Purpose of Healthcare Records

importance of person-first language

it’s a way to emphasize the person and view the disorder, disease, conditon, or disability as only one part of the whole person

turn the phrase into person first language - disabled student

student with a learning disability

effect of person-first language

it frames the condiiton as only one aspect of the person, rather than defining who they are

what to call someone in long term care

resident

patient def

passive reciepients of care, not an active participant

client def

active participant who seeks the services of a skilled professional; preferred within the OT profession

purpose of health records for clinical care and continuity

provide a complete hisotry of patient’s health status, diagnosis, treatments, medications, test results, progress notes, care/discharge plans etc.

purpose of health records for communication

act as a communication tool among interdisciplinary providers for care coordination

purpose of health records as legal documents

serve as a legal record of the care provided, important for auditing and disputing claims

purpose of health care records as quality assurance and improvement

allows helathcare systems to continuously monitor patient safety, quality, and outcomes

What are the components of the Medical Record?

1. patient identification

2. referral information

3. medical hisotry

4. physical exam

5. occupational profil

6. radiology/diagnostic imaging

7. lab reports

8. pathology report

9. treatment reports

10. physician consult notes

11. progress notes

12. social work notes

13. discharge summary

14. follow-up reports

15. death certificate

3 parts of History of Present Illness

1. History (Hx)- documents subjective information, client’s chief complaint (CC) or c/o) complaints of)

2. Details of the complaint documented in the present illness (PI) or hisotyr of present illness (HPI)

3. Duration, severity, symptoms, (Sx, SXS)

what does past medical history include (PMH) (3)

1. past medical illnesses

2. usual childhood diseases (UCHD)

3. surgical operations (s/p), injuries, physical deficits, medications, and allergies

2 categorizations for allergies

1. no known allergies (NKA)

2. No known drug allergies (NKDA)

What is a Review of Symptoms (ROS) or Systems Review (SR)

head to toe review of the function of all body systems, it evaluates symptoms not previously mentioned

What does ROS stand for

Review of Symptoms

What does SR stand for

systems review

what does IMP stand for

impression

What is an IMP

Identification of a disease

4 different parts of an IMP

1. Diagnosis

2. Assessment

3. Differential Diagnosis

4. Rule out other additional procedures

what does A stand for

assessment

what is requried to make an assessment

an evaluation of a subjective and objective data results

what is a differential diagnosis

when one or more dianoses are considered (in question)

what does R/O stand for

Rule out

What does PE stand for

physical examination

What does Px stand for

Physical

What is a Px

objective information- facts observed or detected by testing

what is objective evidence of a disease

vital signs

Different vital signs (6)

1. blood pressure

2. pulse

3. respirations

4. temperature

5. height

6. weight

HEENT stands for

Head, eyes, ears, nose, and throat

what does PERRLA stand for

pupils, equal, round, and reactive to light and accomodating

what does NAD stand for

no acute distress

what does WNL stand for

within normal limits

what does WF stand for

withing functional limits

what does an impression identify

a disease or condition

what does Dx stand for

Diagnosis

What does P stand for

plan

what does the plan include

Recommendations or disposition

1. outline of treatment/intervention

2. meidcation

3. diagnostic tests

4. therapies

what does CC stand for

chief complaints

what does c/o stand for

complaints of

what does Dx stand for

Diagnosis

What does FH stand for

Family History

what does HEENT stand for

Head, eyes, ears, nose, and throat

what does H&P stand for

history and physical

what does HPI or PI stand for

History of present illness/present illness

what does Hx stand for

History

what does IMP stand for

impression

what does L&W stand for

living and well

what does NAD stand for

no acute distress

what does NKA, NKDA stand for

no known allergies, no known drug allergies

what does WFL mean

within functional limits