Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. CHAPTER Introduction to Health Records 2

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. Learning Outcomes After studying this chapter, you will be able to: 2.1Summarize the SOAP method. 2.2Identify the types of health records. 2.3Use common terms on health records. 2.4Use abbreviations associated with heath care facilities, patient care, and prescriptions. 2.5Become familiar with different types of health records. 2-2

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. Introduction to Health Records Health records can be found in a paper chart or an electronic health record (EHR) Health records contain information about the patient –Previous illnesses and treatments –Current medical problems –History of family illnesses –Current medications The health record contains the data that will determine the patient’s care plan 2-3

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. Introduction to Health Records Medical notes share a consistent, logical organization Chapter 2 focuses on the organization of medical documents 2-4

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display The SOAP Method SOAP is an acronym for the different types of information documented by health care providers S = subjective: what the patient says O = objective: what the tests reveal A = assessment: the analysis of the subjective and objective information; performed by the health care provider P = plan: course of action for the patient 2-5

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.2 Types of Health Records Medical records vary in length and content 2-6

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.2 Types of Health Records Example Note #1: Clinic Note 2-7

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.2 Types of Health Records Example Note #2: Consult Note 2-8

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.2 Types of Health Records Example Note #3: Emergency Department Note 2-9

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.2 Types of Health Records Example Note #4: Admission Summary 2-10

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.2 Types of Health Records Example Note #5: Discharge Summary 2-11

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.2 Types of Health Records Example Note #6: Operative Report 2-12

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.2 Types of Health Records Example Note #7: Daily Hospital Note/ Progress Note 2-13

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.2 Types of Health Records Radiology ReportPathology Report 2-14

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.2 Types of Health Records Example Note #10: Prescription 2-15

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records Subjective –These are the problems that the patient states he/she has –Those problems are then translated into medical terms This is so that you can correctly communicate the problems to all health care providers 2-16

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records General subjective terms: symptom noncontributory acute vs. chronic abrupt progressive vs. exacerbation febrile vs. afebrile 2-17

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records Things that are seen: –alert –oriented Things that are heard: –auscultation –percussion Things that are felt: –palpation Descriptions of what is observed: –unremarkable –marked 2-18 General objective terms:

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records General assessment terms: impression diagnosis differential diagnosis etiology vs. idiopathic benign vs. malignant remission 2-19

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records General assessment terms (cont.): morbidity mortality prognosis localized vs. systemic/generalized pathogen lesion sequelae 2-20

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records General plan terms: disposition observation reassurance supportive care palliative 2-21

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records Body Planes and Orientation 2-22

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records Body Planes and Orientation 2-23

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records Body Planes and Orientation 2-24

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records Body Planes and Orientation 2-25

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records Body Planes and Orientation 2-26

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.3 Common Terms on Health Records Body Planes and Orientation 2-27

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.4 Abbreviations Areas of the Health Care Facility pre-op, OR, PACU, post-op ICU – intensive care unit: CCU, SICU, PICU, NICU ER, ED, and ECU L&D 2-28

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.4 Abbreviations Symbols 2-29

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.4 Abbreviations Common on Health Records VS are made up of the HR, RR, BP, and T I/O – input/output Dx DDx Tx Rx Hx: PMHx; FHx 2-30

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.4 Abbreviations Common on Health Records H&P CC HPI ROS PE PCP 2-31

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.4 Abbreviations PERRLA NOS RRR CTA A&O NAD A. alert and oriented B. regular rate and rhythm C. no acute distress D. pupils equal, round, and reactive to light and accommodation E. not otherwise specified F. clear to auscultation 2-32 Used for Symptoms or Exam Findings Match each abbreviation with its correct meaning.

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.4 Abbreviations Associated with Orders and Administering Medication Match each abbreviation with its correct meaning. PO IV SC CVL IM PR NPO A. intraveneous B. central venous line C. per rectum (anal) D. per os. (by mouth) E. subcutaneous F. nil per os (nothing by mouth) G. intramuscular 2-33

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.4 Abbreviations Associated with Prescriptions Match each abbreviation with its correct meaning. prn QID QD AC TID BID PC QHS A. three times a day B. as needed C. four times a day D. before meals E. every day F. after meals G. at night H. two times a day 2-34

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. 2.5 Electronic Health Records Review the examples of health care records and see if you can define the words that were presented in this chapter 2-35

Copyright © 2016 McGraw-Hill Education. Permission required for reproduction or display. Chapter 2 Summary: Learning Outcomes After studying this chapter, you should be able to: 2.1Summarize the SOAP method. 2.2Identify the types of health records. 2.3Use common terms on health records. 2.4Use abbreviations associated with heath care facilities, patient care, and prescriptions. 2.5Become familiar with different types of health records. 2-36