CHAPTER 1

1. CHAPTER 1 THE MEDICAL RECORD

2. PRETEST True or False • The medical record serves as a legal document. • The purpose of progress notes is to update the medical record with new information. • The patient registration record consists of a list of the problems associated with the patient's illness. • All over-the-counter medications taken by the patient should be charted on the medication record form. • A consultation report is a narrative report of a clinical opinion about a patient's condition by a practitioner other than the primary physician.

3. PRETEST, cont. True or False • A report of the analysis of body specimens is known as a diagnostic report. • Medical impressions are conclusions drawn from an interpretation of data. • A consent to treatment form is required for tuberculin skin testing. • Diabetes mellitus is an example of a familial disease. • Pain is an example of an objective symptom.

4. Content Outline Medical record: Written record of important information regarding a patient Patient: An individual receiving medical care Function To make decisions regarding patient's care and treatment To document results of treatment and patient's progress Communicate information to authorized personnel in medical office Serves as a legal document Law requires that patient's care and treatment be documented Introduction to the Medical Record

5. Introduction to the Medical Record, cont. Good documentation Works to legally protect the physician and medical staff Incomplete records Can be used as evidence to show that patient did not receive quality care Information is strictly confidential Must not be read or discussed by anyone not involved in care of the patient

6. Highlight on the HIPAA Privacy Rule HIPAA: Health Insurance Portability and Accountability Act HIPAA Privacy Rule: Federal law that protects patient's privacy Went into effect April 14, 2003 Purpose Provide patients with more control over use and disclosure of their health information (Known as PHI: Protected health information)

7. Highlight on the HIPAA Privacy Rule, cont. Who must comply: Anyone that uses, stores, maintains or transmits health information Health care providers Health plans Health care clearinghouses (e.g., billing services) What is included in the HIPAA Privacy Rule See Highlight on the HIPAA Privacy Rule

8. Components of the Medical Record Consists of numerous documents Each document has a specific function Preprinted forms are often used Documents can be classified into categories

9. Medical Office Administrative Documents Contain information for efficient record keeping of office • Consists of demographic and billing information • Must be completed by all new patients Patient Registration Record

10. Patient Registration Record, cont. Most offices enter this information into the computer Original placed in front of patient's chart Information is used for a number of computerized functions (e.g., scheduling appointments, posting patient transactions, processing patient statements and insurance claims) Original registration record Placed in front of patient’s medical record

11. Patient Registration Record, cont. 6. Includes: Demographic information • Full name • Address • Phone (home and work) • Date of birth • Gender • Marital status • Employer

12. Patient Registration Record, cont. Billing information Name of responsible party Social Security number Address of responsible party Name of insured Insurance company Policy and group number

13. Correspondence May be received from: Insurance companies Example: Precertification authorization Patient’s attorney Patient

14. Correspondence, cont. • May be sent from office: • Patient referral letter • Collection letter

15. Medical Office Clinical Documents Subjective data about the patient Records and reports that assist physician in care and treatment of patient Health History Report

16. Health History Report, cont. Health history obtained by: Having patient complete a preprinted form Physician or MA during an interview

17. Health History Report, cont. Health history, physical examination, and laboratory and diagnostic tests are used to: Determine patient's state of health Arrive at a diagnosis Diagnosis: The scientific method of determining and identifying a patient's condition Prescribe treatment Document change in patient's illness after treatment

18. Health History Report, cont. Thorough history obtained on each new patient Subsequent visits Provides additional information regarding changes in: Patient's condition Treatment

19. Physical Examination Report Physical examination: Assessment of each part of patient's body Purpose: Provides objective data about the patient Assists physician in determining patient's state of health

20. Physical Examination Report, cont. • Physical Examination Report: • A summary of the physician's findings from each part of the body • Includes: • General appearance • Head and neck • Eyes • Ears • Nose

21. Physical Examination Report, cont. Mouth and pharynx Arms and hands Chest and lungs Heart Breasts Abdomen Genitalia and rectum Legs and feet

22. Progress Notes Purpose Update medical record with new information when patient visits the office or telephones Must include: Date and time Signature and credentials of individual making entry

23. Medication Record Detailed information on patient's medications Includes: Prescription meds Over-the-counter medications Meds administered at medical office

24. Medication Record, cont. Types of forms Prescription and Over-the-Counter Medication Record Form Medications Administration Record Form

25. Medication Record, cont.

26. Consultation Report Narrative report of clinical opinion about a patient's condition by a practitioner other than primary physician (consultant) Usually is usually a specialist (e.g., cardiologist) Consultant's opinion is based on: Review of patient's record Examination of patient

27. Consultation Report,cont. Modified from Diehl MO, Fordney MT: Medical transcription: techniques and procedures, ed 5, Philadelphia, 2003, Saunders.

28. Home Health Care Report Home health care: The provision of medical and nonmedical care in a patient's home Purpose Minimize effect of disease or disability on the patient by: Promoting health Maintaining health Restoring health Home health care must be ordered by physician

29. Home Health Care Report, cont. Home health care professionals Nurses Home health aides Dietitians Physical therapists Occupational therapists Speech therapists Social workers

30. Home Health Care Report, cont. Home health services Cardiac Infusion (IV) therapy Respiratory therapy Pain management Diabetes management Rehabilitation Maternal-child care Summary report sent to patient's physician

31. Home Health Care Report, cont. Courtesy of and Modified from Briggs, Des Moines, Iowa.

32. Laboratory Documents Laboratory Report: A report of the analysis or examination of body specimens Purpose Relay results of laboratory tests to physician to assist in diagnosis and treatment of disease

33. Laboratory Documents, cont. Categories of Laboratory tests Hematology Clinical chemistry Serology Urinalysis Microbiology Parasitology Cytology Histology

34. Diagnostic Procedure Documents Diagnostic Procedure Report: Narrative description and interpretation of a diagnostic procedure Diagnostic procedure: A type of procedure performed to assist in diagnosis, management, or treatment of a patient's condition. Performed by physician, MA, or specially trained technician Interpretation of results made by physician Physician completes a written report

35. Diagnostic Procedure Documents, cont. Examples of diagnostic procedure reports Electrocardiogram report Holter monitor report Sigmoidoscopy report Colonoscopy report Spirometry report Radiology report Diagnostic imaging report

36. Radiology Report Modified from Diehl MO, Fordney MT: Medical keyboarding, typing, and transcribing, ed 4, Philadelphia, 1997, Saunders.

37. Diagnostic Imaging Report (CT Scan)

38. Therapeutic Service Documents Therapeutic Service Report: Documents the assessments and treatment designed to restore a patient’s ability to function

39. Therapeutic Service Documents, cont. • Example of therapeutic services: • Physical therapy: Use os physical agents to restore function and promote healing following an illness or injury • Therapeutic exercise • Thermal modalities • Cold • Hydrotherapy • Electrical stimulation • Massage

40. Therapeutic Service Documents, cont. Occupational therapy: Helps the patient learn new skills to adapt to a disabling condition Enables patient to perform activities of daily living Achieve as much independence as possible Speech therapy: Treatment for the correction of a speech impairment resulting from: Birth Disease Injury

41. Hospital Documents Prepared by the physician responsible for care of the patient in the hospital Known as the attending physician May be: Patient’s regular physician A different physician (e.g., emergency room physician)

42. Hospital Documents, cont. Dictated by attending physician and transcribed at the hospital Original kept on file at hospital Copy sent to patient’s physician Assists patient’s physician in: Reviewing patient’s hospital visit Providing follow-up care

43. History and Physical Report Inpatient: Patient who has been admitted to hospital for at least one overnight stay Health history and physical examination must be performed on all inpatients Exception: If history and physical examination are performed at medical office 1 week before admission Can be used instead

44. History and Physical Report, cont. If reliable health history cannot be obtained from patient Obtained from a person able to relay the facts Consists of a narrative report of: Health history Physical examination Physician’s medical impressions

45. History and Physical Report, cont. Purpose of health history: document patient’s current complaints and symptoms Purpose of physical examination: assess patient’s current health status

46. History and Physical Report, cont. Medical impressions: Conclusions drawn from interpretation of data Other terms used: Provisional diagnosis Tentative diagnosis Physician interprets data from health history and physical examination Draws conclusions (medical impressions) as to patient’s state of health

47. Hospital History and Physical Examination Report

48. Operative Report Must be completed on all patients who have had a surgical procedure Purpose: describes the surgical procedure Completed and signed by surgeon performing operation

49. Operative Report, cont. Includes: Patient identification information Date of surgery Preoperative diagnosis Name of surgical procedure Full description of findings

50. Operative Report, cont. Description of technique and procedures used Ligatures and sutures used Number of packs, drains, and sponges used Description of specimens removed Condition of patient after completion of surgery Postoperative diagnosis Name of surgeon