Medical Record for Medical Scribes


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The demand is growing for Medical Scribes. If you are looking for a new career and love the mix of medical language and technology, and want a challenging career with a bright future, this is for you!

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Medical Record for Medical Scribes

  1. 1. The Medical Scribe’s Role
  2. 2.  The medical record is an important part of the patient’s care in the clinic or emergency room.  The information a scribe records on the chart could affect how the patient is managed currently or in the future.
  3. 3.  To communicate relevant information to other medical personnel.  It is a legal document that can be presented in a court of law.
  4. 4. A physician may be asked to testify in cases of: ◦ Rape ◦ Homicide ◦ Assault ◦ Child abuse ◦ Civil procedures involving personal injury
  5. 5.  The method used in charting the patient’s stay through the clinic/ED must follow a logical progression.  The most common method is to consider the chart to have four generalized sections: ◦ Subjective ◦ Objective ◦ Assessment ◦ Plan
  6. 6.  The Subjective portion includes: ◦ Chief Complaint (CC) ◦ History of Present Illness (HPI) ◦ Review of Systems (ROS) ◦ Past Medical History (PMHx) ◦ Family History (FHx) ◦ Social History (SHx)
  7. 7.  The Subjective section pertains to any information that the patient and/or family states.  This information is dependent upon the patient’s condition, beliefs, personality, etc.  This section will contain the patient’s story in his/her own words.
  8. 8.  Chief Complaint ◦ The main reason the patient has come to the clinic/ED. ◦ Every chart must have a Chief Complaint. ◦ A short statement in the first sentence of the HPI identifying why the patient has come to the clinic/ED. ◦ Should be in the patient’s own words (if possible).
  9. 9.  History of Present Illness (HPI) ◦ Explains the Chief Complaint. ◦ Describes why the patient is in the clinic/ED and lists any pertinent positives and negatives. ◦ This should be in a narrative paragraph consisting of 4-5 sentences depending on the severity of the patient’s condition. ◦ The HPI is a chronological description of the development of the patient’s present illness from the first sign/symptom or from the previous encounter to the
  10. 10.  8 dimensions of HPI - directly related to Chief Complaint ◦ Location ◦ Quality ◦ Severity ◦ Duration ◦ Timing ◦ Context ◦ Modifying factors ◦ Associated signs and symptoms
  11. 11.  Location ◦ A place on the body  Examples: R flank, midsternal chest, etc.  Quality ◦ Description of the complaint  Constant, dull, crampy, intermittent, etc.  Severity ◦ How bad is it? ◦ Usually on a scale of 1 to 10  Examples: Acute, mild/moderate/severe, 7/10, 3 pads in the last hour, etc.
  12. 12.  Duration ◦ How long do the episodes last?  Examples: 30 seconds each, 5 years, etc.  Timing ◦ When did it start?  Examples: 3:00 AM, this afternoon, etc.  Context ◦ What were you doing when it happened?  Examples: Running laps, just ate 7 doughnuts, awoken from sleep, etc.
  13. 13.  Modifying factors ◦ What makes it better or worse?  Examples: Worse with activity, improve with nitroglycerin, increased pain with movement.  Associated signs and symptoms ◦ Any other symptoms  Examples: If CC is chest pain, associated with diaphoresis and N/V.
  14. 14.  A review of the patient’s past medical, social history, and family medical history.  Depending on the circumstances or encounter, the patient’s Chief Complaint could be an indication of a complication of, or a result of, a preexisting condition or the patient’s past medical history.
  15. 15.  Past Medical History (PMHx) ◦ Includes injuries, chronic illnesses, and surgeries.  Social History (SHx) ◦ Identifies behavioral risks such as tobacco alcohol, or drug use.  Family History (FHx) ◦ Includes relevant past family medical information.
  16. 16.  Past Medical History (PMHx) ◦ Hypertension (HTN), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), diabetes (DM), coronary artery bypass graft (CABG), cancer (Ca).  Past Surgical History ◦ A subcategory under PMHx.  Social History (SHx) ◦ Tobacco use (Tob), alcohol use (EtOH), intravenous drug use (IVDA), living situation (lives alone, lives with others, nursing home, or lives at home with parents).  Family History (FHx) ◦ Includes genetic traits, DM, Ca, cardiac disease, etc.
  17. 17. Common ROS: ◦ General ◦ Eyes ◦ ENT ◦ CVS ◦ Resp ◦ GI ◦ GU Review of Systems (ROS) Identifies any recent symptoms the patient may have other than the current illness.
  18. 18. A Review of Systems is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.
  19. 19.  General Symptoms ◦ e.g. diaphoresis, cold symptoms, fever, chills.  Eyes ◦ e.g. Visual changes, blindness, ophthalmoplegia, blurry, eye pain, discharge.  Ear, Nose, Throat, Mouth ◦ e.g. dysphagia, tinnitus, epistaxis, rhinorrhea.  Cardiovascular ◦ e.g. palpitations, edema, cyanosis, dyspnea on exertion, CP.  Respiratory ◦ e.g. SOB/dyspnea, wheezing, cough.  Gastrointestinal ◦ e.g. dysmenorrhea, dyspareunia, dysuria, vaginal bleeding.  Musculoskeletal ◦ e.g. arthralgia, myalgia.
  20. 20.  Skin/Breast ◦ e.g. rashes, hives, discoloration, pallor, mastectomy.  Neurological ◦ e.g. H/A, dizziness, LOC, numbness, paresthesia.  Psychiatric ◦ e.g. suicidal, depressed.  Endocrine ◦ e.g. cold intolerance, heat intolerance, polydipsia, polyuria.
  21. 21.  EXCEPTIONS: ◦ If a patient is unable to provide any information due to severity of illness, inebriation, intubation, unconscious, etc., you may check the “Unable to obtain HPI/ROS/PMFHSH secondary to pt’s condition. ◦ Be careful when using this caveat, and only use it if it really applies (HPI, Past Medical/Social/Family History, and ROS only). ◦ Ask the physician for clarification when needed. ◦ Speaking another language is not an exception. ◦ Physical exam must be documented.
  22. 22.  The Objective portion includes: ◦Physical Exam ◦Medical Decision-Making Elements
  23. 23. The Objective section contains information that is obtained through observation and testing and is independent of an individual’s interpretation.
  24. 24.  Physical Examination (PEx) ◦ Information is more medically-oriented ◦ Information elicited through observation, palpitation, percussion, and auscultation.  Medical Decision Making (MDM) ◦ Documented under “Progress Notes” and contains Differential Diagnosis, Progress notes, attending note.
  25. 25.  Differential Diagnosis (DDx) ◦ Lists the different conditions that testing will rule out.  Progress Notes ◦ Any new subjective information provided by the patient and any new or changed findings upon reexamination of the patient.
  26. 26.  Example: Re-eval at 1532 – Pt states she is improved. Nausea resolved. PEx: Abd soft, NT/ND, nl active BS. Pt will be discharged and f/u with PMD advised within 24 hours.
  27. 27.  Attending Note ◦ Recorded when a physician oversees a resident case. ◦ This will follow the SOAP format. ◦ Example: A) Attending Note: Reviewed and agree c Hx. B) PEx – GI: abd soft, NT, CVS: RRR s MGR. RESP: Lungs CTA. C) A: UTI vs. Kidney stone D) P: Labs, CT abd/pelvis r/o stone
  28. 28.  The Assessment portion includes: ◦ Diagnosis:  The physician’s impression of the patient after combining the information in both the Subjective &
  29. 29.  The Plan consists of: ◦ How the physician manages the patient’s care after the final diagnosis has been identified and can include:  Admission ◦ Ensure that the chart has been coded to the appropriate level and enter admission information.  Discharge Instructions ◦ Lists the various treatments, medications
  30. 30.  Level 1: Visits requiring very minor care. This level is seldom used in the ED but would be used in a clinic setting. ◦ Removal of sutures from a well-healed, uncomplicated laceration. ◦ Tetanus toxoid immunization; Depo-Provera injection; hormone injections. ◦ Several uncomplicated insect bites.  Level 2: Diagnosis reached without the aid of any labs or x-rays. ◦ Painful sunburn with blister formation on the back in an otherwise healthy patient. ◦ Child presenting with impetigo localized to the face. ◦ Minor traumatic injury of an extremity with localized pain, swelling, and bruising. ◦ Red, swollen cystic lesion on patient’s back in an otherwise healthy patient.
  31. 31.  Level 3: Visits requiring minor lab work such as CBC, U/A, or a few x-rays. ◦ Well-appearing child who has a fever, diarrhea, and abdominal cramps and is tolerating oral fluid. ◦ Inversion ankle injury, patient is unable to bear weight on the injured foot and ankle. ◦ Acute pain associated with a suspected foreign body in the painful eye. ◦ Blunt head injury with local swelling and bruising without subsequent confusion, loss of consciousness, or memory deficit in an otherwise young and healthy adult.  Level 4: Visits requiring extensive lab workup or CT scan. ◦ Child sustaining a head injury (falling off bicycle) with brief loss of consciousness.
  32. 32.  Level 5: Visits requiring admission into the hospital, critical care patients. ◦ Complicated overdose requiring aggressive management to prevent side effects from the ingested materials. ◦ New onset of palpitations/tachycardia requiring IV drugs. ◦ Active upper gastrointestinal bleeding. ◦ Motor vehicle accident with intraabdominal injuries or multiple extremity injuries. ◦ Acute onset of chest pain compatible with symptoms of cardiac ischemia and/or pulmonary embolus. ◦ Sudden onset of “the worst headache of my life” with associated meningismus, nausea, and vomiting. ◦ New onset of a cerebral vascular accident. ◦ Acute febrile illness in an adult, associated with shortness of breath and an altered level of alertness.
  33. 33. Copyright ©2013 MDS of Kansas, LLC. All rights reserved.