PATIENT MEDICAL RECORDS Chapter 7 PATIENT MEDICAL RECORDS

Patient Medical Records Learning Objectives List the components that make up medical records and discuss their importance to the practice, including their role as legal documents. Describe the components of the SOAP format—the most common format used for recording medical information about patients. Identify the three parts of the problem-oriented medical record (POMR) format. Chapter 7

Patient Medical Records (cont’d) Learning Objectives Transcribe medical data dictated by a physician, while applying guidelines for punctuation, capitalization, and the use of standard medical abbreviations, numbers, and symbols. Discuss the preservation of medical records. Explain who actually owns a patient’s medical record. List standards to be used for quality assurance in maintaining medical records. Chapter 7

Key Terms Assessment Chief complaint (CC) Diagnosis (Dx) Family history (FH) History of present illness (HPI) Impression Objective Past medical history (PMH) Physical exam (PE) Plan Problem-oriented medical record (POMR) Review of systems (ROS) Chapter 7

Key Terms (cont’d) Rule out (R/O) SOAP Social history (SH) Subjective Chapter 7

The Medical Record Patient’s chart or patient’s file Information on all aspects of a patient’s health care Vital to medical practice Continuum of patient care Financial and legal success of practice Research purposes Chapter 7

Legal Document Medical record is the legal record of the medical practice Used in litigation Content and quality of medical record Should be complete, legible, properly maintained Chapter 7

Contents of a Medical Record Chart notes History and physical Referral and consultation letters Medical reports Correspondence Clinical forms Medication list Administrative data Insurance and billing records Release of information and assignment of benefits Chapter 7

Why Maintain the Medical Record? Source of information for carrying out patient care Record of treatment Record of quality of care Tool for communication and continuity of care Legal record for the practice Record for reimbursement Data for research purposes Chapter 7

Maintaining the Medical Record An entry is made for each contact with patient Patient identifying information Date of contact Signature and title of provider Keyed or written in ink Compact Entries organized by type and date Chapter 7

Making Corrections Legal documents Cross out errors Do not erase; do not use correction fluid Cross out errors Single line; entry should still be legible Enter the word error next to the cross out Write your initials and the date Enter the correct information Chapter 7

The SOAP Method Subjective findings Objective findings Assessment Plan Patient’s chief complaint, history of present illness, past medical history, family history, social history, and review of symptoms Objective findings Results of physician’s exam of patient Assessment Also called diagnosis or impression Plan Also called treatment Includes prescribed medications, patient instructions, recommendations for procedures or tests Chapter 7

The POMR Method Problem-Oriented Medical Record Essential components Database Complete patient history and information from complete examination and tests Initial plan Details of the course of treatment Problem list Running list of patient’s problems Recorded in SOAP format Chapter 7

Transcribing Chart notes, other medical documents, and correspondence Good listening techniques Format guidelines Office policy Abbreviations used carefully Chapter 7

Records Retention and Ownership Time period determined by state law Move records from active to inactive storage Guidelines for transferring records should include when to transfer and storage medium to be used Ownership Physician’s property Information in record belongs to patient Patient controls the amount and type of information released Chapter 7

Quality Assurance Medical record is testament to quality of care given to patient Helps to maintain high standard of care Records should contain Dated notes describing patient services Notes recording every procedure performed Accurate notations Justification for hospitalization Discharge summaries Chapter 7

Quiz Match the abbreviation with the correct term. CC ROS POMR Dx HPI PE Problem-Oriented Medical Record History of present illness Chief complaint Review of systems Physical exam Diagnosis Chapter 7

Critical Thinking What are some advantages of using the POMR format for medical records? The physician can easily read what problems the patient has had, the frequency of the problems, and the treatments received. It saves the physician time by eliminating the need to read the entire chart to obtain necessary information. Chapter 7