Define: charting diagnosis discharge summary report electronic medical record health history report Informed consent medical record medical record format paper-based patient record physical exam report prognosis subjective symptoms

Chp 1 Managing Medical Records Lesson 1: Managing Medical Records

Lesson Objectives Upon completion of this lesson, students should be able to … Define and spell the terms to learn for this chapter. Discuss the problem-oriented medical record. Describe the four components of the SOAP charting method.

Categories and Reports Found in a Medical Record (pg 6) Health hx report Physical exam report Office notes Progress notes Pathology results Admin. documents Medication record Physician orders Radiology reports Laboratory reports Operative reports ECGs Miscellaneous

Sections of the Medical Record Database Problem list Treatment plan Progress notes

SOAP Charting four parts (see page 29) “S” ◦ subjective information gathered from the patient –usually the CC “O” ◦ Objective data gathered during the visit -measurable

SOAP Charting “A” ◦ assessment, physician’s preliminary diagnosis ◦ “P” ◦ plan of care for this patient

Practice SOAP Charting Problem list form

Critical Thinking Question 1. What types of information should not be included in the patient chart, and why?

Information that SHOULD NOT be Included in a Patient’s Chart Your opinions Internal office problems Subjective comments

Contents that SHOULD BE Included in the Medical Record Factual (objective) statements Everything…. Legible writing in black ink only

Study Guide (aka workbook) Evaluation of Learning ◦ Page 5 ◦ Questions 1-10 ◦ Write in book!

How to Correct an Error in the Medical Record Do not erase or scribble out the original error NO White Out Draw a single line through the error Initial above the single line Date entry write in the correction

Correcting errors

Steps for Adding Items to a Patient’s Chart Add item as soon as it is found that the item was omitted Locate the last entry Using a pen with black ink, place the current date On the same line, after the date, write, “Late entry”

Steps for Adding Items to a Patient’s Chart Enter the information that was originally omitted Sign the entry with your full name and credentials

Responsibilities of the MA Document clearly Be accurate Keep up to date easily accessible

Study Guide (aka workbook) Evaluation of Learning ◦ Page 6 ◦ Questions ◦ Write in book!

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