1. Medical Records

2. What are medical records?  Legal documents  Management of patient care  Alert healthcare providers to changes in patient conditions  Provide clinical data for research  Documents belong to healthcare provider  Medical information belongs to patient  Governed by HIPAA guidelines  May be paper, electronic, or combination of both

3. Types/format  Inpatient:  Hospital, rehabilitation facility, nursing home  Admission demographics  Admission assessment  Physician’s orders  History and physical  Intake/output; vital signs  Medication administration records  Progress notes  Multidisciplinary team notes  Nurses notes/flow sheets  Transfer forms  Lab, radiological reports  Billing information

4. Types/format  Outpatient  Physician’s practice  Clinic  History and physical  Lab/radiological reports  Physician’s orders  Vitals signs flow sheet  Physician’s progress notes

5. Admission  Physician must authorize; RN has primary responsibility  Assistive personnel help as directed  Identify patient  Customer service important to patient and family; provide comfort and reassurance  Admission assessment; specimen collection, document medications from home, equipment or prosthesis from home, valuables  History and physical  Physician’s orders  Lab/radiological reports  Physician and multidisciplinary team notes

6. Transfer  To another unit or hospital (discharge); usually dependent upon patient condition  transfer form including assessment  If patient to be transferred to another facility; pack all belongings. Document if belongings sent with patient or family member.  If patient transferred to another unit, pack belongings, may have to gather medications, take medical record; document that belongings and records sent with patient

7. Discharge  Home, another hospital, extended care facility, funeral home  discharge assessment and documentation  Disposition of belongings

8. Summary  Medical records provide vital information about the patient over a period of time  Follow facility policy and HIPAA guidelines re: access, storage, retrieval