Medical Records

components of medical record

patient identification, medical history, diagnosis, treatment plans, progress notes, test results, correspondence

source oriented

traditional form of charting; easy to locate; scattered through record; ex. admissions sheet

charting by exception

documents only items, issues, problems that are outside the norm; less time consuming; limits documentation

problem oriented record

focuses on problems patients are having; must be completed in a timely manner. ex SOAP

what should be documented

informed consent, refusal of care, discharge instructions, follow ups, patient complaints, telephone calls, missed appointments, medication

SOAPIER

subjective, objective, assessment, plan, interventions, evaluation, revision

SBAR

situation, background, assessment, recommendation

included in a referral request

patient's name and DOB, insurance number, ICD-10 code, referring provider info, referral provider info, CPT-4 codes