Intro to Medical Records

Medical Records Provide :

• Means of documenting patient (pt) care

• The main form of communication between healthcare providers

• Advantageous as a legal document if a patient sues a medical professional or vice versa.

• If not documented it never occurred

What is included in a medical record?

Medical records contain medical and non-medical information.

• Progress Note

• Discharge Summary

• LabStudies/ Pathology

• History and Physical (H&P) - Initiated on 1st visit

• Operative Report - Narrative about the surgery written by the surgeon who performed the surgery.

• Emergency Department (ED) Reports

• Consultation (specialist)

• Diagnostic Studies (imaging)

• Personal Information/Insurance

Progress Note (Chart Note): -

Created with every examination or face-to-face conversation

S.O.A.P

• Subjective: what the patient tells you

• Objective: measurements, vitals, lab values, previous prescriptions, etc

• Assessment: Diagnoses

• Plan: referrals, treatments, etc.

History and Physical (H&P) - Baseline

Comprehensive in nature, initiated on the first visit, provides information about the patient's history and physical state, social history (do they drink, their profession, etc), and Chief Complaint (CC)(what they are here for this visit).

Consultation

When further evaluation is needed by a specialist. Will be documented in a patient chart in a letter format.