chapter18

What is medical documentation?

Notes and documents added to the medical record by health care professionals.

What is a medical record?

A collection of all documents that form a complete chronological health history of a patient.

What is charting?

The process of recording observations and information about patients.

What types of information are included in medical records?

Patient statistics, care information, test results, diagnoses, treatments, and prescribed medications.

Why is complete and accurate medical documentation critical?

It supports consistent patient care and coordination among health professionals.

How does good medical documentation improve coordination of care?

It provides necessary information for health care providers to make informed decisions.

What legal protections do medical records provide?

They serve as legal documents admissible in court, proving what has occurred with the patient.

What can poor medical documentation lead to?

Misinformed professionals, increased legal risks, unnecessary tests, and poor patient care.

What are some characteristics of good medical documentation?

Complete, concise, properly identified, legible, and clearly expressed.

What should each entry in a medical record include?

The date and signature of the appropriate health care personnel.

Why is it important for medical records to be legible?

Illegible notes can lead to miscommunication and negative legal outcomes.

What should be avoided in medical documentation?

Recording guesses, opinions, and judgmental remarks about patients.

What is the significance of using correct spelling and terminology in medical records?

It prevents misinterpretation and reflects professionalism.

What does it mean for documentation to be concise?

It should be clear and to the point, avoiding unnecessary verbosity.

What is the role of abbreviations in medical documentation?

They should only be used if approved to avoid misunderstandings.

What is the purpose of recording vital statistics in medical records?

To provide accurate data on deaths, disease outbreaks, and other health statistics.

What should be done if a finding is abnormal in a medical record?

It should be documented along with the action taken and follow-up assessment.

How can proper documentation improve cost control in healthcare?

By preventing unnecessary procedures and ensuring appropriate interventions.

What is the impact of documentation on insurance claims?

Proper documentation decreases denials from insurance companies.

What is the importance of confidentiality in medical communication?

It protects patient privacy and complies with regulations like HIPAA.

What should be done immediately after charting observations?

Charting should be completed as soon as possible to avoid omissions.

What is an example of a concise statement in medical documentation?

"I feel a sharp pain in my left leg every time I try to walk."

What does it mean for documentation to not duplicate findings?

Avoid repeating information already recorded unless it is abnormal.

What is the consequence of poor recordkeeping in healthcare?

It can lead to longer hospital stays and poor patient care.

What is the significance of the phrase 'If it isn't documented, it isn't done'?

It emphasizes the necessity of written records in healthcare.

What role does medical documentation play in malpractice lawsuits?

It provides proof of care and actions taken, crucial for legal defense.

What are some tasks health care professionals may perform related to charting?

Recording demographic information, vital signs, and procedures performed.

What is the purpose of the Joint Commission in healthcare documentation?

To accredit healthcare organizations that meet quality and safety performance standards.

Why should abbreviations be used cautiously in medical documentation?

Abbreviations can have multiple meanings, leading to misunderstandings.

What is the importance of showing time and date in medical entries?

Accurate and chronological charting reflects the patient's condition over time.

What should be done if an entry is recorded late?

A 'late entry' notation should be made, including the correct date and time.

What is the consequence of signing for someone else in medical documentation?

It is a serious offense and can lead to legal repercussions.

What should be avoided in medical charting to maintain integrity?

Leaving empty lines or spaces above entries should be avoided.

What is the proper way to correct an error in medical documentation?

Draw a line through the error, write the correct information, and date and initial the correction.

What should never be used to correct written medical documentation?

Correction fluid, erasers, or correction tape should never be used.

What is the purpose of the 'M.E.' notation in medical records?

'M.E.' stands for 'mistaken entry' and is used to note an error.

How should electronic errors be corrected in medical documentation?

Errors cannot be deleted; a special field must be used to note the error.

What are the two common formats for organizing medical records?

Continuous chronological record format and source-oriented approach.

What is included in the history and physical (H&P) section of a medical record?

Reports on initial findings, medical history, familial history, social history, and suspected diagnosis.

What does the social history in a medical record include?

Use of tobacco, alcohol, and illegal drugs.

What is the advantage of a source-oriented charting format?

It makes it easy to find specific information related to a specialty.

What is a disadvantage of the source-oriented charting format?

It can make it difficult to see the overall view of the patient.

What should be done after a health care professional finishes charting?

They should sign the entry to indicate responsibility for the information.

What is the role of transcription services in medical documentation?

They transcribe dictated findings from providers into the medical chart.

What happens if charting is not done in a timely manner?

It can lead to confusion and inaccurate records by other health care professionals.

What is the significance of maintaining the integrity of the medical record?

It ensures that the record is a reliable legal document.

What should be included in a late entry in charting?

The current date, time, and the date and time of the original entry.

What is the consequence of charting medications before they are administered?

It can lead to patients not receiving the medications they need.

What is the recommended ink color for medical documentation?

Black or blue ink, as specified by the facility.

What should be done if an entry is made after a procedure has occurred?

Chart only after the event has occurred, never in advance.

What is the purpose of documenting a patient's past medical problems?

To assess potential health risks and inform treatment plans.

What does the term 'consultation' refer to in medical records?

When a primary provider requests another provider to evaluate a specific problem.

What is the importance of following facility policies in medical documentation?

To maintain compliance and ensure accurate and legal records.

What is the purpose of a medical history form?

To collect the patient's personal details, family history, and past medical history.

What types of information are included in a patient's past history on the medical history form?

Yes or no questions regarding skin, eyes, ears, nose, throat, cardiopulmonary, gastrointestinal, glands, genitourinary, and neuromuscular.

What are provider's orders in a medical chart?

A written record of all orders for medications and treatments prescribed for the patient.

What do diagnostic tests in a medical chart include?

Reports that include findings from laboratory tests, X-rays, and electrocardiograms (ECGs).

What is the purpose of progress notes in a medical chart?

To provide a written record of every aspect of a patient's relationship with health care providers.

What does the acronym SOAP stand for in medical charting?

Subjective, Objective, Assessment, Plan.

What type of information is recorded in the Subjective section of SOAP?

Information sensed and reported by the patient, including symptoms and the chief complaint.

What type of information is included in the Objective section of SOAP?

Observations and measurements made by health care personnel, such as vital signs and lab test results.

What does the Assessment section of SOAP represent?

The health care professional's impression of what is wrong with the patient based on signs and symptoms.

What is documented in the Plan section of SOAP?

Procedures, treatments, and patient instructions that make up the patient care.

What is a problem-oriented medical record?

A record organized around the patient's health problems, with a list of problems and related plans of care.

What is the advantage of problem-oriented charting?

It allows all health care professionals to focus their charting on the same problems.

What is a disadvantage of problem-oriented charting?

It can lead to difficulties in keeping the problem list up to date and may cause patients to be seen more as problems than individuals.

What is the significance of verifying patient names on documents?

To ensure that the correct form is in the chart and to prevent misunderstandings and errors.

What does 'thinning a chart' refer to?

Starting a new file for a patient when the existing file becomes too thick, while noting that an older file exists.

What should be included in progress notes?

Chronological statements about a patient's care, including observations, treatments performed, and patient responses.

Why is careful documentation important for health care professionals?

It is critical for recording, communicating, and coordinating patient care.

What is the role of a medical assistant in maintaining patient records?

To ensure the accuracy and neatness of patient records, which is vital for legal and clinical purposes.

What can happen if patient records are poorly maintained?

It can lead to legal issues and negatively impact patient care.

What types of forms may be included in a patient's medical chart?

Admission forms, surgical consents, medication records, diagnostic test results, and progress notes.

What is the purpose of flow sheets in medical documentation?

To monitor specific health metrics, such as blood sugar levels or wound measurements.

What is the importance of using quotation marks in the Subjective section?

To accurately record the patient's own words regarding their symptoms.

What should health care professionals do before charting?

Organize their thoughts and reflect on their observations and the patient's responses.

What is the significance of a medication record in a medical chart?

It includes all medications administered by health care professionals at the facility.

What is the function of graphics in a medical chart?

To graphically represent vital signs such as blood pressure, temperature, pulse, and respiratory rate.

What is the purpose of the Problem List in patient care?

To track patient problems, their identification, and resolution dates.

What is the goal for a patient with angina related to coronary artery disease?

Prior to discharge, the patient will be able to ambulate 300 feet with no angina.

What does the 'S' in the SOAPIE charting format stand for?

Subjective: The patient's reported symptoms.

What does the 'O' in the SOAPIE charting format represent?

Objective: Observable and measurable data.

What does the 'A' in the SOAPIE format indicate?

Assessment: The healthcare professional's interpretation of the subjective and objective data.

In SOAPIE, what does 'P' stand for?

Plan: The planned tests and treatments.

What does the 'I' in SOAPIE represent?

Interventions: The actions taken to address the patient's issues.

What does the 'E' in SOAPIE stand for?

Evaluation: The assessment of the effectiveness of the interventions.

What is narrative charting?

A method that includes detailed written notes on all aspects of patient care.

What is a major advantage of narrative charting?

It allows healthcare professionals to use their own approach to describe patient care.

What is a disadvantage of narrative charting?

It can be time-consuming and result in extensive records that are hard to read.

What is Charting by Exception (CBE)?

An abbreviated format that only notes abnormal findings.

What is a key advantage of Charting by Exception?

It saves time and highlights problems easily.

What is a disadvantage of Charting by Exception?

It may overlook preventative or wellness aspects of care.

What are Electronic Medical Records (EMRs)?

Digital versions of paper medical records.

What do Electronic Health Records (EHRs) include?

Information from all healthcare professionals involved in a patient's care.

What federal initiative promoted the use of computerized records in healthcare?

The 2009 economic stimulus package for providers accepting Medicare and Medicaid.

What are the three options for facilities when deciding to computerize charting?

1. Use a standard program. 2. Modify a program. 3. Develop a custom program.

Which option is most commonly chosen by facilities for computerized charting?

Option 2: Purchase a program and modify it to meet specific needs.

What is a potential future trend in computerized record systems?

Vendors are learning to create systems that better meet the specific needs of facilities.

What is the significance of the 'alert and oriented x 3' note?

It indicates the patient is aware of person, place, and time.

What does a note indicating 'no complaints of pain' suggest?

The patient is currently not experiencing any discomfort.