Medical Records and Documentation
The Chart- contains important medical information about patient's past and current medical history
General Information
All Medical Records should contain the following:
- Address and phone number
- Occupation
- Medical History
- Current complaint of condition
- Healthcare needs
- Medical treatment plan or services received
- Radiology and Laboratory Reports
- Response to care
Contents of Medical Records
- Patient Registration Form- demographic information- DOB, SSN, Name, Address, phone number, Insurance information
- Medical History- Past medical history (surgeries, illnesses, allergies, medications) Family History, Social and Occupational History, Reason for visits (HPI, CC). Progress Notes
- Physical Exam Form- ROS- inventory of the body obtained by questions. Physical Exam, vital signs,
- Lab/ Radiology Tests- Any results including EKG or other diagnostic tests
- Documents from other sources- another physician/ hospital
- Diagnosis/ Treatment Plan- includes treatment options and the final treatment plan, instructions to patient and any medications prescribed
- Operative Reports/Follow Up Visits Telephone Calls- log of telephone contacts
- Hospital Discharge Summary- summarizes reason for hospitalization, tests, procedures, performed, medication discharge plan, and patient outcome
- Consent Forms- informed consent, HIPAA,
- Correspondence with or about the patient- letters, labs, other providers, Medical Necessity (so insurance will pay) etc.
- Information received via fax or email
Documentation-process of recording information in the medical record
Noncompliant- patient does not follow the medical advice he/she receives. Document patient understanding of advice and follow up with documentation if needed when patient does not follow medical instructions.
Documenting
subjective information that should be described using the patient's own words. Put the statement in quotation marks " I have had a headache for three days and it won't let up"
\n Doctor usually documents: How the patient was prepared for the procedure, the position used, the last time patient ate/drank, process of the procedure, how the patient tolerated the procedure,
MA will document:
- Pre and post procedure information/ instructions
- Vital Signs
Types of Medical Records
SOMR- SOURCE ORIENTED MEDICAL RECORD
- Information is arranged according to who supplied the data- patient, provider, specialist, lab, hospital
POMR- PROBLEM ORIENTED MEDICAL RECORD
- Easier to track patient progress
- Database- past medical history- info gained from patient interview
- Problem list- conditions listed separately with date of onset- Signs/ Symptoms
- Educational, Diagnostic and Treatment Plan- each problem above should have detailed summary in the record
- Progress Notes- documentation entered for each problem
Types of Progress Notes
SOAP
S: Subjective data coming from the patient- Symptoms and patient comments
O: Objective data coming from provider, exam and test results, signs that provider documents
A: Assessment- diagnosis or impression of the patient's problem
P: Plan of action- treatment, medications, tests, consultations, education and follow up
CHEDDAR
C: Chief Complaint, presenting problems, subjective Statements
H: History, HPI
E: Exam and review of systems
D: Details of problem and complaints
D: Drugs and Dosage, current medications and frequency
A: Assessment- diagnostic process and diagnosis made
R. Return visit information or referral if appropriate
Six "Cs" of Charting
Client Words- document exactly what they tell you
Clarity- Precise descriptions and accepted medical terminology
Completeness- Fill out completely all the forms used in the patient record. Make sure information is readily understandable
Conciseness- Abbreviations and appropriate medical terminology save time and space when recording.
Chronological Order- Dated
Confidentiality- Never discuss, forward, or share with anyone unless you have WRITTEN permission to do so
Appearance, Timeliness and Accuracy of Records
Neat and legible- use a good pen (no smudges). Close letters and numbers when writing to avoid confusion (o could look like u, a 0 could look like a 6, a 1 could look like a 7, etc.)
Transcription- spoken word transferred into written form (provider may record and a transcriptionist types it out)
Keep UP-TO-DATE. Document timely and enter a late entry if needed
Never guess or assume, Double check accuracy and that latest information is in the chart
Professional tone and attitude in writing. Never record personal comments, judgments, opinions (Patient called and was totally acting a fool)
Correcting and Updating Records
NO WHITE OUT!
Don't throw away an error, erase or otherwise "make it disappear"
Identify the mistake, correct it immediately.
Draw a SINGLE LINE through the error and initial after. Do not scribble or try to hide anything. The error must remain legible.
Make a notation correcting the error, date and initial the new entry.
Sometimes having a witness also initial the entry can help (especially if the error seems quite significant)