1. PATIENT MEDICAL RECORDS
Chapter 7
PATIENT MEDICAL RECORDS

2. Patient Medical Records
Learning Objectives
List the components that make up medical records and discuss their importance to the practice, including their role as legal documents.
Describe the components of the SOAP format—the most common format used for recording medical information about patients.
Identify the three parts of the problem-oriented medical record (POMR) format.
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3. Patient Medical Records (cont’d)
Learning Objectives
Transcribe medical data dictated by a physician, while applying guidelines for punctuation, capitalization, and the use of standard medical abbreviations, numbers, and symbols.
Discuss the preservation of medical records.
Explain who actually owns a patient’s medical record.
List standards to be used for quality assurance in maintaining medical records.
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4. Key Terms Assessment Chief complaint (CC) Diagnosis (Dx)
Family history (FH)
History of present illness (HPI)
Impression
Objective
Past medical history (PMH)
Physical exam (PE)
Plan
Problem-oriented medical record (POMR)
Review of systems (ROS)
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5. Key Terms (cont’d) Rule out (R/O) SOAP Social history (SH) Subjective
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6. The Medical Record Patient’s chart or patient’s file
Information on all aspects of a patient’s health care
Vital to medical practice
Continuum of patient care
Financial and legal success of practice
Research purposes
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7. Legal Document
Medical record is the legal record of the medical practice
Used in litigation
Content and quality of medical record
Should be complete, legible, properly maintained
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8. Contents of a Medical Record
Chart notes
History and physical
Referral and consultation letters
Medical reports
Correspondence
Clinical forms
Medication list
Administrative data
Insurance and billing records
Release of information and assignment of benefits
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9. Why Maintain the Medical Record?
Source of information for carrying out patient care
Record of treatment
Record of quality of care
Tool for communication and continuity of care
Legal record for the practice
Record for reimbursement
Data for research purposes
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10. Maintaining the Medical Record
An entry is made for each contact with patient
Patient identifying information
Date of contact
Signature and title of provider
Keyed or written in ink
Compact
Entries organized by type and date
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11. Making Corrections Legal documents Cross out errors
Do not erase; do not use correction fluid
Cross out errors
Single line; entry should still be legible
Enter the word error next to the cross out
Write your initials and the date
Enter the correct information
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12. The SOAP Method Subjective findings Objective findings Assessment Plan
Patient’s chief complaint, history of present illness, past medical history, family history, social history, and review of symptoms
Objective findings
Results of physician’s exam of patient
Assessment
Also called diagnosis or impression
Plan
Also called treatment
Includes prescribed medications, patient instructions, recommendations for procedures or tests
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13. The POMR Method Problem-Oriented Medical Record Essential components
Database
Complete patient history and information from complete examination and tests
Initial plan
Details of the course of treatment
Problem list
Running list of patient’s problems
Recorded in SOAP format
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14. Transcribing Chart notes, other medical documents, and correspondence
Good listening techniques
Format guidelines
Office policy
Abbreviations used carefully
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15. Records Retention and Ownership
Time period determined by state law
Move records from active to inactive storage
Guidelines for transferring records should include when to transfer and storage medium to be used
Ownership
Physician’s property
Information in record belongs to patient
Patient controls the amount and type of information released
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16. Quality Assurance
Medical record is testament to quality of care given to patient
Helps to maintain high standard of care
Records should contain
Dated notes describing patient services
Notes recording every procedure performed
Accurate notations
Justification for hospitalization
Discharge summaries
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17. Quiz Match the abbreviation with the correct term. CC
ROS
POMR Dx
HPI PE
Problem-Oriented Medical Record
History of present illness
Chief complaint
Review of systems
Physical exam
Diagnosis
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18. Critical Thinking
What are some advantages of using the POMR format for medical records?
The physician can easily read what problems the patient has had, the frequency of the problems, and the treatments received. It saves the physician time by eliminating the need to read the entire chart to obtain necessary information.
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