Function of the medical record
1. Written record of important patient information
2. Basis for health care decisions
3. Serves as a legal document
Components of the medical record
1. Medical office administrative documents – 3 parts to it. o Patient Registration Record - Demographic info -Billing info o Notice of Privacy Practices (NPP) o Correspondence
2. Medical office clinical documents - 6 parts to it. o Health Hx Report o Physical Exam Report o Progrss Notes o Medication Record
- Medication Administration Record (MAR) o Consaltation Report o Home Health Report
HIPAA o Provides patients with better control over the use and disclosure of their personal health information. o Health care providers, health plans, health care clearinghouses (billing services) must all comply o Federal law
Different types of Documents
Lab documents - Reports of analysis of exam of body specimens to assist physician in diagnosing and treating disease. o Ex) Hematology, urinalysis, Microbiology, cytology, histology
Diagnostic procedure documents- procedures performed to assist in the diagnosis, management or treatment of patient. o Ex) ECG/EKG, Holter monitor report, colonoscopy report, Spirometry Report, Radiology Report
Therapeutic services Documents- Documents the assessments and treatments designed to help restore a patient’s function. o EX) Physical therapy, Occupational therapy, Speech therapy
Hospital Documents- Dictated by a physician and transcribed at the hospital and a copy is sent to the patient’s regular attending (primary) physician. o EX) H&P report, Operative report, Discharge summary report, Pathology report, emergency department report.
Consent Documents- legal documents required to perform certain procedures or to release info contained in the patient’s medical record.
PHYSCIANS responsibility to INFORM patient of risks, benefits, and prognosis of procedures being performed.
Signature must be WITNESSED when the patient signs, to verify that the correct patient has signed. – the MA does this
Is it your responsibility to explain prognosis/risks/benefits?
No, only to witness the signature.
Types of medical records – Know the difference’s
Paper based patient record (PPRs)- almost all paper
Electronical Medical Record (EMR)- all stored on computer
- Speed/productivity - Initial cost
- Efficiency - Time investment
- Accessibility - Occupational tasks
Medical record formats – 2 types
Source oriented record-
Usually reverse chronological order (oldest