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Chapter 19 Documentation & Medical Records
1.
Chapter 19 Documentation and
Medical Records © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
2.
Definitions • Medical documentation •
Medical record • Charting © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
3.
Purposes •
Contributes to good patient care • Provides legal protection • Helps ensure regulatory compliance • Improves cost control • Decreases denials from insurance companies © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
4.
Characteristics •
Complete with all requested information • Concise and factual • Properly identified • Legible • Correct spelling, terminology, punctuation, and grammar © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
5.
Characteristics • Clearly and
objectively expressed • Findings not duplicated • Approved abbreviations listed in facility’s policy used • Time and date given for all entries © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
6.
Characteristics • Signed by
proper person • Completed without leaving empty lines • Always charted after giving medication or performing procedure • Written with black or blue ink © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
7.
Making Corrections •
Draw single line through error • Write in correct information • Note error per facility policy • Date and initial correction • Correct immediately on computer • If discovered later, correct as above © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
8.
Question • Which of
the following is the recording of observations and information about patients? A. Charting B. Medical documentation C. Medical record © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
9.
Answer • A. Charting •
Charting – Recording of observations and information about patients • Medical documentation – Notes and documents that health care professionals add to medical record © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
10.
Answer • A. Charting •
Medical record – Collection of all documents filed together – Form complete chronological health history © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
11.
Medical Records • Organized
per facility policy • All health care workers responsible to maintain records per facility policy • Chronological or source-oriented © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
12.
Medical Records Content •
History and physical (H&P) • Physician’s orders • Diagnostic tests • Admissions • Surgical procedures © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
13.
Medical Records Content •
Graphics • Flow sheets • Medications record • Progress notes © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
14.
Medical Records Content •
Reminder: – Verify correct form in chart by ensuring patient’s name on each document • Each section chronological • Thinning a chart • Security of files © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
15.
Question • Which of
the following is a form used for specialty needs? A. Progress notes B. Graphics C. Flow sheets © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
16.
Answer • C. Flow
sheets • Flow sheets – Forms for specialty needs • Progress notes – Written chronological statements about patient’s care © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
17.
Answer • C. Flow
sheets • Graphics – Graphed forms for vital signs © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
18.
Progress Notes • Primary
tool – Recording, communicating, and coordinating care of patient • May include the following: – Observations – Treatments – Patient response © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
19.
Progress Notes: Formats •
Problem-oriented charting • Narrative charting • Charting by exception • Computerized © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
20.
Question • True or
False: – The chief complaint is the reason the patient is seeking medical care. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
21.
Answer • True • Chief
complaint – Reason patient seeks medical care © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
22.
EMRs • EMR systems
can go far beyond core charting – Coordination tools – Information – Safety tools – Scanned documents © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
23.
EMRs • Can only
communicate within same health care system © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
24.
Personal Health Record
(PHR) • Recommended for patients – Due to mobility of individuals – Frequent changes in providers – Frequent changes in insurance coverage • Assists patient to recall events and dates © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
25.
Personal Health Record
(PHR) • Prevents long delays in requesting information • Types of information to include – Demographics, such as name, address, contact information, etc – Emergency contacts – Name, specialty and contact information of previous providers – Insurance provider(s) © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
26.
Personal Health Record
(PHR) • Types of information to include – Medical directives, living will, organ donation, etc. – General medical information: height, weight, blood type, vital signs, etc. – Allergies and drug sensitivities – Current conditions and date of diagnosis – Previous surgeries, including date and results © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
27.
Personal Health Record
(PHR) • Types of information to include – Medications (prescription and nonprescription) – Immunizations and when last received – Any relevant health care visits, such as hospitalizations, other specialists or therapists – Pregnancies – Medical devices © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
28.
Personal Health Record
(PHR) • Types of information to include – Foreign travel – Family history information © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
29.
Question • True or
False: – EMRs have about the same capabilities and limitations as written charting. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
30.
Answer • False • EMR
systems can go far beyond core charting © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
31.
HIPAA • The Privacy
Rule • The Security Rule • Possible consequences of not following HIPAA regulations © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
32.
Question • Which of
the following is true about HIPAA? A. It protects the health care facilities B. It protects patients C. It protects the safety of health care professionals © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
33.
Answer • B. It
protects patients • HIPAA Privacy Rule gives patient specific rights related to medical records • HIPAA Security Rule requires administrative, physical, and technical safeguards be developed by facilities to protect patient information © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.