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Chapter 19   Documentation & Medical Records
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Chapter 19 Documentation & Medical Records

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    Chapter 19   Documentation & Medical Records Chapter 19 Documentation & Medical Records Presentation Transcript

    • Chapter 19Documentation and Medical Records © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Definitions• Medical documentation• Medical record• Charting © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Purposes• Contributes to good patient care• Provides legal protection• Helps ensure regulatory compliance• Improves cost control• Decreases denials from insurance companies © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Characteristics• Complete with all requested information• Concise and factual• Properly identified• Legible• Correct spelling, terminology, punctuation, and grammar © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Characteristics• Clearly and objectively expressed• Findings not duplicated• Approved abbreviations listed in facility’s policy used• Time and date given for all entries © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Characteristics• Signed by proper person• Completed without leaving empty lines• Always charted after giving medication or performing procedure• Written with black or blue ink © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Making Corrections• Draw single line through error• Write in correct information• Note error per facility policy• Date and initial correction• Correct immediately on computer• If discovered later, correct as above © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Question• Which of the following is the recording of observations and information about patients? A. Charting B. Medical documentation C. Medical record © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Answer• A. Charting• Charting – Recording of observations and information about patients• Medical documentation – Notes and documents that health care professionals add to medical record © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Answer• A. Charting• Medical record – Collection of all documents filed together – Form complete chronological health history © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Medical Records• Organized per facility policy• All health care workers responsible to maintain records per facility policy• Chronological or source-oriented © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Medical Records Content• History and physical (H&P)• Physician’s orders• Diagnostic tests• Admissions• Surgical procedures © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Medical Records Content• Graphics• Flow sheets• Medications record• Progress notes © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Medical Records Content• Reminder: – Verify correct form in chart by ensuring patient’s name on each document• Each section chronological• Thinning a chart• Security of files © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Question• Which of the following is a form used for specialty needs? A. Progress notes B. Graphics C. Flow sheets © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Answer• C. Flow sheets• Flow sheets – Forms for specialty needs• Progress notes – Written chronological statements about patient’s care © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Answer• C. Flow sheets• Graphics – Graphed forms for vital signs © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Progress Notes• Primary tool – Recording, communicating, and coordinating care of patient• May include the following: – Observations – Treatments – Patient response © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Progress Notes: Formats• Problem-oriented charting• Narrative charting• Charting by exception• Computerized © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Question• True or False: – The chief complaint is the reason the patient is seeking medical care. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Answer• True• Chief complaint – Reason patient seeks medical care © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • EMRs• EMR systems can go far beyond core charting – Coordination tools – Information – Safety tools – Scanned documents © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • EMRs• Can only communicate within same health care system © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Personal Health Record (PHR)• Recommended for patients – Due to mobility of individuals – Frequent changes in providers – Frequent changes in insurance coverage• Assists patient to recall events and dates © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Personal Health Record (PHR)• Prevents long delays in requesting information• Types of information to include – Demographics, such as name, address, contact information, etc – Emergency contacts – Name, specialty and contact information of previous providers – Insurance provider(s) © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Personal Health Record (PHR)• Types of information to include – Medical directives, living will, organ donation, etc. – General medical information: height, weight, blood type, vital signs, etc. – Allergies and drug sensitivities – Current conditions and date of diagnosis – Previous surgeries, including date and results © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Personal Health Record (PHR)• Types of information to include – Medications (prescription and nonprescription) – Immunizations and when last received – Any relevant health care visits, such as hospitalizations, other specialists or therapists – Pregnancies – Medical devices © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Personal Health Record (PHR)• Types of information to include – Foreign travel – Family history information © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Question• True or False: – EMRs have about the same capabilities and limitations as written charting. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Answer• False• EMR systems can go far beyond core charting © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • HIPAA• The Privacy Rule• The Security Rule• Possible consequences of not following HIPAA regulations © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Question• Which of the following is true about HIPAA? A. It protects the health care facilities B. It protects patients C. It protects the safety of health care professionals © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.
    • Answer• B. It protects patients• HIPAA Privacy Rule gives patient specific rights related to medical records• HIPAA Security Rule requires administrative, physical, and technical safeguards be developed by facilities to protect patient information © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.