MOPS

Card Set Information

Author:
shaketarenae
ID:
49306
Filename:
MOPS
Updated:
2010-11-13 17:54:04
Tags:
Standardized Medical Record Format
Folders:

Description:
Preparing a Patient Medical Record/Chart
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  1. How should information be placed into a patient's chart?
    All information placed in the medical record shall be filed in reverse chronological order, most recent on top.
  2. What should we know about a patient's financial information?
    **No financial information shall be kept in the patient's medical record**
  3. What does the Left side of the chart consist of?
    • REFERRALS
    • INSURANCE
    • PATIENT INFORMATION
  4. What does the Right side of the chart consist of?
    • PROGRESS NOTES
    • LABS
    • X-RAYS/EKG
    • HOSPITAL
    • CORRESPONDENCE
  5. What does the Referrals section contain?
    Current referrals
  6. What does the Insurance section contain?
    • Expired and current cards
    • All HIPPA related documents
    • Financial Agreements
    • Insurance verification sheet
  7. What does the Patient Information section contain?
    • Patient information sheet
    • Patient history form
    • Prescription/Prescription refills
    • Living Will
    • Phone Messages
  8. What should we always remember about the Left side of the chart?
    • Information should be placed in reverse chronological order regardless of the category.
    • For ex. a telephone message might be placed on the top of a financial agreement.
  9. What should we know about Progress notes?
    • Progress notes are placed on top of the divider.
    • *all other reports are filed behind the divider of proper section*
  10. What does the Labs section contain?
    All lab and pathology reports
  11. What does the X-ray/EKG section contain?
    • All x-ray reports
    • EKG's/Stress Test results
    • Mammogram results
    • Echo reports
    • Ultrasound reports
  12. What does the Hospital section contain?
    • Emergency Room reports
    • Hospital admissions
    • Surgical/Operative reports
    • Discharge Summary
  13. What does the Correspondence section contain?
    • Records from other physicians
    • Letters
    • Requests for medical records

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