Bài giảng Medical Assisting - Chapter 9: Maintaining Patient Records

Objectives 9-1 Explain the purpose of compiling patient medical records. 9-2 Describe the contents of patient record forms. 9-3 Describe how to create and maintain a patient record. 9-4 Identify and describe common approaches to documenting information in medical records.

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PowerPoint® to accompanyChapter 9 Second EditionRamutkowski  Booth  Pugh  Thompson  WhickerChapterCopyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.Medical Assisting Chapter 91Objectives9-1 Explain the purpose of compiling patient medical records.9-2 Describe the contents of patient record forms.9-3 Describe how to create and maintain a patient record.9-4 Identify and describe common approaches to documenting information in medical records. Maintaining Patient Records2Maintaining Patient Records9-5 Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records.9-6 Discuss tips for performing accurate transcription.9-7 Explain how to correct a medical record.9-8 Explain how to update a medical record.9-9 Identify when and how a medical record may be released.Objectives (cont.)3Maintaining Patient Records Importance of Patient RecordsPatient RecordsAlso known as chartscontaining: Past and present medical conditions Communications between health team members Name and address Insurance coverage Occupation Medical treatment plan Health-care needs Response to care Lab and radiology reportsThe chart is a legal document and can play a role in patient and staff education. It may also be used for quality control and research. 4Importance of Patient RecordsLegal Guidelines forPatient RecordsAs a general rule, if information is not documented, there is no proof it was ever done.Charts are used in court.Standards for RecordsComplete, accurate, and well-documented records can serve as convincing evidence that the doctor provided appropriate care.Incomplete, inaccurate, altered, or illegible records may imply poor standards.5Importance of Patient RecordsAdditional Uses of Patient RecordsPatient EducationQuality of TreatmentResearch6Contents of Patient Charts Standard Chart InformationPatient Registration FormDate of current visitDemographic data (age, date of birth, SS#, address, telephone number, marital status, etc.)Medical insurance informationEmergency contact personFamily medical historyList of medical problems7Past Medical HistoryIllnesses, surgeries, allergies, and current medicationsFamily medical historySocial history (use of drugs and alcohol, cigarette smoker, etc.)Occupational historyStatement of current patient complaint recorded in patient’s own wordsContents of Patient Charts Standard Chart Information (cont.)8Physical Examination ResultsContaining results of a general physical examResults of Laboratory and other TestsResults from lab tests performed on patientRecords from other Physicians or HospitalsInclude along with these records a copy of the patient consent authorizing release of informationContents of Patient Charts Standard Chart Information (cont.)9Doctor’s Diagnosis and Treatment PlanLists doctor’s diagnosis, medications prescribed, and overall treatment planOperative Reports, Follow-Up Visits, and Telephone CallsA continuous record of all care provided to the patient while under the doctor’s careAlso document calls made to and from the patientContents of Patient Charts Standard Chart Information (cont.)10Informed Consent FormsSigned consent forms show that the patient understands procedure, outcomes, and optionsPatient may still change his/her mind even after signing the consent formHospital Discharge Summary FormsIncludes information summarizing the patient’s hospitalizationFollow-up care after discharge is also included and the physician signs itContents of Patient Charts Standard Chart Information (cont.)11Correspondence With or About the PatientAll written correspondences regarding the patient should be includedBe sure to record date each was received on the actual formContents of Patient Charts Standard Chart Information (cont.)Information Received by FaxRequest an original copy, if not available make a photocopy of the fax.Dating and InitialingBe sure to date and place your initials on everything you place in the chart.12Initiating and Maintaining Patient RecordsInitial InterviewCompleting MedicalHistory FormsDocumenting Patient StatementsDocumenting TestResultsExamination Preparation & Vital Signs13Follow-Up DutiesTranscribe notes the doctor dictatesPost results of laboratory and examinations on summary sheetRecord all telephone communication with the clientRecord all medical or discharge instructions given to the clientInitiating and Maintaining Patient Records (cont.)14Apply Your KnowledgeThe medical assistant is obtaining the initial information from a patient. The patient informs the medical assistant that he/she has used intravenous drugs for the past 3 years. Which section of the chart will this be recorded in?15The medical assistant is obtaining the initial information from a patient. The patient informs the medical assistant that he/she has used intravenous drugs for the past 3 years. Which section of the chart will this be recorded in?This should be recorded in the past medical history section. More specifically under the social history section.Apply Your Knowledge -Answer16Client’s wordsBe sure to record the client’s exact words and do not rephrase his/her statements.larityBe precise and use accepted medical terminology when describing a patient’s condition.ompletenessFill out all forms in the patient record completely so others will understand your notations and entries.oncisenessBe as brief and to the point as possible. Use medical abbreviations to save time.hronological orderDate entries in the order they occur. This shows consistency with accurate documentation.onfidentialityAll information in patient record must be kept confidential to protect patient privacy.The Six Cs of Charting17Types of Medical RecordsSource-Oriented Medical RecordsProblem-Oriented Medical RecordsAlso called conventionalInformation is arranged according to who supplied the dataProblems and treatments are described on the same formPresents some difficulty with tracking progress of specific events(POMR) makes it easier to track specific illnessesConsists of:Data baseProblem listEducational, diagnostic, and treatment planProgress notes18SOAP DocumentationIncorporated with POMRUtilizes an orderly series of steps for dealing with any medical caseLists the following:Patient symptomsDiagnosisSuggested treatment19Subjective dataObjective dataAssessment PlanSubjective data is information the patient tells you about their symptoms.Objective data is data observed by the physician during the examination.Assessment is the impression of the patient’s problem that leads to a diagnosis.Plan of action consists of the treatment plan to correct the illness or problem.SOAP Documentation20Appearance, Timeliness, and Accuracy of RecordsNeatness & Legibility Use a good quality pen, black ink preferably. Make all writing legible. Never use white out in charts.Timeliness Record all findings as soon as they are available For late entries, record both original date and current date Record date and time of telephone calls and information discussed Check information carefully Double check accuracy of information Make sure most recent information is recorded Follow correct procedure for correcting errorsAccuracy21Professional Attitude and ToneMaintain a professional tone with your writing by:Recording patient comments in his/her own wordsNot recording your personal, subjective comments, judgments, opinions, or speculationsYou may call attention to a problem by attaching a note to the chart, but do not make such comments part of the chart.22Computer RecordsAdvantagesCan be accessed by more than one person at a timeCan be used in teleconferencesUseful for tickler filesSecurity ConcernsProtecting patient confidentiality is a major area of concern23Medical TranscriptionTranscription means transforming spoken words into written format.Dictated information is part of the medical record and must be kept confidential.Always date and initial each transcription page.Strive for ultimate accuracy and completeness of transcribed information.24Transcribing Recorded DictationOrganize your work areaAdjust transcription machine speed, tone, and volume as neededListen initially to entire recording before transcribing and document areas with difficult interpretationsListen to voice tones to determine correct punctuationNever try to guess at meaningsRe-read for accuracy and correct spelling and punctuationPhysicians should initial all transcribed doctor’s notesMedical Transcription (cont.)25Transcribing Direct DictationUse a writing pad and good pen that will not smearUse incomplete sentences and phrases to keep up with physicians paceUse abbreviations Ask for clarification immediately if something is unclearRead the dictation back to verify accuracyMedical Transcription (cont.)26Medical Transcription (cont.)Transcription AidsTranscriptionReference BooksMedicalTerminology BooksSecretarialBooksMedical ReferenceBooks27Label the following items as either (S) “subjective” or (O)“objective”.headachevomitingnauseachest painrespirations = 22 and non-laboredskin colorApply Your KnowledgeSorO28headachevomitingLabel the following items as either (S) “subjective” or (O)“objective”.chest painnausearespirations = 22 and non-laboredskin colorApply Your Knowledge -AnswerSheadacheOvomitingSnauseaSchest painOskin colorOrespirations = 22 and non-labored29Correcting and Updating Patient RecordsMedical records in legal terms are regarded as “due course,” meaning information is to be entered at the time of occurrence and not “conveniently” later.Use care with corrections because it is more difficult to explain a chart that has been altered after something was documented.Date and initial each addition to the medical record.30Release of RecordsProcedures for Releasing RecordsObtain a signed and newly dated release form authorizing the transfer of their information, and place in file.Make photocopies of original materials.Copy and send only documents covered in the release authorization.Special CasesDivorce and deathConfidentialityChildren age 18 in many states are to be treated as adults, and their parents do not have the right to see their records without authorization.31Apply Your KnowledgeThe medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another physician’s office. What would you do in this situation?32The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another fax number. What would you do in this situation?It is difficult to know the actual originator of a fax transmittal and to verify the signature. The safest solution would be not to release any information ever via fax.Apply Your Knowledge -Answer33End of ChapterEnd of Chapter34
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