Chapter 3

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  1. Chief Complaint
    Nature and duration of the symptoms that caused the patient to seek medical attention as stated in his or her own words
  2. Operative Reports
    • A formal document prepared by the principal surgeon to describe the surgical procedure(s) performed for the patient
    • Should be written or dictated immediately after surgery and filed in the health record within 24 hours
  3. Preoperative H&P
    • Except in emergency situations, every surgical patients chart must include a report of the complete history and physical conducted no more than 7 days before the surgery is to be performed
    • Advance directives and organ donation forms must also be in chart
  4. APGAR
    • Infant rating system done at 1 and 5 minutes after birth
    • Score up to 10 (higher # better)
    • Includes: Heart rate, Muscle tone, Respirations, Reflex, Color
  5. Prenatal Record
    • Begins in the office or clinic when seen for first time for pregnancy
    • Copy or abstract of prenatal information should be available at the birthing site by the 36th week of pregnancy
    • Comprehensive history and physical exam includes many items
  6. Prenatal Record Ex.
    • menstrual history
    • reproductive history
    • risk assessment
    • health status
    • reason for visit
    • tobacco and/or alcohol usage
    • dietary assessment
    • history of abuse or neglect
    • sexual practice
    • physical fitness status
  7. Diagnosis at time of admission 
    What is happening when arrived at hospital.
  8. Consultation Reports
    • Documents the clinical opinion of a physician other than the primary or attending physician
    • Requested by primary or attending normally documented in physician orders or progress notes
    • Based on consulting physician’s exam of the patient and a review of the patient health record
  9. Path Reports
    • Analysis of all tissue and foreign objects removed surgically from a patient
    • Normally dictated with an electronic signature from the Pathologist
  10. Path Reports Incl.
    • Patient name, and MR#
    • Date of Exam
    • Description of tissue examined
    • Diagnosis (both clinical and final)
    • Findings-macroscopic (with own eye) and microscopic
    • Name, credentials, and signature of pathologist
  11. Postpartum
    • Information about the condition of the mother after the delivery process
    • Example
    • the condition of the breasts
  12. Physician Orders
    • Instructions the physician gives to other healthcare professionals who actually perform diagnostic tests and treatments, administer medications, and provide specific services to the patients
    • Orders must be legible dated and signed by physician
    • Moving towards Computerized Physician Order Entry (CPOE) with the EHR
  13. Source-Oriented
    • Documents are grouped together based on point of origin (according to patient care department)
    • Reports in each section may be in chronological or reverse chronological order
    • Example: Labs with Labs, Radiology with Radiology
  14. Source Oriented Advantages
    • Very organized for each department to locate section for documentation
    • Easy for adding loose papers
  15. Source Oriented Disadvantages
    • Cannot determine all the patient’s problems and treatment quickly
    • Must look in each area of the chart which is timely
  16. Problem-Oriented
    • Itemized list of patient’s past and present social, psychological, and medical problems
    • Each problem is indexed with unique number (problem list)
    • Three sections: Database, Initial care plan, Progress notes
  17. Integrated Medical Record
    Documentation from various sources is intermingled and follows strict chronological order
  18. Integrated Medical Record Adv.
    Easy to follow the course of the patient’s diagnosis and treatment
  19. Integrated Medical Record Disadv.
    Difficult to compare similar information
  20. SOAP
    • Subjective
    • Objective
    • Assessment 
    • Plan 
  21. Types of Progress Notes
    • Admission Note
    • Daily Notes
    • Integrated Progress Notes
    • Nursing Notes
    • Discharge Note
  22. Recovery Room Report
    A type of health record documentation used by nurses to document the patient’s reaction to anesthesia and condition after surgery; also called recovery room record
  23. Clinical Data
    Documents medical condition, diagnoses, procedures, and treatment
  24. Clinical Data Ex.
    • History and Phys.
    • Diagnostic and therapeutic orders and results
    • Progress Notes (clinical observations)
    • Consultation Reports
    • Nursing Notes
    • Discharge Summary with discharge Instructions
  25. Administrative Data
    • Demographic and financial information
    • Consents and authorization
  26. Administrative Data Ex.
    • Demographics and Financial Information
    • Consents
    • Authorizations (ROI)
    • Advance Directives
  27. Authenticated
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Chapter 3
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