Chapter 38: The Medical Record

What is a Notice of Privacy Practices (NPP)?

Written document provided to patients that explains how their protected health information will be used and safeguarded by the medical office.

Why should the following be updated an/or documented in the patient's medical record? a. Allergies and current medications: b. Procedures performed on the patient: c. Specimens collected from the patient: d. Laboratory tests ordered for the patient: e. Instructions given to the patient regarding medical care:

a. Allergies and current medications: To maintain a current list. b. Procedures performed on the patient: To document that the procedure was performed. c. Specimens collected from the patient: To let the physician know that the specimen was collected and sent to the laboratory when test results are not back yet. d. Laboratory tests ordered for the patient: If the patient does not undergo the test, documented proof exists that the test was ordered. e. Instructions given to the patient regarding medical care: To document instructions given to the patient in the event that he or she fails to follow the instructions and causes further harm or damage to a body part.

List examples of when HIPAA does not require written consent for the use or disclosure of a patient's health information in the following categories: a. Treatment: b. Payment: c. Health care operations:

a. Treatment: Patient referral to a specialist, emergency care at a hospital, performance of tests on a patient by a laboratory. b. Payment: Determination of eligibility for insurance benefits, review of services provided for medical necessity, utilization review activities. c. Health care operations: Quality assessment activities, contacting of patients with information about care or treatment, employee review activities, training of health care students.

What type of information is documented on flow sheets in the medical record?

Similar data that may be viewed chronologically such as immunization records and vital signs.

Why is a copy of an emergency room report sent to the patient's family physician?

So that follow-up care can be provided.

What guidelines should be followed in recording the chief complaint?

-An open-ended question should be used to elicit the chief complaint. -The chief complaint should be limited to one or two symptoms and should refer to a specific rather than a vague symptom. -The chief complaint should be recorded concisely and briefly. -The duration of the symptoms should be included in the chief complaint. -Names of diseases or diagnostic terms should be avoided in recording the chief complaint.

List general guidelines for documenting in a patient's medical record.

-Check the name on the chart before making an entry. -Document information accurately in a logical order, using clear and concise phrases. -Spell correctly. -Document immediately after performing a procedure. -Procedures should never be documented in advance.

What does the term "meaningful use" refer to?

"Meaningful use" refers to the CMS incentive program that requires providers and institutions to prove that they are using the EMR in a meaningful way. For each stage of the program, there are additional requirements in order to receive financial incentive payments for Medicare patients.

What information must be included on a medical records release form?

-Patient's full name and address -Name of the medical practice releasing the information -Name of the individual or facility to receive the information -Specific information to be released -Purpose of or need for the information -Method of release of the information -Signature of the patient or the legal representative -Date that the consent form was signed -Expiration date of the consent form.

List the specific guidelines for documenting in the paper-based medical record.

-Use black ink to make entries. -Write in legible handwriting. -Begin each entry on a separate line but do not leave blank lines. -Ensure that each charting entry is signed by the person making it. -Never erase or obliterate an entry.

What is the purpose of a laboratory report?

A laboratory report documents the results of any laboratory test performed on patient specimens.

Who must comply with HIPAA?

All health care providers, health plans, and health care clearinghouses (e.g., billing services) that use, store, maintain, or transmit health information.

List five examples of home health services.

Cardiac home care, infusion (IV) therapy, respiratory therapy, pain management, diabetes management, rehabilitation, maternal-child care.

List and describe the four parts of a POR.

Database: Collection of subjective and objective data used to compile a patient list. Problem list: List of patient conditions that require observation, diagnosis, management, or patient education. Plan: Plan of action for further evaluation and treatment of each problem. Progress notes: Follow-up for each problem in SOAP format.

What information is included in a consultation report?

Documentation that the consultant reviewed the patient's health history, that the consultant examined the patient as well as a report of the consultant's impressions, care provided, and recommendations.

When is a procedure consent form required?

For all surgical operations and nonroutine diagnostic and therapeutic procedures performed in the medical office.

When must a patient complete a release of medical information form?

For release of medical information that is not part of medical treatment, payment, or health care operations (for example, moving and having records forwarded to a new physician).

What is the current illness, and how is this information obtained?

Full and detailed description of the patient's current illness from the time of its onset. It is obtained by asking a series of questions.

What is the meaning of the acronym HIPAA?

Health Insurance Portability and Accountability Act.

List three examples of familial diseases.

Hypertension, heart disease, allergies, diabetes mellitus.

What are the seven parts of the health history?

Identification data, chief complaint, present illness, past history, family history, social history, review of systems.

How can the EMR facilitate continuity of care?

It is easier to transmit records electronically when patients are referred to another setting of care or provider of care. In addition, continuity of care measures must be documented for Stage 2 Meaningful Use.

What does witnessing a signature mean? What does it not mean?

It means that the medical assistant verified the patient's identity and watched the patient sign the form. It does not mean that the medical assistant is attesting to the accuracy of the information provided.

List five examples of information included in the past medical history.

Major illnesses, childhood diseases, unusual infections, accidents and injuries, hospitalizations and operations, previous medical tests, immunizations, allergies, current medications.

What information must the patient receive before signing a procedure consent form?

Nature of the patient's condition, nature and purpose of the recommended procedure, explanation of any risks involved in the procedure, any alternative treatments or procedures available, likely outcome (prognosis), risks associated with declining or delaying the procedure.

List three examples of subjective symptoms.

Pain, pruritus, vertigo, nausea.

What are the two most common types of medical records?

Paper-based medical records and electronic medical records are the two most common types of medical records.

What is the difference between physical therapy and occupational therapy?

Physical therapy involves the use of physical agents to restore function and promote healing after an illness or injury; occupational therapy helps the patient learn new skills to adapt to a disabling condition.

List three categories of medications that may be included in a medication record.

Prescription medications, over-the-counter medications, and natural remedies or supplements.

What is the purpose of progress notes?

Progress notes provide an update of new information each time the patient visits the medical office.

List three examples of objective symptoms.

Rash, coughing, cyanosis.

List five examples of diagnostic procedure reports.

Reports on the results of electrocardiography, Holter monitoring, sigmoidoscopy, colonoscopy, spirometry, radiology, and diagnostic imaging.

What is reverse chronological order?

Reverse chronological order files notes and reports with the most recent on top.

Describe each of the following medical record formats: source-oriented record, problem-oriented record and electronic health record?

Source-oriented record- A medical record arranged by the source of each paper document (e.g. laboratory reports, hospital reports, diagnostic reports, etc. Problem-oriented record - a medical record arranged by patient problems. Progress notes are in SOAP format (subjective, objective, assessment, plan). Electronic health record - a medical record maintained using a computerized system where patient information is accessed from a database section, with major divisions into billing, clinical and scheduling sections. Within the clinical section there are tables that allow the clinician to link to various types of clinical information.

What is a chief complaint?

Symptom that is causing the patient the most trouble.

What is an advantage of the EMR related to allergies?

The EMR can cross check between allergies and medications ordered and flag any potential conflicts.

Briefly describe how the Health Information Technology for Economic and Clinical Health (ITECH) Act has accelerated the adoption of electronic health records.

The HITECH Act includes financial incentive payments to health care facilities and providers who adopt electronic medical records.

List three uses of the health history.

The health history is used to determine the patient's general state of health, to arrive at a diagnosis, to prescribe treatment, and to document any change in a patient's illness after treatment has been instituted.

What two general categories of information are included on a patient registration record?

The patient registration record includes demographic and billing information.

Explain the importance of the social history.

The patient's lifestyle may have an impact on the condition of that individual and influence the course of treatment chosen by the physician.

What is the purpose of the physical examination?

The physical examination is used to obtain objective data bout the patient.

List three functions of the medical record.

The physician uses the information in the medical record as a basis for making decisions regarding the patient's care and treatment; it serves to document the results of treatment and the patient's progress and provides an efficient and effective method by which information can be communicated to authorized personnel in the medical office; it also serves as a legal document.

What is the function of the problem list?

The problem list keeps track of all patient problems with date of onset and resolution (if any). It functions as a patient care plan.

Why are correspondence and messages filed or documented in a patient's medical record?

They constitute part of the patient's record of care for legal purposes.

What is the purpose of the review of systems (ROS)?

To assist in identifying symptoms that might otherwise remain undetected.

What is the purpose of an operative report?

To describe a surgical procedure performed on a patient.

What is the purpose of a therapeutic service report?

To document the assessments performed and the treatments designed to restore the patient's ability to function.

What is the purpose of the discharge summary report?

To provide information to the patient's family physician to ensure the continuity of future care and to respond to authorized requests for information regarding a patient's hospitalization.

What is the purpose of the HIPAA privacy rule?

To provide patients with more control over the use and disclosure of their health information.

What is the purpose of a procedure consent form?

To provide written evidence that the patient agrees to undergo the procedure(s) listed on the form.