Quality of care a patient received and the competence of the professionals who provided that care

What does a health care audit do?

They check over medical records in order to make sure there are no deficiencies, and if there are, in-service training is done to help fix the issue and improve quality of care.

What is the cornerstone of medical documentation?

Patient medical records

Why is documentation contained in the patient’s medical record there?

To determine the reason for a patient visit, the type of care given, any diagnosis made, any tests that were ordered, and any treatment provided

How do plan administrators determine how much the plan will pay?

Reason for a patient visit, the type of care given, any diagnosis made, any tests that were ordered, and any treatment provided. They also use codes put in the medical documentation.

What is the golden rule of medical documentation?

If it isn’t documented, it wasn’t done

Why can medical documents be used in court?

They are legal documents

What is a symptom?

Indications of disease or dysfunction that are sensed by the patient

What is a sign?

Indications of disease or dysfunction that can be observed or measured

When can medical documents be destroyed?

Must be held up until a certain time period but NEVER

What happens when a healthcare professional breaks the legal, ethical, or moral standards?

A breach of contract may occur which subjects the patient to embarrassment or harm and leaves the healthcare professional vulnerable to fines and lawsuits.

How are patient medical records used educationally?

Patient medical records can be used as tools to teach new people in the field

How are patient medical records used for research?

Researchers learn how to recognize or treat health problems through similar cases, data gathered from groups of patient records can help determine significant similarities in disease prevention, contributing factors, and effectiveness of therapies

Why are healthcare professionals switching to EMR?

Healthcare professionals being more willing to switch to electronic due to easy access to multiple people at once in various different areas

List benefits of switching to computerized documentation:

Information is easy to store and receive, Nearly unlimited file space, Easier to back up for added security, Information easily added or attached to records, Charting it easier to read, Data is written in computer quicker,  order supplies/services for patients, to store billing and financial data, and to maintain health care information

What does the switch to EMR mean?

Increased use of computerized patient information systems means that there are necessary procedures that need to be taken

What has the American Health Information Management Association(AHIMA) been doing to ensure computerized medical documentation safety?

They have guidelines and strategies for safe computerized recordkeeping.

What does the AHIMA advise to do?

Never give a personal password or computer signature to anyone, even other healthcare professionals, Never leave a computer unattended after log on, Follow correct protocol when correcting errors such as writing “mistaken entry” with the correct info., date, and your initials, Only allow authorized personnel to correct, create, or delete records, Make sure stored records are backed up regularly, Keep running log of electronic copies made of computerized files, NEVER use email to mail protected health information, unless it is encrypted, Follow healthcare agencies procedures and policies

What is a patient’s medical record?

A compilation of health related information. The only permanent legal document detailing a patient’s medical history, test results, and interactions with healthcare professionals. A collection of many types of documents.

What is in an admission sheet?

Demographic data/insurance info): name, address, number, social security number, birthdate, marital status, gender, race, and employers info(name, address, number), primary health insurance carrier, policy number, insurance company address/number, co-payment or deductible info, and secondary insurance info

What do medical history/examination forms usually include?

Patient history(allergies, immunizations, childhood diseases, current and past medications, previous illnesses, surgeries, and hospitalizations), family history, social history, results of physical examination, and current medical condition

What does social history allow for?

Social history allows for providers to see conflicts between habits and treatment and what to add/get rid of for patient care

What is in the reports section of medical documentation?

Contains any reports or findings from laboratory or test work.

What should medical documents be?

Medical documents should be accurate, complete, concise, legible, and well-organized from most recent to least recent.

What is the one rule of all organization methods?

Most recent information appears first in its section

What should a patient’s medical record contain?

A copy of all correspondence relating to patient care, signed copy of the HIPAA privacy notice and end-of-life notices is included in this

When should charting/documentation be done?

Immediately following a procedure, never before

What are benefits of the charting by exception method?

Decreased charting time, greater emphasis and easier retrieval on significant data, timely bedside charting, standardized assessment, greater interdisciplinary communication, better track of important patient responses, lower costs

What abbreviations and acronyms should be used?

They should only be used if they will be understood and are from an accepted abbreviations list.

What do a patient’s vital signs include?

Vital signs, respiration rate,blood pressure, pulse, and temperature

What do medical documents help defend in court?

Malpractice and improper care cases

What are the six c’s of charting?

Client’s words, clarity, completeness, conciseness, chronological order, confidentiality

What does the s of SOAP consist of?

Statements from patient describing condition and symptoms experienced

What does the o of SOAP consist of?

Data that provider can measure, see, feel, or smell, test results, vital signs

What does the a of SOAP consist of?

Patient’s diagnosis and possible disorders to be ruled out

What does the p of SOAP consist of?

Description of what should be done, diagnostic tests, treatments, follow-up

What came first, POMR or SOAP?

SOAP originated from POMR fifty years ago by Lawrence Weed

What do you do if your patient cannot describe their pain?

GIve them time to try, and then list off a bunch of words they could possibly use as listing them off one by one could make them believe they have that pain.

What is the PQRST pain assessment?

P= **Provocation/Palliation**

Q= **Quality/Quantity]**

R= **Region/Radiation**

S= **Severity Scale**

T= Timing

What are the New Jersey standards for keeping medical documentation for private doctors?

Private Doctors need to keep medical records for 7 years from the date of the most recent entry

What are the New Jersey standards for keeping medical documentation for hospitals?

* Adult patients 10 years following the most recent discharge. 
* Minor patients 10 years following the most recent discharge or until the patient is 23 years of age, whichever is longer. 
* Discharge summary sheets (all) 20 years after discharge. 

\+

Currently happening

\-

was happening

Acute

quick

emesis

vomited

ambulated=

walked

Dtap

whooping cough

Tdap

Tetanus(most)

Abdominal chamber sections

RU(right upper), RL(right lower), LU(left upper), LL(left lower)

Auscultate

listen

Feel

palpate

See

observe/assessment

AAO x 4

Awake, Alert, Oriented x 4(who,where,event, time)

Medical Biller

Collect payment for services provided by health care physicians, accept copayments, submit claims to insurance companies, and invoice patients

Medical transcriptionist

Listen to recordings made by physicians and other health care professionals and transcribe them into medical reports, letters, and other documents.

Health information technician

Work with patient information, responsible for assembling and organizing medical charts and making sure all documentation is properly records, entered in the computer, and added to the patient’s file.

ICD-10(tenth edition)

A manual of diseases known as the ICD that gives information on symptoms, diagnoses, and treatment.