1. The Medical Record
Chapter 4

2. 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?

3. 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**

4. 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

5. 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)

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

14. 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

15. 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

16. 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

17. 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

18. 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”

19. 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”

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

21. 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)

22. 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)

23. 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

24. Parenteral drug administration

25. 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

26. 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

27. 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

28. Sample prescription

29. 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