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CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 15 The Health Record.

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Presentation on theme: "CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 15 The Health Record."— Presentation transcript:

1 CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 15 The Health Record

2 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes After completing Chapter 15, you will be able to: 15.1Explain the importance of accurate patient medical records. 15.2Explain the differences between SOMR and POMR records, and define SOAP and CHEDDAR. 15.3List the documents commonly used in the medical record. 15.4Explain the purpose of the initial patient interview, including the name of the document completed in that interview that becomes the basis for the patient’s medical record. 15.5List and describe the components of the six Cs of medical charting. 15.6Compare the paper medical record to the electronic health record. 15.7Explain and demonstrate the process used to correct errors in the medical record. 15.8Outline the procedure used to correctly and legally release patient medical information. 15-2

3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Introduction Patient Records –Continuity of Care Parts of the Medical Record 15-3

4 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Importance of Patient Records Legal Guidelines for Patient Records Standards for Records Additional Uses of Patient Records –Patient Education –Quality of Care –Research 15-4

5 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Checkpoint LO 15.1 Why is it important to document noncompliant patient behavior in the medical record? 15-5

6 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Types of Medical Records Conventional or Source-Oriented Records Problem-Oriented Medical Records –Database –Problem List –Educational, Diagnostic, and Treatment Plan –Progress Notes SOAP Documentation CHEDDAR Format 15-6

7 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Checkpoint LO 15.2 What does SOAP stand for? 15-7

8 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Contents of Patient Charts Standard Chart Information –Patient Registration Form –Patient Medical History –Physical Examination Results –Results of Laboratory and Other Tests –Records from Other Physicians or Hospitals –Physician’s Diagnosis and Treatment Plan –Operative Reports, Follow-Up Visits, and Telephone Calls 15-8

9 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Contents of Patient Charts (continued) –Informed Consent Forms –Hospital Discharge Summary Forms –Correspondence with or about the Patient Information Received by Fax Dating and Initialing 15-9

10 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Checkpoint LO 15.3 Name the financial and medical forms found in the medical record. 15-10

11 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Initiating and Maintaining Patient Records Initial Interview –Completing Medical History Forms –Documenting Patient Statements –Documenting Test Results –Examination Preparation and Vital Signs Follow-Up 15-11

12 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Checkpoint LO 15.4 What is documentation? 15-12

13 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Accuracy, Appearance, and Timeliness of Records The Six Cs of Charting Neatness and Legibility Timeliness Accuracy Professional Attitude and Tone 15-13

14 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Checkpoint LO 15.5 Why should comments or opinions not be part of the patient’s permanent record? 15-14

15 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Electronic Health Records versus Paper Health Records Electronic Medical Records Additional Advantages of Computerizing Records Safety Concerns 15-15

16 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Checkpoint LO 15.6 Explain the advantages and disadvantages of the electronic health record. 15-16

17 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Correcting and Updating Patient Records Using Care with Corrections Updating Patient Records 15-17

18 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Checkpoint LO 15.7 Why is it important that any correction to the medical record does not cover up or mask the original documentation? 15-18

19 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Release of Records Procedures for Releasing Records Special Cases Confidentiality Auditing Medical Records –Internal Audits –External Audits 15-19

20 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Checkpoint LO 15.8 What is the difference between an internal audit and an external audit? 15-20

21 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Summary LO 15.1 Medical records are legal documents that give a complete, concise, chronological history of a patient’s medical history, treatment plan, and treatment outcome. Additionally, they act as a communication tool between care providers. Regardless of the type of record, the patient chart provides physicians and other medical care providers with all the important information, observations, and opinions that have been recorded about a patient. 15-21

22 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 15-22 Summary (continued) LO 15.2 SOMR stands for source-oriented medical records. All items within the patient medical record are filed according to the location from which they originated. POMR stands for problem-oriented medical records. Items filed in these medical records are filed under the problem (number) to which they relate. SOAP format of documentation is used with POMR records and stands for subjective, objective, assessment, and plan. CHEDDAR format of documentation takes the SOAP format to the next level and stands for chief complaint, history, exam, detailed problem/complaint, drugs and dosages, assessment, and return information (if applicable).

23 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 15-23 Summary (continued) LO 15.3 Documents commonly found in the paper medical record include patient registration; medical history and physical examination forms; laboratory, x- ray, and other results; records from other physicians, hospitals, and other providers; physician diagnosis and treatment plans; operative and other hospital reports; and consent forms for any information that has been released to or received from other providers. LO 15.4 The initial interview provides the base information for a new patient coming to the medical practice. It introduces the practice to the patient and the patient to the practice. Prior to, or during, the initial interview, the patient will complete the medical history form, which is the basis of the patient medical record.

24 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 15-24 Summary (continued) LO 15.5 The 6 Cs of medical charting are client’s words, clarity, completeness, conciseness, chronological order, and confidentiality. LO 15.6 The federal government recommends that all health records become electronic by 2014. The electronic health record has many advantages over the paper health record, such as simultaneous access from more than one site and low risk of record loss. A dual system of paper and electronic records will continue for several years since conversion will not occur for all existing records.

25 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 15-25 Summary (continued) LO 15.7 The proper way to make corrections in a medical record is to draw a single line through the error so that the original entry is still legible. Make the correction as close as possible to the original entry, noting the reason for the correction; date and initial the correction. LO 15.8 In order to release any medical record, express written permission from the patient must be received. Unless it is impossible to do so, copies should be made and the originals should remain in the office. If originals must be released, verification that the records have been received and by whom should be noted in the chart. Follow-up should take place until the original records are returned to the office.


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