Ch.3 Health Records Systems

obtaining the patients medical hx is usually the responsibility of the

attending physician

who must sign the dc summary

attending physician

expressed consent

spoken or written consent

describe: standards

statements of expected behavior

define: care plan

summary of the pts problems with a detailed plan for intervention

Who may provide some preliminary information on a patient before they are admitted to a hospital?

the attending or primary physician

ADMINISTRATIVE DATA

...

CLINICAL DATA

...

3 common accrediators for hospitals

1. AOA 2. TJC 3. DNV's NIAHO

what type of documentation are nurses held responsible for?

1. admission and dc notes 2. pts condition at regular intervals 3. notes regarding pts death if necessary 4. pts vitals 5. medication orders and/or flow records

2 types of data found in the health record

1. clinical 2. administrative

Medical history usually documents

1. current complaints 2. past medical, personal, and family hx

The EHR may also be known as:

1. electronic medical record 2. computer based patient record

Functions of the dc summary

1. ensures continuity of care 2. provides info to support activities to the medical staff review committee 3. provides concise info used to answer info requests from authorized individuals

4 main sources to locate standards

1. facility by laws 2. licensure requirements 3. govt. reimbursement programs (Medicare) 4. Accrediation standards

List ways the health record may be used

1. planning services 2. evaluation effectiveness of care 3. reimbursement 4. protects against legal issues 5. communication 6. research 7. public health 8. organization activites

What must the statement include concerning a pts death

1. reason for admission 2. dx 3. course in the hospital 4. description of events that led up to pts death

10 basic components of the acute care health record

1. registration record 2. medical hx 3. physical exam 4. clinical observations 5. Phsicians orders 6. dx and therupeutic procedures 7. consult reports 8. dx summary 9. patient instructions 10. consent, authorizations, etc...

When did HHS publish the first set of federal rules dealing with health info privacy and security?

2001

What does the Privacy Rule require providers to secure?

A signed acknowledgement that he or she received the provider's notice of privacy practices.

When may covered entities use and disclose patient information without prior written permission from the patient? When did them become effective?

TPOs; Oct. 2002

What must be done when a pt dies?

The attending physician must add a summary statement to the hr to doc. the circumstances surrounding the death. May be in the form of a seperate report or a final progress note

what typically follows an assessment

a care plan

What type of record should be documented on every patient?

admission and dc orders (unless pt. is AMA)

face sheet aka

admission or registration record

provisional dx aka

admitting or working dx

administrative data is generally collected by the

admitting personnel

when must a pt consent to tx?

after an explanation and oppurtunity to ask questions

dc summary

an account of the pts illness, course of tx, reponse to tx, and condition at time of dc. Also has follow up instructions

nurses documentation begins with

an assessment focused on understanging the pts condition from the perspective of their specialized knowledge

preop notes are made by the

anesthesiologist and surgeon

implied consent

assumed when a pt voluntarily submits to tx

postpartum records

begins after the birth and contains progress notes

what does state govts use to collect health stats?

birth and death certificates

a newborn record begins with

birth hx

what should be included in the transfer note

brief review of pt stay, current status, dc and transfer orders, any additonal instructions if needed

describe: clinical data

contain medical information

describe: administrative data

contains demographic information and financial information

What is a main purpose of the health record?

documentation of patient care

consult report

documents the clinical opinion of a physican other than the primary

what is a post-anesthesia notes

documents the pts recovery from an anesthia

how are the results of most lab procedures generated

electronically by automated testing equipment

when may some information be collected via a orgs web site or by phone interview

for elective admissions

physician documentation begins with

h&p exams

What is the main communication source during patient care?

health record

when may a transfer record be intiated

if a pt is being moved from one facility to another

when may a consulting physician enter info into the progess notes?

if they have medical staff privilieges

where does a mother's record begin

in her practitioners office

where is the baby's info maintained in the case the baby dies during delivery

in the mothers record

recovery room report

includes post anesthesia notes, pt. condition and surgical site, vitals, fluids, etc

delivery record

includes type of delivery, meds administered, vitals, data about the baby such as weight, apgar scores, etc...

define: physicians orders

instructions the physician gives to other healthcare professionals

who reports preop patient preparations?

nurses

consent to tx

obtained before providing services except in emergency situations

if instructions were given to anyone other than the pt what should be done?

it should be documented that they were given to another responsible party

What type of results may require to be interpreted by a trained specialist?

monitors, radiology, and pathologies

written consents should be witnessed by at least

one person

define: standing order

orders preestrablished for specific dx or procedures

a pathology report is dictated by a

pathologist

an autopsy report is completed by a

pathologist

when tissue is removed for evaluation what type of report must be done?

pathology report

elective admit

planned in advance

documentation of clinical observations are usually provided in the

progress notes

what is financial information limited to in an acute care health record

pts insurance information

a transfer record is aka

referral form

who has the responsibilty to ensure the pt understands the nature of a procedure

the physicians

define: admission

the process of formal registration

what determines the frequency of the progress notes

the pts. condition

what is the purpose of the progress notes

to create a chronological report of the patients care and justify continuing care

battery

unlawful touching of an individ. (w/out consent)

when is record generated for a newborn?

upon live birth

how are signatures attached to physican orders in an electronic system?

via an authentication process

what is an example of a special type of situation that may require special types of notes

when a pt is receiving an anesthia, the anethesiologist will have to document factors that may have an impact on that procedure

when may a dc note be acceptable in the place of a full report

when stay was uncomplicated and lasted less than 48 hrs

patient instructions should be communicated in ___ and ___

writing and verbally

Does a consent become part of the patients hr

yes

are consents part of the administrative record?

yes

does the autopsy report become part of the patients record

yes

is the mother's ob record seperate from the infants record?

yes

may a pathology exam be done during the surgical procedure?

yes

must standing orders be signed and dated?

yes

May the content of the health record vary?

yes depending on the setting and specialty

if a patient brings items with them to the healthcare facility must it be documented? what type of documentation is this?

yes. administrative