Documentation, SAMPLE Survery, Patient Assessment and Medical Records

S

Signs and Symptoms

OPQRST

onset, provocation, quality, radiation, severity, time

Signs

Objective physical evidence

Symptoms

Subjective feelings described by patient

A

Allergies

M

Medications

P

Pertinent Past History

pertinent past history

underlying reason for issue(s)

AVPU

Alert, Verbal, Pain and Unresponsive. Used to determine responsiveness

L

Last oral intake

E

Events leading to injury

Medical Documents

contain information about patient’s medical history

basic identifying information in health records

name, s*x, age, social security, contact information

medical history

ongoing document recording patient treatments and conditions

chief complaint (CC)

why patient is being seen

history of present illness

account of patient’s current experiences

review of systems (ROS)

checklist of symptoms of common diseases not mentioned in patient’s interview

past medical history (PMH)

confirmation of past illnesses and symptoms that could affect patient’s current

social history (SH)

drug, alcohol, tobacco use, occupation, relationship status

family history (FH)

illnesses tracked back to other family members

guidelines for collecting and reporting medical history

• be sensitive and aware of pateint’s mood

• review patient records before talking with patient

• ask patient to repeat something if it was unclear

• include date, time and patient’s contacts

• have patient sign or initial info

American Recovery and Reinvestment ACt

gives healthcare industry money to allocate between different areas in personal health information

Health Information Technology for Economic and Clinical Health (HITECH)

strengthens privacy requirements and broadens patient rights for accessing PHI

Health Informatics Technology

Field revolving around medical documents

EMR

Electrical Medical Record. Includes diagnoses, medical history, medications, immunization dates and allergies

EHR

Electrical Health Records. contains vital signs, progress notes, lab data, imaging reports, insurance information, and demographic data

Benefits of EHRs/EMRs

easier to access and allows for real time updates

Drawbacks to EHRs/EMRs

data loss and potential violations of privacy

lab results

tests performed on substances in the body

hospitalizations

when patient is admitted to hospital

immunization records

history of vaccines recieved

insurance information

insurance company and details of coverage

HIPAA

ensures patient privacy and protection of the rights of caregivers. gives patient’s right to access medical record

billing and payment records

dates and amounts charged and paid

advanced directive (AD)/living will

patient’s wishes regarding medical treatment if patient can’t communicate

how can health record data be collected?

mobile apps, medical wearable devices, patient monitoring equipment, telemedicine

patient forms

info that goes to patient’s medical record. filled by either patient or provider

what could a patient form data include?

personal information, chief complaint, current medical conditions, medications, allergies, medical history

prescription records

contains medication history including prescribed medications, dosages, durations

immunization records

contains info about type of vaccine received, date of administration, adverse reactions

SOAP notes

Subjective, Objective, Assessment, Plan. Allow healthcare professionals to write and compile medical summaries

narrative notes

written in a chronological order to tell the patient’s story. show change overtime

Screening Reports

reports for screening tests for disease or disorder detection. genetic tests, Pap smear, mammogram, colonoscopy, DEXA

Pathology reports

summarize analysis of a removed specimen of tissue, blood or organ. tumor biopsy, blood sample, mole removal

diagnostic reports

results of any test used to aid in diagnosing patient condition. blood tests, urine tests and pathogen cultures

radiology reports

results of imaging tests. x rays, ct scans, MRIs

Surgical reports

info about patient’s surgery and surgical history. this includes type of surgery performed, date of surgery, complications or adverse events

progress reports

updated evaluation of patient

discharge reports

final patient evaluation releasing patient to their regular lifestyle