CLINPHARM Module 2

Patient's Medical Chart

Contains all significant clinical information which enables the physician to give effective continuing care to the patient

Patient demographics

[Patient Data Sheet] Contains the identification and sociological data

Final diagnosis

[Patient Data Sheet] Contains the major procedures done during current admission

Condition upon discharge

[Patient Data Sheet] Contains the Discharge summary and Autopsy findings

Consent Forms

[Parts of a Medical Chart] Permission or approval given by patient admission, testing, procedure and access to health related or personal information

"informed consent"

Healthcare provider must make sure that the patient is duly informed to make the decision for his/herself hence the term __________

History

[Parts of a Medical Chart] It contains history of present illness, Review of Systems, Past history, Personal/Social History, and Family History.

Past history

[Type of History] Birth, Nutritional and Developmental history

Past history

[Type of History] Immunization history, childhood illnesses

Past history

[Type of History] Operations/Treatments/Transfusions

Past history

[Type of History] Obstetric and Gynecological history (menstrual, marital and sexual history)

Past history

[Type of History] Adult medical history

Personal/Social History

[Type of History] Illegal Drug-use History

Personal/Social History

[Type of History] Smoking and drinking history

Physical Examination

[Parts of a Medical Chart] Includes all data gathered from direct examination of the patient; Conducted by the main service/primary care physician

Physical Examination

[Parts of a Medical Chart] Auscultation and palpation data are written in this part of the medical chart

Physician's order sheet

[Parts of a Medical Chart] Contains the Doctor's progress notes and Doctor's orders

Left

[Physician's order sheet] Doctor's Progress notes are located on the (left/right)

Right

[Physician's order sheet] Doctor's orders are located on the (left/right)

SOAP Format

[Physician's order sheet] Doctor's progress notes should be written in ______ Format

Subjective, Objective, Assessment, Plan

SOAP Format meaning

True

True or False: Doctor's orders must always compliment the assessments written in the progress notes

Consultation, Examination and Findings

[Parts of a Medical Chart] Used by other specialized services needed by the patient for a particular problem which cannot be resolved by the primary care service

Consultation, Examination and Findings

[Parts of a Medical Chart] Used for transfer or referral to other physicians

Graphic Chart

[Parts of a Medical Chart] Summary of all information collected by the nurse during the shift; All vital signs can be found here

bedside nurses

The graphic chart is accomplished by the ____________ every shift

4 hours

Vital signs are usually measured every _______ hours

Multidisciplinary Progress Notes

[Parts of a Medical Chart] Used by all other medical professionals except for physicians for documentation

Multidisciplinary Progress Notes

[Parts of a Medical Chart] Primary means of communication between members of the healthcare team

PDAAR Format

Multidisciplinary Progress Notes are documented using _______ format

Problem, Data, Assessment, Action, Response

PDAAR Format meaning

Fluid Input and Output Record/Fluid Balance Sheet

[Parts of a Medical Chart] Includes enteral and parenteral fluids taken by the patient; Urine output and bowel movement is also indicated here

Bedside nurse

The fluid balance sheet is accomplished by the _________ every shift

Tube and Oral

[Fluid Balance Sheet] Two types of Enteral Fluid intake

Foley Catheter

[Fluid Balance Sheet] Urine output usually observed in patients with Sphincter paralysis, acute kidney failure, or tumor in the urethra

Voiding Freely

[Fluid Balance Sheet] Urine output of normally urinating patients

A pleural effusion

It is the accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung.

Manual (thoracentesis)

[Fluid Balance Sheet] Manual draining of fluid in lungs; more painful; temporary relief

Pigtail drain

[Fluid Balance Sheet] Other way of draining fluid in lungs; more prone in infection; more invasive; consistent relief

Medication Administration Record (MAR)

[Parts of a Medical Chart] Accomplished by the bedside nurse simultaneously during time of medication administration; All doses must be accurately documented; If doses are missed, appropriate documentation must be made to state reason

dose, route, frequency and time of actual administration

Data written in MAR (4)

Waiver

[Parts of a Medical Chart] Is the relinquishment of some known right or privilege • Is also the term used for the actual form

Waiver

[Parts of a Medical Chart] DAMA (Discharge Against Medical Advice) and DNR/DNI (Do Not Resuscitate / Do Not Intubate) are under this part

Medical or Surgical Treatment Records

[Parts of a Medical Chart] Accomplished by the service concerned • All records of treatment whether for diagnostic or treatment purposes • Always written in detail

Laboratory Results

[Parts of a Medical Chart] Includes gross and microbiological findings

Laboratory Results

[Parts of a Medical Chart] Usually found at the end of the medical chart

Drug Therapy Monitoring and Assessment Form

[Parts of a Medical Chart] Used by clinical pharmacists to document and intervene with drug-food and drug-drug interactions that need dose-spacing and diet modification; Usually accomplished in duplicate, 1 to be filed and 1 to be forwarded to the concerned department

Patient Medication Administration Record

[Parts of a Medical Chart] A form issued to the patient or the patient's caregiver, whoever is responsible for the administration, storage and care of the medications given to the patient that does not come from the hospital pharmacy

Patient Medication Administration Record

[Parts of a Medical Chart] A form for the Patient's Own Medication

Multi-disciplinary Initial Assessment Database (MIAD)

[Parts of a Medical Chart] Tool used by the admitting bedside nurse, pharmacist, physician, and other HCP for the initial assessment of the patient

Violet:Pharmacist ; Green:Doctor ; Red:Nurse

MIAD is usually given in triplicate: _______ color for the pharmacist, ________ color for the doctor, and ________ color for the nurse

Patient Medication Profile

[Parts of a Medical Chart] Are record of information relative to the drug therapy of the patient

Patient Medication Profile

[Parts of a Medical Chart] The second page of the medical chart, found after the patient's data sheet