1. Introduction to Health Records
Chapter 2
Introduction to Health Records

2. Introduction to Health Records
Health records can be found in a paper chart or an electronic health record (EHR)
Health records contain information about the patient
Previous illnesses and treatments
Current medical problems
History of family illnesses
Current medications
The health record contains the data that will determine the patient’s care plan
It is important that the patient’s health record contains accurate data. Documentation is the bedrock of solid communication among health care providers.

3. Introduction to Health Records
Medical notes share a consistent, logical organization
Chapter 2 focuses on the organization of medical documents
Health information Career Map from the American Health Information Management Association

4. The SOAP Method
SOAP is an acronym for the different types of information documented by health care providers
S = subjective: what the patient says
O = objective: what the tests reveal
A = assessment: the analysis of the subjective and objective information; performed by the health care provider
P = plan: course of action for the patient
Subjective: These are the complaints that the patient comes in with. Subjective information includes pain and the sensation of feeling hot or cold.
Objective: This is the information gathered by the health care provider (HCP). This information could be results from tests such as vital signs (heart rate, respiratory rate, or body temperature) or other more complicated tests such as x-rays, electrocardiograms, or blood tests.
Assessment: The HCP then interprets the tests and documents them here. This may be things such as, “The high body temperature along with the blood results show an increased white blood cell count, indicating a probable bacterial infection,” or, “The electrocardiogram is normal.”
Plan: This is the actions that will be taken to address the S,O, and A. For example, “Antibiotics will be started to address the bacterial infection.”

5. Types of Health Records
Medical records vary in length and content
Medical records come in different lengths and formats. A record from the emergency department is shorter than a record from a primary care physician’s office.
These components of the health record can be obtained by many health care practitioners, from the certified medical assistant to the physician. It is therefore important to understand each component of the health record.

6. Types of Health Records
Example Note #1: Clinic Note
Discuss each area of the SOAP note presented here. This is an example of a EHR (electronic health record).
SOAP notes are color-coded here to assist in learning each area, however, this is not typically done.
- The blue area is the patient information, medications that the patient currently takes, and her allergies. The subjective information is also presented along with the patient’s family history.
- The red area is the objective information, the tests that were performed and their results. No interpretations of this information are presented in this section.
- The yellow is the assessment, which is the interpretation of the subjective and the objective information.
- The green is the plan for the patient. f/u is the abbreviation for “follow up” .
Words are blurred so as to avoid focus on newly presented medical terms. At the end of the chapter, the student will see these examples again, including the words that were previously blurred out.

7. Types of Health Records
Example Note #2: Consult Note
This is an example of a paper health record. A consult is when one health care provider asks another to evaluate a patient. The patient agrees to see another health care provider that is a specialist in his or her condition.
Dr. Passemon had consulted (asked) Dr. Jameson in regards to a patient, Mr. Robert Meeds. After evaluating the patient, the consulted doctor (Dr. Jameson) communicates his findings with the consulting doctor (Dr. Passemon). This is because Dr. Passemon is responsible for the patient’s overall care.
Note the type of information in blue (subjective), red (objective), yellow (assessment), and green (plan).

8. Types of Health Records
Example Note #3: Emergency Department Note
This is a health record from the emergency department. Note that this record is very short and contains only the information that is needed. It does not contain information that would tell a story; it is just the facts.

9. Types of Health Records
Example Note #4: Admission Summary
An admission summary is written when the patient is admitted to the hospital.
The patient is admitted with chest pain, which could have several causes. The subjective information (in blue) is provided by the patient. The objective information (in red) are the tests that gain information from the body systems.
In this health record, the assessment and plan are combined. The assessment ends with the colon, and the information after that is the plan for the assessment.

10. Types of Health Records
Example Note #5: Discharge Summary
This example also shows that the most important information, the assessment, goes first in an operative report. Note that the preoperative and postoperative diagnoses are the same. This is not always the case, which is why these are two separate entries.
Operative reports are concise and tell the story of the surgery. This record does not include the results of tests or vital signs. Vital signs are taken and recorded, but they are included in another report (usually the anesthesiologist’s record).

11. Types of Health Records
Example Note #6: Operative Report
Example Note #7: Daily Hospital Note/ Progress Note
Radiology Report
Pathology Report
By now I am sure you get the idea of SOAP, but here are few more examples of SOAP and medical documentation:
Example #6: This example also shows that the most important information, the assessment, goes first in an operative report.
Note that the preoperative and postoperative diagnoses are the same. This is not always the case, which is why these are two separate entries.
Operative reports are concise and tell the story of the surgery. This record does not include the results of tests or vital signs. Vital signs are taken and recorded but in another report (usually the anesthesiologist’s record).
Example #7: The health care professional (e.g., doctor, nurse practitioner, or physician assistant) makes a daily entry on the patient’s condition and any progress the patient is or is not making.
It includes a physical exam because it is important to assess all body systems on a daily basis.
Again, the assessment and plan are combined, but they are separated by a colon.
Radiology and Pathology Reports: These reports are very short and only include information pertaining to the subject of the report.

12. Types of Health Records
Example Note #10: Prescription
A prescription has a unique structure.
The prescriber writes the name of the patient.
This prescription is for medication. Prescriptions can also be for treatment, such as physical therapy.
Information included:
- The first line specifies the medication name and dosage.
- Sig contains the instructions for the patient. The pharmacist will translate this into language that the patient can understand
- Dispense tells the pharmacist the quantity of medication to give to the patient.
- Refill lets the pharmacist and the patient know if they will be able to obtain more medication after the initial medication is taken.
The pharmacist will substitute a generic medicine for the name brand medication unless the prescriber states that only the brand name medication should be used. In this prescription, only the name brand medication should be dispensed.

13. Common Terms on Health Records
Subjective
These are the problems that the patient states he/she has
Those problems are then translated into medical terms
This is so that you can correctly communicate the problems to all health care providers
Subjective statements are those given by the patient. They are his or her “complaints.”

14. Common Terms on Health Records
General subjective terms:
symptom
noncontributory
acute vs. chronic
abrupt
progressive vs. exacerbation
febrile vs. afebrile
Symptom – what the patient feels
Noncontributory – patient’s symptom is not related to the current problem
Acute – occurs recently, or sharp severe symptoms
Chronic – a problem that occurs for a while
Abrupt – occurs suddenly
Progressive – worsening of symptoms
Exacerbation – worsening of a condition
Febrile – has a fever
Afebrile – does not have a fever

15. Common Terms on Health Records
General objective terms:
Things that are felt:
Things that are seen:
Palpation
alert
oriented
Descriptions of what is observed:
Things that are heard:
auscultation
unremarkable
percussion
marked
Alert – patient can answer questions; responsive, interactive
Oriented – patient knows who they are, where they are, and what time it is (current date and time)
Auscultation – to listen (usually with a stethoscope)
Percussion – to hit or strike and then listen for the sound; the returned sound indicates the condition of the body
Palpation – to feel something; how something feels can indicate its condition, be it normal or abnormal

16. Common Terms on Health Records
General assessment terms:
impression
diagnosis
differential diagnosis
etiology vs. idiopathic
benign vs. malignant
remission
Assessment is the gathering and analyzing of the facts about the patient. The facts come from the subjective and objective information.
Impression – another word for assessment
Diagnosis – using the subjective and objective data to determine the patient’s condition
Differential diagnosis – based on the subjective and objective data, the health care professional cannot yet determine the diagnosis; for example, vague chest pain could lead to a differential diagnosis of pneumonia or a heart condition
Etiology – the cause
Idiopathic – no known cause
Benign – not cancerous
Malignant – cancerous
Remission – no longer having the symptoms of a disease; usually used when referring to cancer

17. Common Terms on Health Records
General assessment terms (cont.):
morbidity
mortality
prognosis
localized vs. systemic/generalized
pathogen
lesion
sequelae
Morbidity – risk of being sick or diseased
Mortality – risk for dying
Prognosis – chance of getting better
Localized – one area
Systemic/generalized – over a large area or body system
Pathogen – organism that causes the disease
Lesion – diseased tissue
Sequelae – result of disease or injury; for example, paralysis can be the sequelae of spinal cord injury

18. Common Terms on Health Records
General plan terms:
disposition
observation
reassurance
supportive care
Palliative
The plan is what the provider plans to do for the patient. It could be a treatment plan or a plan for future care, such as testing blood values every three months.
Disposition – where the patient went at the conclusion of the visit. Examples would be home, hospital, or a nursing home.
Observation – to watch
Reassurance – actions that make the patient feel better
Supportive care – treat symptoms to make the patient feel better
Palliative – relieve symptoms, but not cure

19. Common Terms on Health Records
Body Planes and Orientation
Proximal vs. distal – refers to the attachment to the trunk; used when describing the upper extremities (arms) and lower extremities (legs)
Lateral vs. medial – describes the relationship to the center
Anterior/antral/ventral – all mean front when referring to the human
Posterior/dorsal – all mean back when referring to the human
Cranial vs. caudal – cranial means head, caudal means tail; used when describing areas of the trunk, head, and neck
Superior vs. inferior – top and bottom

20. Common Terms on Health Records
Body Planes and Orientation
Supine – lying on the back; patient is looking up, supine; lying on the spine
Prone – lying on the belly

21. Common Terms on Health Records
Body Planes and Orientation
ipsilateral – same side
contralateral – opposite side
The image shows that the brain controls the opposite limb, or has a contralateral control.

22. Common Terms on Health Records
Body Planes and Orientation
Unilateral means one side; bilateral means two sides.

23. Common Terms on Health Records
Body Planes and Orientation
Plantar refers to the sole of the foot. Palmar refers to the palm of the hand. Dorsum refers to the back of something, such as the hand or foot. It is the opposite of palmar and the opposite of plantar.

24. Common Terms on Health Records
Body Planes and Orientation
The coronal plane divides the body into anterior and posterior sides. The sagittal plane divides the body into right and left. The transverse plane divides the body into superior and inferior (top and bottom).

25. A Few Common Abbreviations
Areas of the Health Care Facility pre-op, OR, PACU, post-op ICU – intensive care unit: CCU, SICU, PICU, NICU ER, ED, and ECU L&D
The first list of terms has to do with the operating room. First, the patient goes to pre-op. This area prepares the patient for surgery. Then, the patient goes to the operating room, then to the postanesthesia care unit, and then to postoperative care.
Special areas of the ICU depend on the patient. The CCU is the coronary care unit (heart problems); SICU is the surgical ICU; PICU is the pediatric ICU; and NICU is the neonatal (newborn) ICU.
Many years ago, one room was all that was necessary to treat patients requiring emergency care, so it was called the ER (emergency room). Now, it has been enlarged to an emergency department (ED) and even an emergency care unit (ECU).
L&D is labor and delivery, where a mother will go through the stages of labor as well as the actual delivery of the newborn in one room.

26. A Few More Abbreviations
Common on Health Records
H&P – the history and physical
CC – the patient’s chief complaint
HPI – history of present illness
ROS – review of systems
PE – physical exam
PCP – primary care provider
And there are many more you will need to know!
H&P – the history and physical
CC – the patient’s chief complaint
HPI – history of present illness
ROS – review of systems
PE – physical exam
PCP – primary care provider

27. Health Records and Health Information Management
There is substantially more to a Career in Health Information Management than Health Records
HIM careermap
HIM professional video
HIM professional 2 video
HIM professional 3 video
You can focus an entire career in the management of health information and medical records.