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Documentation and Medical Records
Chapter 19 Documentation and Medical Records
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HIPAA PHI (protected health information) The Privacy Rule
The Security Rule Possible consequences of not following HIPAA regulations
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Question Which of the following is true about HIPAA?
It protects the health care facilities It protects patients It protects the safety of health care professionals
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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
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Definitions Medical documentation Medical record Charting
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Purposes Contributes to good patient care Provides legal protection
Helps ensure regulatory compliance Improves cost control Decreases denials from insurance companies
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Characteristics Complete with all requested information
Concise and factual Properly identified Legible Correct spelling, terminology, punctuation, and grammar
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Characteristics Clearly and objectively expressed
Findings not duplicated Approved abbreviations listed in facility’s policy used Time and date given for all entries
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Characteristics Signed by proper person
Completed without leaving empty lines Always charted after giving medication or performing procedure, not in advance Written with black or blue ink
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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
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Question Which of the following is the recording of observations and information about patients? Charting Medical documentation Medical record
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Answer A. Charting Charting Medical documentation
Recording of observations and information about patients Medical documentation Notes and documents that health care professionals add to medical record
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Answer A. Charting Medical record
Collection of all documents filed together Form complete chronological health history
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Medical Records Organized per facility policy
All health care workers responsible to maintain records per facility policy Chronological or source-oriented
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Medical Records Content
History and physical (H&P) Physician’s orders Diagnostic tests Admissions Surgical procedures
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Medical Records Content
Graphics Flow sheets Medication record Progress notes
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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
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Question Which of the following is a form used for specialty needs?
Progress notes Graphics Flow sheets
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Answer C. Flow sheets Flow sheets Progress notes
Forms for specialty needs Progress notes Written chronological statements about patient’s care
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Answer C. Flow sheets Graphics Graphed forms for vital signs
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Progress Notes Primary tool May include the following:
Recording, communicating, and coordinating care of patient May include the following: Observations Treatments Patient response
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Progress Notes: Formats
Problem-oriented charting Narrative charting Charting by exception Computerized
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Question True or False:
The chief complaint is the reason the patient is seeking medical care.
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Answer True Chief complaint Reason patient seeks medical care
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EHRs EHR systems can go far beyond core charting Coordination tools
Information Safety tools Scanned documents
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EHRs Can only communicate within same health care system
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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
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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)
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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
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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
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Personal Health Record (PHR)
Types of information to include Foreign travel Family history information
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Question True or False:
EHRs have about the same capabilities and limitations as written charting.
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Answer False EHR systems can go far beyond core charting
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