Medical Documentation

Key Terms, Abbreviations, Key Terms from Packet

Charting by Exception Format

Abbreviated documentation method that makes use of well-defined standards of practice and documents only significant or abnormal findings

Familial

Diseases that occur in a particular family

Military Time

24 hour time cycle that counts the hours of the day from 0000 to 2359

Narrative Format

Oldest and least structured medical documentation style

Problem-Oriented Medical Record (POMR)

Organizes information by the patient’s problem

SOAP Format

Has 4 parts that make the acronym SOAP

* Subjective Data
* Objective Data
* Assessment 
* Plan

Source-Oriented Medical Record (SOMR)

Groups information by type instead of by problem

TPR

Temperature, Pulse, Respiration ex./ 97.2/68/16

B/P

Blood Pressure

OD

Once Daily

BID

Twice Daily

TID

Three times daily

QID

Four times daily

IM

Intramuscular

SQ/SC

Subcutaneous

ID

Intradermal

PO

By mouth/ Take it orally

NPO

Nothing by Mouth

c/o

Complaint of

r/o

Rule out

s/p

Status post

C w/ a line

With

S w/ a line

Without

A w/ a line

Before

P w/ a line

After

d/c

Discharge or discontinue

q

every

q^6

every 6 hours

q^12

every 12 hours

Rx

Prescription

Tx

Treatment

dx

Diagnosis

NKDA

No Known Drug Allergies

LMP

Last Menstrual Period

SOB

Shortness of Breath

CXR

Chest X-Ray

AC

With Meals

HS

At night

CC

Milliliter

PHI

Information in a medical record that can be used to identify a personal anything related to the health status of a person, ex: name, social security number, email address, phone numbers

Informed Consent

Must be obtained when any procedure is being performed on a particular patient must understand the treatment offered and the possible outcomes and side effects of the treatment

Noncompliant

A term to describe a patient who does not follow the medical advice he or she recieves

Vital Signs

Temperature, Pulse, Blood Pressure and Respirations

Diagnosis

To determine the identity of a disease, or illness, by the medical advice he or she recieves

Patient Medical Records

Serves as both a communication tool and legal document, contains important patient information

HIPAA

A federal law whose goals include improving the continuity of health coverage, confidentiality, combating waste, fraud and abuse, and improving long term care services, among other things

Problem List

Each condition or diagnosis a patient has is listed separately and given its own number and is put on this document

Documentation

The process of recording information in the medical record

Past Medical History

Information such as previous surgeries, known allergies, current medications

Chief Complaint

The primary reason why the person is seeking healthcare

Demographic Information

Specific information required of a population such as address, phone number and DOB

Review of Systems

An inventory of the body, system by system, obtained by the healthcare provider through a series of questions

Subjective Data

Data that comes from the patient, internal conditions that are not necessarily apparent in a physical examination

Prognosis

Probable outcome of a disease or injury

Patient Education

The process by which health professionals impart information to patients by their caregivers that will alter their health behaviors or improve their health status

Physical Examination

The process of evaluating anatomic findings through the use of observation, palpation, percussion and auscultation

Patient Registration Form

The part of the record that contains demographic information and medical insurance information

Objective Data

Data that comes from the physicial, examinations, or test results that can be seen, felt or measured

Treatment Plan

May include medical care given to a patient for an illness or injury, instructions to the patient, and any medications prescribed

Hospital Discharge Summary

Includes Information that summarizes the reason why the person was in the hospital, procedures, surgeries, tests, medications and the outcome of the visit

SOAP Note

A type of documentation that uses subjective, objective, assessment and plan data

Progress Note

Describes the care given and the person’s response and progress

The 6 C’s of Charting

Clients words, clarity, completeness, conciseness, chronological order and confidentiality

Transcription

Transforming spoken notes into accurate written form

Release of Information

A form that must be signed by the patient in order to provide a copy of the person’s health record to either themselves, an insurance company, or another’s healthcare provider

Audit

To review and examine a group of patient records for completeness and accuracy

Emancipated Minor

Legal mechanism by which a child before attaining the age of majority is freed from control by their parents or guardians are freed from any and all responsibilities toward the child

SBAR Communication

A way of reporting patient information that involves situation, background, assessment, and recommendation

EHR

A patient record in a digital format

Cumulative

Collected over a period of time

Medication Administration Record

A record of the drugs or medications administered by the licensees nursing staff during a stay at a healthcare facility

Incident Report

A form that is completed when there is an error or accident in a healthcare facility

Addendum

An item of additional material is added to a health record to correct an error or to add omitted data

Confidential

Personal or private data, information, or knowledge that is not shared with others

Assessment

The notes, reports, and various types of information included in medical records

When medical records can be destroyed

Never. Even records for inactive patients must be kept in a safe place

Charting

The recording of Information about and observations of patients

SOAPIE

A format for charting in which the letters stand for subjective, objective, assessment, plan, interventions and evaluations

Medical Record

The collection of all documents that are filed together and form a complete health history of a particular patient

PIE

A format for charting in which the letters stand for problem, implementation, evaluation

Narrative Charting

A written statement about a patient’s care

What must be done before releasing medical records?

A consent authorizing their release must be signed by the patient

Corrections on Medical Documentation

These cannot be erased; instead draw a single line through them

Patient’s requests for medical records

Patients must request in writing and include their signature

Medical History

Data collected about a patient that includes health, personal, family and social information

Symptom

Indications of disease or dysfunction that can be observed or measured

Errors made when charting

Write these as close as possible to the incorrect information, write “error,” and date and initial

Flow Sheets

Preprinted forms, graphs, checklists, etc. for recording patient data

Golden Rule of Documentation

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

Why documentation can be used in court

Medical records are legal documents