© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Chapter 19 Documentation and Medical Records

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Definitions Medical documentation Medical record Charting

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Purposes Contributes to good patient care Provides legal protection Helps ensure regulatory compliance Improves cost control Decreases denials from insurance companies

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Characteristics Complete with all requested information Concise and factual Properly identified Legible Correct spelling, terminology, punctuation, and grammar

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Characteristics Clearly and objectively expressed Findings not duplicated Approved abbreviations listed in facility’s policy used Time and date given for all entries

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Characteristics Signed by proper person Completed without leaving empty lines Always charted after giving medication or performing procedure Written with black or blue ink

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Question Which of the following is the recording of observations and information about patients? A.Charting B.Medical documentation C.Medical record

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Answer A. Charting Charting –Recording of observations and information about patients Medical documentation –Notes and documents that health care professionals add to medical record

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Answer A. Charting Medical record –Collection of all documents filed together –Form complete chronological health history

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Records Organized per facility policy All health care workers responsible to maintain records per facility policy Chronological or source-oriented

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Records Content History and physical (H&P) Physician’s orders Diagnostic tests Admissions Surgical procedures

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Records Content Graphics Flow sheets Medications record Progress notes

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Question Which of the following is a form used for specialty needs? A.Progress notes B.Graphics C.Flow sheets

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Answer C. Flow sheets Flow sheets –Forms for specialty needs Progress notes –Written chronological statements about patient’s care

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Answer C. Flow sheets Graphics –Graphed forms for vital signs

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Progress Notes Primary tool –Recording, communicating, and coordinating care of patient May include the following: –Observations –Treatments –Patient response

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Progress Notes: Formats Problem-oriented charting Narrative charting Charting by exception Computerized

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Question True or False: –The chief complaint is the reason the patient is seeking medical care.

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Answer True Chief complaint –Reason patient seeks medical care

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. EMRs EMR systems can go far beyond core charting –Coordination tools –Information –Safety tools –Scanned documents

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. EMRs Can only communicate within same health care system

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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)

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Personal Health Record (PHR) Types of information to include –Foreign travel –Family history information

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Question True or False: –EMRs have about the same capabilities and limitations as written charting.

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Answer False EMR systems can go far beyond core charting

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. HIPAA The Privacy Rule The Security Rule Possible consequences of not following HIPAA regulations

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Question Which of the following is true about HIPAA? A.It protects the health care facilities B.It protects patients C.It protects the safety of health care professionals

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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