Lecture 6


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9-21 after break. See lecture 9-28.2 for etymology

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Lecture 6

  1. 1. V550 Medical Documentation Charting & Terminology Richard E. Meetz, OD, MS 2008
  2. 2. Medical Records <ul><li>A record of the patient’s care. </li></ul><ul><li>Basis for 3rd party reimbursement. </li></ul><ul><li>Medical-Legal document. </li></ul>
  3. 3. Medical Records <ul><li>A record of patient care </li></ul><ul><li>Provides essential information on the day of the exam. </li></ul><ul><li>Continuity of care from one practitioner/visit to the next. </li></ul><ul><li>Allows evaluation of changes in a patient’s health or condition. </li></ul>
  4. 4. Medical Records <ul><li>Basis for 3 rd party reimbursement </li></ul><ul><li>Shows the necessity for any procedures and level of care. </li></ul><ul><ul><li>By counting Hx entries, numbers and types of tests and procedures, the complexity of the case can be established and correctly billed for. </li></ul></ul><ul><li>Supports claims in cases of reviews & audits . </li></ul><ul><ul><li>Medicare/Medicaid, VSP, etc. </li></ul></ul>
  5. 5. Medical Records <ul><li>Medical-Legal Record </li></ul><ul><li>The medical record provides a legal record of care . </li></ul><ul><li>Defense of the doctor and staff in cases of malpractice claims. </li></ul><ul><li>“ In court, the medical record IS the care rendered! </li></ul><ul><li>If it isn’t in the record, it never happened!” </li></ul>
  6. 6. Medical Records <ul><li>Medical-Legal Record </li></ul><ul><li>Should include all the vital information needed to reconstruct the events of the exam. </li></ul><ul><li>Should reflect the current standard of care. </li></ul><ul><li>Should NEVER be altered after care is called into question for review or litigation. (See error correction) </li></ul>
  7. 7. Medical Records <ul><li>Confidentiality </li></ul><ul><li>Records are confidential information </li></ul><ul><ul><li>Patient’s written permission is necessary for record release </li></ul></ul><ul><ul><li>Records should not leave the clinic or office </li></ul></ul><ul><ul><ul><li>Must be kept in secure location </li></ul></ul></ul><ul><ul><ul><ul><li>Locked or restricted </li></ul></ul></ul></ul><ul><ul><li>Avoid discussing patient care issues in public areas </li></ul></ul>
  8. 8. Medical Records <ul><li>Confidentiality </li></ul><ul><li>Computerized/electronic records are new security/confidentiality issue </li></ul><ul><ul><li>Hipaa: Health Information Portability and Accountability Act </li></ul></ul><ul><ul><ul><li>Standardized how and when information is released and how transferred. </li></ul></ul></ul><ul><ul><ul><li>1st Requested by the insurance companies, FTC took over </li></ul></ul></ul><ul><ul><ul><li>Strict rules on record keeping & rule for release </li></ul></ul></ul><ul><ul><ul><li>HAD to have sign copy of Hipaa policy in record in every office </li></ul></ul></ul>
  9. 9. Medical Records <ul><li>Content of Medical records </li></ul><ul><li>All parts of the examination </li></ul><ul><ul><li>Intake Hx, exam forms, F/U forms, prescription copies, informed consents </li></ul></ul><ul><li>Laboratory results </li></ul><ul><ul><li>Visual Field print outs </li></ul></ul><ul><li>Correspondence </li></ul><ul><ul><li>Referrals, forwarded records </li></ul></ul><ul><ul><li>Patient letters and telephone communications </li></ul></ul><ul><ul><ul><li>With date, time, “question” & instructions </li></ul></ul></ul>
  10. 10. Medical Records <ul><li>Content of Medical records </li></ul><ul><li>Billing information </li></ul><ul><ul><li>Patient personal data </li></ul></ul><ul><ul><ul><li>Address, phone contact </li></ul></ul></ul><ul><ul><ul><li>Place & Date of birth </li></ul></ul></ul><ul><ul><li>Copies of past bills sent </li></ul></ul><ul><ul><li>Patient releases </li></ul></ul>
  11. 11. Medical Charting <ul><li>Guidelines for Documentation </li></ul><ul><li>1. The patient’s full name MUST appear on every page. </li></ul><ul><li>2.The full date MUST appear on all pages. </li></ul><ul><ul><li>Entries with only a month and day are NO better than a lost page. </li></ul></ul><ul><ul><li>3. All Entries/exams MUST be signed! </li></ul></ul><ul><ul><li>By writer’s full name & degree. </li></ul></ul>
  12. 12. Medical Charting <ul><li>Guidelines for Documentation </li></ul><ul><li>4. All entries MUST be in permanent ink. </li></ul><ul><ul><ul><li>NO pencils or erasable pens </li></ul></ul></ul><ul><ul><ul><li>Best in black ink, best if ball point . </li></ul></ul></ul><ul><li>5. All entries MUST be LEGIBLE! </li></ul><ul><li>6. Entries should use only approved terminology & abbreviations. </li></ul>
  13. 13. Medical Charting <ul><li>Guidelines for Documentation </li></ul><ul><li>7. Entries should only be made on approved forms. </li></ul><ul><li>8. Entries should be made in the appropriate sequence. </li></ul><ul><li>9. Never skip lines or leave blanks. </li></ul><ul><li>10. Late entries should be marked as such. </li></ul>
  14. 14. Medical Charting <ul><li>Miscellaneous Documentation </li></ul><ul><li>Patient intake forms </li></ul><ul><ul><li>Patient generated history forms. </li></ul></ul><ul><ul><li>Must be signed by patient. </li></ul></ul><ul><ul><li>Should be dated & initialed by Dr. indicating that it was reviewed. </li></ul></ul><ul><ul><li>Must be reviewed, updated and initialed at each visit. </li></ul></ul><ul><li>Laboratory results </li></ul><ul><ul><li>Should be dated & initial indicating that it was read. </li></ul></ul><ul><ul><li>Documentation that the patient was notified of the results. </li></ul></ul>
  15. 15. Medical Charting <ul><li>Miscellaneous Documentation </li></ul><ul><li>Telephone calls from patients regarding health </li></ul><ul><ul><li>Documentation of date, time, “question” and instructions to patient. </li></ul></ul><ul><li>Late entries - </li></ul><ul><li>Cancelled or missed appointments </li></ul><ul><ul><li>Also attempts to contact patient should be documented </li></ul></ul><ul><ul><li>Any returned postal notices (cards) are to be kept in the record. </li></ul></ul>
  16. 16. Medical Charting <ul><li>Adding to a record </li></ul><ul><li>After a chart has been signed off, DO NOT go back and alter it at a later date. </li></ul><ul><li>Use the following procedure: </li></ul><ul><ul><li>Date </li></ul></ul><ul><ul><li>Time </li></ul></ul><ul><ul><li>“ Late entry to (date)” </li></ul></ul><ul><ul><li>Complete note and sign off as usual </li></ul></ul>
  17. 17. Medical Charting <ul><li>Adding to a record </li></ul><ul><li>Late entries/same day: on a fill in the blank form, add to bottom of subject page (front) </li></ul><ul><ul><li>Addition to subjective CC: “pt. states he now recalls skipping lines when reading.” </li></ul></ul><ul><li>Different day </li></ul><ul><ul><li>11/3/04 Late entry to 9/2: XXXXXXXXXXXX 9:00am XXXXXXXXXXXXXXXXXXXXXXXXX Signature </li></ul></ul>
  18. 18. Medical Charting <ul><li>Documentation of procedures: </li></ul><ul><li>Who performed the procedure (if other than the person charting) </li></ul><ul><li>How procedure was done </li></ul><ul><li>How patient tolerated the procedure </li></ul><ul><li>Any change in symptoms </li></ul><ul><li>Condition/status of patient at time of release </li></ul><ul><li>Signed release/informed consent in chart </li></ul>
  19. 19. Medical Charting <ul><li>Error Correction </li></ul><ul><li>Never Cross out, overwrite or blacken an error! </li></ul><ul><li>Use a single line </li></ul><ul><ul><li>Then: </li></ul></ul><ul><ul><li>Your initials </li></ul></ul><ul><ul><li>Date </li></ul></ul><ul><ul><li>Add correcting information </li></ul></ul>
  20. 20. Medical Charting <ul><li>Incorrect Error Correction </li></ul><ul><li>Correct Error Correction </li></ul>
  21. 21. Medical Charting <ul><li>Recording the History </li></ul><ul><li>Things to avoid </li></ul><ul><li>Jousting </li></ul><ul><ul><li>Arguing, complaining, belittling, criticizing others to defend oneself. </li></ul></ul><ul><li>Stating opinions vs. fact </li></ul><ul><ul><li>Patient is intoxicated </li></ul></ul><ul><li>Vague statements </li></ul><ul><ul><li>Patient appears to be sleeping </li></ul></ul><ul><li>Derogatory or frivolous comments </li></ul><ul><ul><li>Patient is a rock </li></ul></ul>
  22. 22. Medical Charting <ul><li>Recording the History </li></ul><ul><li>Defn: Jargon </li></ul><ul><li>Nonsensical gibberish </li></ul><ul><li>A hybrid language </li></ul><ul><li>Language or terminology peculiar to a specific field, profession or group. To exclude outsiders. </li></ul><ul><li> Excessive use of abbreviations falls into this category . </li></ul>
  23. 23. Medical Charting <ul><li>Medical Abbreviations </li></ul><ul><li>The need for speed & to shorten record keeping has greatly increased the use of abbreviations. </li></ul><ul><li>However, they add convenience at the expense of communication & safety </li></ul><ul><ul><li>Problems arise when an abbreviation has more than one meaning </li></ul></ul><ul><ul><li>Recent study found that abbreviations account for 5% of medical errors </li></ul></ul><ul><ul><ul><li>“ QD” most common error (means once daily) </li></ul></ul></ul><ul><ul><ul><li>U for units next most common in error </li></ul></ul></ul>
  24. 24. Medical Charting <ul><li>Medical Abbreviations </li></ul><ul><li>THERE ARE NO UNIFORM ABBREVIATIONS </li></ul><ul><li>Abbreviations are site specific. </li></ul><ul><li>EXAMPLE: LLL </li></ul><ul><ul><li>IUSO = Lids, lashes & Lacrimal (apparatus) </li></ul></ul><ul><ul><li>IUHC = Left Lower Lobe (lung) </li></ul></ul><ul><li>Each site MUST have its own approved list. </li></ul><ul><ul><li>Can be called in to court in in cases of malpractice </li></ul></ul><ul><ul><li>Support documentation in chart reviews </li></ul></ul>
  25. 25. Medical Charting <ul><li>Medical Abbreviations </li></ul><ul><li>Problems: Abbreviations and symbols can be easily misread or interpreted in a manner not intended. </li></ul><ul><li>Example: OD usually means Right eye </li></ul><ul><ul><ul><li>Could also mean one drop </li></ul></ul></ul><ul><ul><ul><li>Or mean once daily ? </li></ul></ul></ul><ul><li>So... OD OD OD could mean: </li></ul><ul><li>One drop in the right eye once daily . NOT! </li></ul>
  26. 26. Medical Charting <ul><li>Medical Abbreviations </li></ul><ul><li>Abbreviations with different Lay meaning. </li></ul><ul><li>SOB : Short of Breath </li></ul><ul><li>BS : Blood Sugar </li></ul><ul><li>FBS : Fasting blood sugar or </li></ul><ul><li>ASS : Anterior superior spine </li></ul><ul><li>T&A : Tonsillectomy and adenoidectomy </li></ul>
  27. 27. Common Medical Terms and Their Abbreviations <ul><li>Cerebrovascular accident </li></ul><ul><ul><li>CVA = Stroke </li></ul></ul><ul><li>Myocardial infarction </li></ul><ul><ul><li>MI = Heart Attack </li></ul></ul><ul><li>Hypertension </li></ul><ul><ul><li>HTN = High blood pressure </li></ul></ul><ul><li>Diabetes Mellitus </li></ul><ul><ul><li>DM = high blood sugar </li></ul></ul><ul><ul><li>IDDM = Insulin dependant diabetes </li></ul></ul><ul><ul><li>NIDDM = Non insulin dependant diabetes </li></ul></ul>
  28. 28. Medical Charting <ul><li>Medical Abbreviations </li></ul><ul><li>Abbreviations with more than one meaning. </li></ul><ul><ul><li>On average any abbreviation will have 2 to 3 different meanings; </li></ul></ul><ul><li>BS can mean blood sugar or </li></ul><ul><ul><ul><ul><ul><li>blind spot </li></ul></ul></ul></ul></ul><ul><li>FBS can mean fasting blood sugar or </li></ul><ul><ul><ul><ul><li>foreign body sensation </li></ul></ul></ul></ul><ul><li>OU can mean oculi unitas = both eyes or </li></ul><ul><ul><ul><ul><li>oculus uterque = each eye </li></ul></ul></ul></ul>
  29. 29. Medical Terminology
  30. 30. Medical Terminology <ul><li>Etymology </li></ul><ul><li>Study of word origins from Latin, Greek or the earliest known use. </li></ul><ul><li>Study of the basic elements and their application </li></ul><ul><li>Medical etymology based on “word roots” </li></ul><ul><li>If familiar with root words and general anatomy, you will usually be able to figure out the medical terminology </li></ul>
  31. 31. Medical Terminology <ul><li>Etymology </li></ul><ul><li>90-95% of medical & technical scientific vocabulary comes from Greek and Latin sources </li></ul><ul><li>On average, learning one of these “building block” words will help you learn about 50 different medical words </li></ul><ul><li>Just 500 Greek & 500 Latin word components account for the vast bulk of all the medical words you are likely to encounter in any single health field </li></ul>
  32. 32. Medical Terminology <ul><li>Etymology: Word Roots </li></ul><ul><ul><li>The main part or stem of a word. </li></ul></ul><ul><ul><li>Frequently indicates a body part. </li></ul></ul><ul><li>Examples: </li></ul><ul><ul><li>Kardia (heart) = cardi </li></ul></ul><ul><ul><li>Gaster (stomach) = gastr </li></ul></ul><ul><ul><li>Hepar (liver) = hepat </li></ul></ul><ul><ul><li>Nephros (kidney) = nephr </li></ul></ul><ul><ul><li>Osteon (bone) = oste </li></ul></ul>
  33. 33. Medical Terminology <ul><li>Etymology: Combined form </li></ul><ul><ul><li>Is a word root plus a vowel usually “o” </li></ul></ul><ul><ul><li>Usually indicates a body part. </li></ul></ul><ul><li>Examples: </li></ul><ul><ul><li>cardi +o = cardio (heart) </li></ul></ul><ul><ul><li>gastr + o = gastro (stomach) </li></ul></ul><ul><ul><li>hepat + o = hepato (liver) </li></ul></ul><ul><ul><li>nephr + o = nephro (kidney) </li></ul></ul><ul><ul><li>oste + o = osteo (bone) </li></ul></ul><ul><ul><li>phac + o = phaco (lens) </li></ul></ul>
  34. 34. Medical Terminology <ul><li>Etymology: Combined form-“Ocular” </li></ul><ul><li>Examples: </li></ul><ul><ul><li>Amblyo = dull, dim </li></ul></ul><ul><ul><li>Aqueo = water </li></ul></ul><ul><ul><li>Blepharo = lid </li></ul></ul><ul><ul><li>Coreo = pupil </li></ul></ul><ul><ul><li>Dacryo = tear, lacrimal sac </li></ul></ul><ul><ul><li>Kerato = cornea </li></ul></ul><ul><ul><li>Cyclo = ciliary body </li></ul></ul><ul><ul><li>Irido = iris </li></ul></ul><ul><ul><li>Presbyo = old age </li></ul></ul>
  35. 35. Medical Terminology <ul><li>Etymology: Suffix </li></ul><ul><ul><li>Is a word ending. </li></ul></ul><ul><ul><li>Usually indicates a procedure, condition, disease. </li></ul></ul><ul><li>Examples: </li></ul><ul><ul><li>itis = inflammation </li></ul></ul><ul><ul><li>megaly = enlargement </li></ul></ul><ul><ul><li>plegia = paralysis condition </li></ul></ul><ul><ul><li>ia = condition </li></ul></ul><ul><ul><li>osis = abnormal condition </li></ul></ul><ul><ul><li>opia = vision </li></ul></ul><ul><ul><li>stenosis = narrowing condition </li></ul></ul>
  36. 36. Medical Terminology <ul><li>Etymology: Suffix; Procedures </li></ul><ul><li>Examples: </li></ul><ul><ul><li>ectomy = excision, removal </li></ul></ul><ul><ul><li>centesis = puncture </li></ul></ul><ul><ul><li>plasty = surgical repair </li></ul></ul><ul><ul><li>tomy = incision, cut into </li></ul></ul><ul><ul><li>lysis = separation, destruction, loosening </li></ul></ul>
  37. 37. Medical Terminology <ul><li>Etymology: Prefix </li></ul><ul><li>Is a word element at the beginning of a word. </li></ul><ul><li>When a medical word contains a prefix the meaning of the word is altered. </li></ul><ul><li>Usually indicates a number, time, position, direction, color or sense of negation. </li></ul>
  38. 38. Medical Terminology <ul><li>Etymology: Prefixes of Position </li></ul><ul><li>Examples: </li></ul><ul><ul><li>ante, pre, pro = before </li></ul></ul><ul><ul><li>hyper = excessive or high (also of number) </li></ul></ul><ul><ul><li>hypo, infra, sub = under, below (also of #) </li></ul></ul><ul><ul><li>Intra = within* </li></ul></ul><ul><ul><li>Inter = between* </li></ul></ul><ul><ul><li>peri = around </li></ul></ul><ul><ul><li>medi, meso = middle </li></ul></ul><ul><ul><li>retro = behind, backward </li></ul></ul><ul><ul><li>Eso = inward / exo = outward, outside </li></ul></ul><ul><ul><ul><li>*most commonly confused ie. IOP </li></ul></ul></ul>
  39. 39. Medical Terminology <ul><li>Etymology: Prefixes of Number </li></ul><ul><li>Examples </li></ul><ul><ul><li>Bi = two </li></ul></ul><ul><ul><li>Dipl, diplo = double </li></ul></ul><ul><ul><li>Hemi = half </li></ul></ul><ul><ul><li>Mono, uni = one </li></ul></ul><ul><ul><li>Macro = large </li></ul></ul><ul><ul><li>Micro = small </li></ul></ul><ul><ul><li>Poly = many </li></ul></ul>
  40. 40. Medical Terminology <ul><li>Etymology: Prefixes of Negation </li></ul><ul><li>Examples : </li></ul><ul><ul><li>a = without, not (used before a consonant) </li></ul></ul><ul><ul><li>an = without, not (used before a vowel) </li></ul></ul><ul><ul><li>im, in = in, not </li></ul></ul>
  41. 41. Medical Terminology <ul><li>Etymology: Other Prefixes </li></ul><ul><li>Examples : </li></ul><ul><ul><li>Anti, contra = against </li></ul></ul><ul><ul><li>Brady = slow </li></ul></ul><ul><ul><li>Tachy = fast </li></ul></ul><ul><ul><li>Dys = bad, painful, difficult </li></ul></ul><ul><ul><li>Hetero = different </li></ul></ul><ul><ul><li>Pan = all </li></ul></ul>
  42. 42. Medical Terminology <ul><li>Etymology: Rules </li></ul><ul><li>Two basic rules for building words . </li></ul><ul><ul><li>1) a root word is used before a suffix that begins with a vowel. </li></ul></ul><ul><ul><li>Example: </li></ul></ul><ul><ul><ul><li>Scler (hardening) + osis (abnormal condition) = sclerosis (abnormal condition of hardening </li></ul></ul></ul>
  43. 43. Medical Terminology <ul><li>Etymology: Rules </li></ul><ul><ul><li>2-1) a combining vowel is used to link a root word to a suffix that begins with a consonant. </li></ul></ul><ul><ul><li>Example: </li></ul></ul><ul><ul><ul><li>ophthalm (eye) + o + scopy (to view) = ophthalmoscopy (visual examination of the eye interior) </li></ul></ul></ul>
  44. 44. Medical Terminology <ul><li>Etymology: Rules </li></ul><ul><ul><li>2-2) a combining vowel is used to link two word roots together. </li></ul></ul><ul><ul><li>Example : </li></ul></ul><ul><ul><ul><li>oste (bone) + o + arthr (joint) + itis (inflammation) = osteoathritis (inflammation of the bone & joint) </li></ul></ul></ul>
  45. 45. Medical Terminology <ul><li>Etymology: Defining words </li></ul><ul><li>Three steps: </li></ul><ul><li>1) Define the suffix, or last part of the word </li></ul><ul><li>2) Define the prefix, or the first part of the word </li></ul><ul><li>3) Define the middle </li></ul>
  46. 46. Medical Terminology <ul><li>Etymology: Defining words </li></ul><ul><li>Example: gastroenteritis </li></ul><ul><li>1) define the suffix, itis = inflammation </li></ul><ul><li>2) define the prefix, gastro = stomach </li></ul><ul><li>3) define the middle, enter = intestine </li></ul><ul><li>Definition: inflammation of the stomach & intestine </li></ul>
  47. 47. Medical Terminology <ul><li>Etymology: Defining words </li></ul><ul><li>Example: polyarthritis </li></ul><ul><li>1) define the suffix, itis = inflammation </li></ul><ul><li>2) define the prefix, poly = many </li></ul><ul><li>3) define the middle, arthr = joint </li></ul><ul><li>Definition: inflammation of many joints </li></ul>
  48. 48. Medical Documentation Charting & Terminology <ul><li>References </li></ul><ul><li>Bates’ Guide to Physical Examination and History Taking , 8th Ed., Chap 1&2 </li></ul><ul><li>The Record That Defends its Friends , all </li></ul><ul><li>Medical Terminology; A Systems Approach , 4th Ed., chap 1-4 & 16 </li></ul>
  49. 49. *