Medical Records

Questionnaire

Asks about a patient’s medical history, insurance coverage, and other important facts

Sexual Orientation and Gender Identity (SOGI)

Sexual Orientation - person’s pattern of emotional, romantic, and sexual attraction to people of a particular gender

Gender Identity - a person's inner sense of where that person belongs on a continuum of masculine to androgynous to feminine traits

Registration/Admission

form used to record info: patient’s name, address, and insurance information

Consent for Treatment

statement indicating the patient has been informed of the treatment plan, including possible side effects and negative outcomes; the patient signs indicating agreement to the treatment and awareness of all possible consequences resulting from the treatment

Doctrine of Informed Consent

each individual has the right to determine what should be done to their own body in connection with medical treatment. When a patient is injured and unaware of the risks, the physician is negligent, even if the patient consented to treatment

Informed Consent

Providing the patient information concerning the nature and risks for what’s recommended, as well as for the alternative treatment options

*Informed consent is NOT possible if the patient is incapacitated and unable to give an informed consent in an emergency medical treatment

Informed Consent (Legal Requirements)

*Varies state - state

• MUST be obtained by the provider who will carry out of physically supervise the procedure (some states allow nurses to get the actual consent signed)

• Is free of coercion from staff or family memebrs

• Is given by a competent patient — if the patient is not competent, a legal guardian or next of kin must be informed and sign

• MUST be gained for all possible procedures

• Is based on information thorough enough that, as some states dictate, a reasonable person could make an informed decision

• Should be discussed in a non-rushed format so that patients have time to ask questions and receive answers

Forms of Informed Consent

Expressed: Given by direct words ; orally or in writing

Implied: Inferred from patient conduct ; Presumed in emergencies

NOT required HIPAA documented consent

• Disclosing communicable disease to public health authorities

• Reporting suspected abuse, neglect or domestic violence to law enforcement (domestic, elder or child)

• Participating in audits and inspections as required by health oversight agencies

• Reporting injuries from criminal conduct

• Providing coroners, medical examiners and funeral directors with necessary information

• Using information for research purposes once stringent requirements are met

• Reporting to prevent serious threat to safety

• Disclosing information to law enforcement

• Processing workers’ compensation claims

Patient History

Critical questions regarding the patient’s health history

Plan of Treatment

The provider records the orders given to the patient regarding treatment ; establish a plan for recovery and provides the patient with clear instructions to follow

Progress Report

Chart changes of all kinds in their patients’ conditions; worsening and improvements in conditions

Medical Records

• Identify the patient

• Record results of tests and treatments

• Justify diagnoses and treatments

• Offer information to all providers involved in the patient’s care

• Detail the patient’s previous care for future providers

• Maintain a record of services for billing third-party payers

• Provide the healthcare facility w a legal business record

• Provide tools for evaluating patient care

• Provide documentation for study and research

• Give healthcare providers data for planning delivery of services and marketing

Documentation

Written record of the services that the priovider performs

A physician’s documentation substantiates the charges on the medical bill

Database for reimbursement decisions for insurance payments

If its NOT documented, it didnt happen

Authentication

Author to an entry in a medical record signed the record. Only the author of the entry can authenticate it

Dictation

Date & time entry was written, patient’s chief complaint, the problem and what the physician did during the service

Chief Complaint

Concise statement that described why a patient is seeking treatment

SOAP (chart note)

SOAP - Subjective, Objective, Assessment, Plan

S - the patient’s pov or complaint

O - refers to the clinical findings

A - the examiner’s diagnosis based on the clinical findings

P - refers to the provider’s order

Documentation Formats

CC - Chief complaint (Subjective)

Px - physical examination (Objective)

Dx - diagnosis (Assessment)

Rx - Prescription (Plan)

Good Documenting Practices

• Legible

• Understandable

• Timely

• Error Free

• Reproductible

Addendum

addition of information that was left out of the original entry

Amendment

Add clarification or missing details from an intitial documentation; clarify original notes; can NOT change the general information in the record

Late entries

Documentation added to the patient record after the care was provided

Correcting a Written Medical Record

1. Entry crossed out w a single line

2. correction should be noted (reason for error)

3. Initials of the person making the correction

4. Date and time the error was discovered

Audit Trail

ability to track corrections or changes to the entry once entered or authenticated

Electronic medical record (EMR)

entire systems based on document imaging, electronic document management systems as a whole

*electronic health record

Electronic Health Record (EHR)

longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting

ex.) patient: demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports

Discrete data / quantifiable information

information that consists of separate and limited values

ex.) distinct points on a numeric scale, distinct intervals between any two values

Information that can be determined, indicated or expressed (any data with numeric value)

Health information exchange (HIE)

Allows healthcare professionals and patients to appropriately access and securely share a patient's medical information electronically

Computer-based patient record (CPR)

8 core fucntions CPR should be capable of performing:

1. Health information and Data

2. Result management

3. Order management (prescription, medication, tests, other services

• Computerized provider order entry (CPOE) - any system which clinicains directly enter medication orders. test, and procudres elctronically with the rders transmited directly to the recipient

4. Decision support

5. Electronic communications and connectivity

6. Patient support

7. Administrative Processes (timeliness)

8. Reporting and Population Health Management