The Medical Record Chapter 4

Medical records The medical record is a legal document that records a single patient’s medical history over time. Some things you might find in a medical record include: Past medical history Past and current treatments and therapies Past and current medications Physician observations X-rays and other test results Regulations and legal considerations State and federal agencies regulate the format, accepted terminology and abbreviations, and who may have access to medical records What does it mean when we say the medical record is a legal document? Who has access to it?

Correcting Medical records How to correct an error made in a medical record: If a mistake is made in a handwritten entry it should be identified by drawing a single line through it in addition to the following; Date of correction The abbreviation “corr” Initials and credentials of person making corrections **Never use white out or correction fluid**

Common records used in documenting care of a patient History and Physical (H & P) Document of medical history and findings from the physical examination Includes: Subjective Information  History obtained from patient including his/her personal perceptions Objective Information  Physical facts and observations made by the examiner Would each of the following be considered subjective or objective information? Patient complains of sore throat and drainage for 4 days Patient has a blood pressure (BP) of 130/85 Physician reports patient has a fever of 102 F Patient has 4 small children ages 2-12

History and Physical (H & P) cont. History (Hx) Record of the patient’s personal medical history including past injuries, illnesses, operations, defects and habits Includes: Chief Complaint (CC) History of present illness (HPI) Past history (PH) Family history (FH) Occupational history (OH) Review of systems (ROS)

History and Physical (H & P) cont. History (Hx) Abbreviations CC Chief Complaint or c/o complains of Brief description of why patient is seeking care PI Present Illness or HPI History of present illness Notation of duration and severity of complaint. How bad is it? How long have they had it? Sx Symptom Evidence of illness that the patient reports PH Past History or PMH Past Medical History Notation of surgeries, injuries, physical defects, medications and allergies

History and Physical (H & P) cont. History (Hx) Abbreviations UCHD usual childhood diseases NKA no known allergies NKDA no known drug allergies FH Family History Notes about the state of health of immediate family members Example: FH: father, age 58, mother, age 54, brother, age 32, all L&W A&W alive and well L&W living and well

History and Physical (H & P) cont. History (Hx) Abbreviations SH Social History Recreational interests, hobbies, use of tobacco/drugs OH Occupational History Work habits that may involve work related risks ROS Review of Systems or SR Systems Review Questions related to function of the body systems

History and Physical (H & P) cont. Physical Exam (Px or PE) Document of physical examination of a patient including notations of positive and negative findings Includes: Results of diagnostic testing Signs, or objective evidence of the disease, is documented and further diagnostic test are ordered if necessary

History and Physical (H & P) cont. Physical Exam (Px or PE) Abbreviations HEENT head, eyes, ears, nose, throat PERRLA pupils equal, round and reactive to light and accommodation NAD no acute distress, no appreciable disease WNL within normal limits

History and Physical (H & P) cont. Physical Exam (Px or PE) Abbreviations cont. A assessment Identification of a disease or condition after evaluation of all subjective and objective information IMP impression Dx diagnosis R/O rule out A differential diagnosis is noted when one or more diagnosis are suspected Example: Dx: R/O pancreatitis R/O gastroenteritis Requires further testing to verify or eliminate each possibility

SOAP Notes Progress notes made after the initial history and physical is recorded. The letters represent the order in which progress is noted: S subjective that which the patient describes O objective observable information, such as test results, blood pressure readings, etc. A assessment progress and evaluation of the effectiveness of the plan P plan decision to proceed or alter strategy

Common Hospital records History and Physical Physician’s orders Directions for care Diagnostic tests/laboratory reports Nurse’s notes Physician’s progress notes Consultation report Included if the case is difficult enough to call in a specialist Operative report Pathology report Anesthesiologist’s report Discharge summary Summary of patient’s hospital care, including date of admission, diagnosis, course of treatment, final diagnosis and date of discharge

Common Patient care abbreviations Individual medical facilities provide their own list of acceptable terms and abbreviations that may differ from site to site. Therefore, use only those acceptable to the specific workplace. ER, ECU emergency facility PAR, PACU place to recover after surgery IP inpatient preop care before surgery pt patient WDWN well developed, well nourished BRP bathroom privileges SOB shortness of breath Tx, Tr treatment

Common Patient care abbreviations cont.  increase  decrease ° degree or hour # pound or number sign VS vital signs T temperature P pulse R respiration BP blood pressure

Error prone abbreviations and symbols Medical errors caused by illegible entries and misinterpretations have led health care agencies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), to require that medical facilities publish lists of authorized abbreviations for use by all personnel, including a list of those unacceptable

Error prone abbreviations and symbols q.d every day Risk: mistaken for q.i.d when period after the “q” is sloppily written to look like an I Preferred use: spell out the term “daily” q.o.d every other day Risk: mistaken for q.d when the “o” is mistaken for a period Preferred use: spell out “every other day” DC, D/C discharge, discontinue Risk: “discharge” could be mistaken for “discontinue” when followed by medications prescribed at the time of discharge Preferred use: spell out “discontinue” or “discharge”

Error prone abbreviations and symbols AS, AD, AU left ear, right ear, both ears Risk: mistaken for each other Preferred use: spell out OS, OD, OU left eye, right eye, both eyes SC or SQ subcutaneous Risk: mistaken for SL (sublingual) or “5 every” Preferred use: spell out “subcutaneously” or use “Sub-Q”

Common terms related to disease acute vs chronic benign vs malignant localized vs systemic exacerbation vs remission progressive recurrent degenerative symptom sign diagnosis syndrome

Pharmaceutical Abbreviations and symbols Metric cc (cubic centimeter) cm (centimeter) g or gm (gram) kg (kilogram) L (liter) mg (milligram) ml,mL (milliliter) Note: 1cc = 1 mL mm (millimeter) cu, mm (cubic millimeter)

Pharmaceutical Abbreviations and symbols Apothecary fl oz (fluid ounce) gr (grain) gt (drop) gtt (drops) dr (dram; 1/8 oz) oz (ounce) lb or # (pound) qt (quart)

Medication Administration—Drug forms Solid and Semisolid Forms Tablet (tab) Capsule (cap) Suppository (suppos) Liquid Forms Fluid Parenteral (ID, Sub-Q, IM, IV) Cream, lotion, ointment Other delivery systems Transdermal Absorption through unbroken skin Implant Imbedded in the body to continually release medicine

Parenteral drug administration

The prescription A prescription is a written direction for dispensing or administering a medication for a patient Must be written in a specific format Rx Symbol at beginning of prescription Stands for recipe Includes name of drug and directions on how to take it

Drug names Chemical name assigned to drug at the time it is formulated to describe the molecular structure of the drug Generic name  the official name given to a drug Trade or brand  the manufacturer’s name for a drug

Drug names For example Chemical name: 1-[[3-(6,7-dihydro-1-methyl-7oxo-3-propyl-1H- pyrazolo[4,3-pyrimidin-5-yl)-4-ethoxyphenyl]sulfonyl]-4- methylpiperazine citrate Generic name: sildenafil Trade or Brand name: Viagra

Sample prescription

Recording date and time The date and time are usually required for all entries in a medical record. Date Always include the month, day, and year Time Military time is often used