1 / 33

Chapter 19

Chapter 19. Documentation and Medical Records. Definitions. Medical documentation Medical record Charting. Purposes. Contributes to good patient care Provides legal protection Helps ensure regulatory compliance Improves cost control Decreases denials from insurance companies.

higginsr
Download Presentation

Chapter 19

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Chapter 19 Documentation and Medical Records

  2. Definitions • Medical documentation • Medical record • Charting

  3. Purposes • Contributes to good patient care • Provides legal protection • Helps ensure regulatory compliance • Improves cost control • Decreases denials from insurance companies

  4. Characteristics • Complete with all requested information • Concise and factual • Properly identified • Legible • Correct spelling, terminology, punctuation, and grammar

  5. Characteristics • Clearly and objectively expressed • Findings not duplicated • Approved abbreviations listed in facility’s policy used • Time and date given for all entries

  6. Characteristics • Signed by proper person • Completed without leaving empty lines • Always charted after giving medication or performing procedure • Written with black or blue ink

  7. 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

  8. Question • Which of the following is the recording of observations and information about patients? • Charting • Medical documentation • Medical record

  9. Answer • A. Charting • Charting • Recording of observations and information about patients • Medical documentation • Notes and documents that health care professionals add to medical record

  10. Answer • A. Charting • Medical record • Collection of all documents filed together • Form complete chronological health history

  11. Medical Records • Organized per facility policy • All health care workers responsible to maintain records per facility policy • Chronological or source-oriented

  12. Medical Records Content • History and physical (H&P) • Physician’s orders • Diagnostic tests • Admissions • Surgical procedures

  13. Medical Records Content • Graphics • Flow sheets • Medications record • Progress notes

  14. 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

  15. Question • Which of the following is a form used for specialty needs? • Progress notes • Graphics • Flow sheets

  16. Answer • C. Flow sheets • Flow sheets • Forms for specialty needs • Progress notes • Written chronological statements about patient’s care

  17. Answer • C. Flow sheets • Graphics • Graphed forms for vital signs

  18. Progress Notes • Primary tool • Recording, communicating, and coordinating care of patient • May include the following: • Observations • Treatments • Patient response

  19. Progress Notes: Formats • Problem-oriented charting • Narrative charting • Charting by exception • Computerized

  20. Question • True or False: • The chief complaint is the reason the patient is seeking medical care.

  21. Answer • True • Chief complaint • Reason patient seeks medical care

  22. EMRs • EMR systems can go far beyond core charting • Coordination tools • Information • Safety tools • Scanned documents

  23. EMRs • Can only communicate within same health care system

  24. 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

  25. 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)

  26. 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

  27. 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

  28. Personal Health Record (PHR) • Types of information to include • Foreign travel • Family history information

  29. Question • True or False: • EMRs have about the same capabilities and limitations as written charting.

  30. Answer • False • EMR systems can go far beyond core charting

  31. HIPAA • The Privacy Rule • The Security Rule • Possible consequences of not following HIPAA regulations

  32. Question • Which of the following is true about HIPAA? • It protects the health care facilities • It protects patients • It protects the safety of health care professionals

  33. 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

More Related