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includes demographic, socioeconomic and financial information.
includes all patient health information obtained throughout the treatment and care of the patient.
Reverse chronological order-
most current document is filed first in a section of a record.
Universal chart order-
discharged patient record is organized in the same order as when the patient was on the nursing floor; eliminates the time-consuming assembly task performed by the HIM department.
- patients records are organized with oldest information filed first in a section.
- Incident reports- collects information about a potentially compensable event (PCE); it is generated on patients and visits and provides a summary of the PCE in case the patient or visit files a lawsuit.(NOT FILED IN RECORD)
- Subjective- patients statement about how she feels(headache)
- Objective- observations about the patient, such as physical findings or labor X-ray results.( chest X-ray negative)
- Assessment- judgement, opinion or evaluation made by the health care provider(acute migraine)
- Plan- diagnostic, therapeutic, and educational plans to resolve the problems(patient to take Tylenols as needed)
usually arranges reports in strict chronological date order(should also be arranged in reverse date order)
systematic method of documentation, which consists of 4 components; database, problem list, initial plan, and progress notes.
traditional patient record format that maintains reports according to source of documentation.
patient name, address, gender, DOB, SSN,TELE#.
3rd-party payers, insurance #, secondary insurance.
marital status, race and ethnicity, occupation place of employment.
Behavioral health information-
authentication performed by an individual( attending physician) in addition to the signature by the original author of an entry(resident)
Review of patient record for inconsistencies that may identify incomplete or inaccurate documentation, including review of final diagnosis or procedures on the face sheet.
review of patient record for completeness(presence of dictated reports, written progress, notes, authentications) including ID of chart deficiencies, which include missing reports and other documentation and missing signatures.
documentation in the POR that acts as a table of contents for the patient record because it is filed at the beginning of the record and contains a list of the patient’s problems. Each problem is numbered, which helps to index, documentation throughout the record.
Length of inpatient record
60 to 100 pages
Requirements for H and P and completing records
must be performed and documented in the patient record whithin 24 hours after admission, and if a H&P was completed within 30 days prior to admission and reviewed and updated,it can be placed in the record within 24 hours after admission.
Advantages of Manual record system-
- low-start up costs
- training staff is simple
- requires less technically trained staff
- paper records are available because there is no downtime
Disadvantages of Manual record system
- Retrival of info is not easily customized
- hand-written info can be illegible
- difficult to abstract info
- undocumented services are not usually discovered until analysis of record occurs.
Advantages of Automated systems-
- Improves access to patient info
- multiple users can access patient info simultaneously and remotely
- Eliminates paper storage
- Improves readability of patient info
- Timely capture of data
- Updates can easily occur
- Reduces administrative data
Disadvantages of Automated systems
- Increased start-up costs
- Selection and development of system is time-consuming
- Staff training is time-consuming and expensive
- Technical staff need to maintain system
- User resistance can occur
registration-admission-discharge-transfer, creates a centralized data base of patient demographic information and has replaced the paper master patient index.
are documented by such departments as lab, radiology,nuclear medicine, they assist physicians in diagnosis and treatment of patients.
allow health care providers the opportunity to access patient info that was generated at another facility, allowing HI exange.
Patient monitoring systems
collect and monitor patient physiological data and record the info.
part of the record is electronic and part is paper.
process of advising a patient about a treatment options and, depending on state laws, the provider may be obligated to disclose a patient's diagnosis.
Patient property form
records items patients bring with them to the hospital.
patients description of medical condition, stated int the patient's own words.
contain statements related to the course of the patient's illness, response to treatment, and stats at discharge.
- measures the baby's apperance on a scale 1-10
- A-skin color
- A-activity(muscle tone & motion)
started in physicians office and includes health history of mother, family, and social history, pregnancy risk factors, care during pregnancy including tests, meds.
Documents info concerning the mothers condition after delivery.
records progress of mother from time of addmission through time of delivery.
Physical exam content
- General survey
- skin,head, eyes
- nose & sinuses
- mouth, throat
- lymphatic vessels
final physician documented to release patient from a facility.
Vital signs record
documents the patients vital sign on a graphic sheet
admitting diagnosis, condition for which the patient is seeking treatment.
commonly used in phyisicans office to capture charges genrated during an office visit and consists of a sigle page that contains a list of common services in the office.initited when the patient registers in the front desk,(Superbill,fee slip)
established to oversee the process of adding, deleting, and changing forms and to approve forms used in a record.
documented by consultant and includes the consultant's opinion and findings based on a physical examination and review of patient records.
documents a patients history of present illness and any pertinet changes and P examinations that occured since a previous inpatient admission if the patient is readmitted within 30 days after discharge for the same condition.
pre-exisiting condition that will, because of its presence with a specific principal diagnosis, cause and increase in a patients LOS at least 1 day in 75% of cases.
additional diagnosis that describes conditons arising after the beginning of hospital observations and treatment and that modify the course of a patients illness of medical care, LOS at least 1 day in 75% of cases
patients registration form similar to inpatient face sheet, and depnding on complexity of Outpatient services provided, can include ancillary reports, operative reports, physician orders, progress notes, etc.
Uniform Hospital Discharge Data
minimum core data set collected on Medicare and Medicaid outpatients
legal document in which patients state the kind of health care they DO or NOT want under certain circumstances.
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