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