(23) CCMA The Medical Record, Documentation, and Filing

Purpose of medical records

Document patient care and history.

HITECH Act

Promotes use of electronic health records.

Interoperability

Ability to share information across systems.

Confidentiality importance

Protects patient privacy.

Subjective vs Objective

Subjective is patient-reported, objective is observed.

POMR vs SOMR

Problem-based vs source-based organization.

Correcting records

Single line, initial, date, no erasing.

Filing systems

Alphabetical, numeric, alphanumeric.

Indexing rules

Standard method for organizing records.

Audit

Review of records.

Chronologic documentation

Entries in time order.

Electronic health record

Digital patient record.

Electronic medical record

Digital version of chart.

Ethnicity

Cultural background.

History physical impression plan

Structured documentation format.

Indexing

Organizing records.

Progress notes

Ongoing patient updates.

Property right

Ownership of records.

Purge

Removing old records.

Privacy officer

Ensures compliance.

SOAP

Documentation format.

Tickler file

Reminder system.