Card Set Information
Standardized Medical Record Format
Preparing a Patient Medical Record/Chart
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.
What should we know about a patient's financial information
**No financial information shall be kept in the patient's medical record**
What does the Left side of the chart consist of?
What does the Right side of the chart consist of?
What does the Referrals section contain?
What does the Insurance section contain?
Expired and current cards
All HIPPA related documents
Insurance verification sheet
What does the Patient Information section contain?
Patient information sheet
Patient history form
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.
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*
What does the Labs section contain?
All lab and pathology reports
What does the X-ray/EKG section contain?
All x-ray reports
EKG's/Stress Test results
What does the Hospital section contain?
Emergency Room reports
What does the Correspondence section contain?
Records from other physicians
Requests for medical records