Medical Records & Technology
Medical documentation- all notes and documents that health care professionals add to the medical record
Medical records- collection of all documents that are filed together and form a chronological health history of a particular patient. Medical records are legal documents used in court.
Charting-recording observations and information about patients.
Purpose of Medical Documentation
Improve continuity of care
Provides health care providers with information they need to make decisions
Helps enforce staff accountability- accountable for what you write in medical records.
More accurate vital statistics (death, disease outbreaks)
Provides legal protection- records shows proof of what has taken place with the patient.
Ensures compliance with regulatory agencies
Improves cost control
Decreases denials from insurance companies
Provides data for investigation of errors and incidents
Contents of Medical Records
Medical History- includes personal, family, and social history. It should include the patient’s past medical problems, surgeries, allergies, and current problems
Progress Notes- chronological statements about a patients care. Each time a doctor see’s a patient, they will make note’s to update findings and plan the care of the patient.
Mistakes in Medical Records
Mistakes in the chart cannot be corrected in a way that covers up what was originally written. It can give the appearance that records have been altered. Never use correction tape (white out)
Draw a single line through the error. Must be able to read the original entry
Write in the correct information where there is space
Note the error as required by your facility
Electronic Health Record keeping
Electronic Medical Records (EMRs)- are digital versions of paper records.
Benefits: medical records are entered into a computerized system. This helps with reduction of errors, easier access, improved communication and efficiency
Challenges: The cost of purchasing a system is very expensive. Cyber security is another issue. Health records can be compromised during a cyber attack.
CT Scan: uses x-ray and computer to create detailed images of bones
MRI: uses large magnet, radio waves, and computer to created detailed
PET Scan: uses radioactive trace material to find diseased tissue to detect cancer
Ultrasongraphy: uses sound waves to create images of organs in your body
Electrical Impedance Technolgy: measures electrical currents to detect differnces in lung tissues
A= electrodes placed
B= EIT image where white indicates highest volume changes and dark blue is non ventilated regions of the lung
C=CT scan of someone with lung disease