the medical record serves as a legal document

Medical Record Formats window.WPCOM_sharing_counts = {"https:\/\/nursekey.com\/the-medical-record\/":179101}; 3. Obtain patient consent for treatment on a consent to treatment form. Disclaimer. reverse chronological order Corrections or modifications should only be made to your own entries. Nature of the illness or injury Figure 36-6 Diagnostic imaging (CT scan) report. State the purpose of each of the following therapeutic services: physical therapy, occupational therapy, and speech therapy. A Notice of Privacy Practices (NPP) is a written document that explains to patients how their protected health information will be used and protected by the medical office. Risk management strategies to stratify patients and/or cases by risk of requiring their medical records for clinical or medico-legal investigation at a later date; c. Archival strategies for the storage of medical records of inactive patients; and, d. Electronic or computerised format of medical records. Home health care must be ordered by the patients physician and is provided by skilled professionals. Hospital documents assist the patients physician in reviewing the patients hospital visit and in providing follow-up care. Conflict of Interest is defined as circumstances a conflict of interest that an individual may have, which could possibly affect Education content about products or services of a commercial interest with which he/she has a financial relationship. Patient registration record The attending physician may be the patients regular physician or a different physician. If your College and the applicable privacy legislation permit the incorrect information to be severed (or stored separately) from the record, a notation must allow the incorrect information to be traced. Billing information is required to bill charges to the patient or an insurance company. All medical records should at the very least provide the following data: Keep the paginated original records and x-rays under lock and key until you have been advised by the IHS Risk Manager that the litigation hold has been lifted. List and describe the seven sections of the health history. 2 PRETEST True or False I I. Never send original records or x-rays to anyone. jQuery('a.ufo-code-toggle').click(function() { The record: 1. Although uncommon, copies of Indian Health Service (IHS) medical records submitted for review occasionally appear to have crucial information that is either missing or that may have been altered. If you do not agree with a change requested by a patient, have you made a note of the patient's request and date in the medical record? jQuery( document.body ).on( 'click', 'a.share-facebook', function() { Date the patient began taking the medication True 7. The objective of this circular is to inform healthcare institutions of the updated national guidelines (2015) for retention periods of medical records. The primary physician at our office is from New York, and we were unfamiliar with his family members. But if the physician has the event in question documented in the chart, then his/her case is strengthened considerably. Instructions given to the patient A report of the consultants impressions List the guidelines that should be followed in recording the chief complaint. Just as important is the fact that most malpractice claims, settlements, and judgments occur because the clinical documentation is inadequate to explain or justify the clinical decisions and care provided to the patient. Physical examination report Log In or. On physical examination, there was tenderness of the lumbo-sacral spine, and limited range of motion in all directions. A patient's medical record serves as a critical piece of care, communication, and legal processes. We immediately jumped in and took charge. She wants to know of any community agencies that could help her with her problem but that would be sure to keep the information confidential. True. In the event that a reliable health history cannot be obtained from the patient, it must be obtained from the person best able to relay the facts. The report also includes a diagnosis of the patients condition (Figure 36-11). Home health care professionals include nurses, home health aides, dietitians, physical therapists, occupational therapists, speech therapists, and social workers. Consent Documents DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. patient The patients physician receives a copy of the radiology report; the actual radiographic film or digital images are kept on file in the hospitals radiology department but are available for review by the patients physician. Chapter Outline INTRODUCTION TO THE MEDICAL RECORD Components of the Medical Record Medical Office Administrative Documents Patient Registration Record NPP Acknowledgment Form Correspondence Medical Office Clinical Documents Health History Report Physical Examination Report Progress Notes Medication Record Consultation Report (3)Tests on a patient performed by the laboratory Date of administration The physician prescribed analgesics, recommended follow up with the patient's family physician, and provided a referral to a physiotherapist. When the physician suggested the patient take the form to their family physician, the patient became argumentative. Operative Report 2. Details of any investigations requested and any treatment provided Pathology report Never use abbreviations for making derogatory comments about the patient. A radiologist examines the radiograph and provides a written report, which includes a detailed interpretation of the radiograph and his or her impressions. Preoperative diagnosis Genitalia and rectum Figure 36-3 Consultation report. A pathology report consists of a macroscopic (gross) and a microscopic description of tissue removed from a patient during surgery or a diagnostic procedure. 6. Unable to load your collection due to an error, Unable to load your delegates due to an error. Providing clinical data for education and research. Spirometry report Administration of medication Courts and legislatures are looking with increasing favor on the patient's interest in the content of his record, a phenomenon which is closely linked to the nationwide trend in favor of the patient's right to know and his right to determine his own physical destiny. Their neurological exam was normal. The Medical Record True The patient registration record consists of a list of the problems associated with the patient's illness. Most of these documents are preprinted forms or computer templates that contain specific information entered by a physician or other health professionals. All health care providers, health plans, and health care clearinghouses (e.g., billing services) that use, store, maintain, or transmit health information must comply with this rule. The medical record chronologically documents the patient's care and is an important element contributing to high quality care. A consultation report is a narrative report of a clinical opinion about a patients condition by a practitioner other than the primary physician, known as a consultant (Figure 36-3). MH 92:02The objective of this circular is to inform healthcare institutions of the updated national guidelines (2015) for retention periods of medical records. The purpose of this report is to document information needed by the patients physician to provide for the continuity of future care. Colonoscopy Report Insurance correspondence includes such documents as a precertification authorization for a hospital admission and a request for additional information from the insurance company. In some jurisdictions, privacy legislation requires the patient's objection to the entry to be included as part of their medical record. windowOpen.close(); 14. Most of this information is obtained by having the patient complete a preprinted form that is then reviewed for completeness by the medical assistant. Figure 36-2 Medication record. Sigmoidoscopy Report Examples of specialized services available through home health care include cardiac home care, intravenous (IV) therapy, respiratory therapy, pain management, diabetes management, rehabilitation, and maternal-child care. Diagnostic Procedure Documents Serving as a legal basis for evidence in itigation and to protect the legal interests of clients and providers. The purpose of the physical examination is to provide objective data about the patient, which assists the physician in determining the patients state of health. The report is prepared and signed by the emergency department physician, and a copy is sent, Completion of a consent to treatment form (Procedure 36-1) is required for all surgical operations and nonroutine therapeutic and diagnostic procedures (e.g., sigmoidoscopy) performed in the medical office. The HIPAA Privacy Rule is outlined here as it relates to the medical office: 1. In one case, the College found that it was insufficient justification to change the record simply because the patient was being difficult or confrontational about the entry. /* ]]> */ Purpose. The NPP must explain to patients how their protected health information (PHI) will be used and protected by the medical office. 2 PHI includes health information in any form that contains patient-dentifiable information 3. List and describe the types of progress notes that are charted by the medical assistant. Name of the medication A thorough discussion of laboratory documents is presented in Chapter 29. 1990 Jun;10(4):71-86. Preparing a Medical Record for a New Patient What Would You Do? The form must be signed by the patient or his or her legally authorized representative and must provide written evidence that the patient agrees to the procedure or procedures listed on the form (, Todays Medical Assistant Clinical Administrative Procedures. Charting in the Medical Record Name of responsible party (person responsible for the account), Along with the physical examination and laboratory and diagnostic tests, the health history is used for the following reasons: to determine the patients general state of health, to arrive at a diagnosis and to prescribe treatment, and to document any change in a patients illness after treatment has been instituted. Business associates may include the following organizations and firms: 7. Patients have a right to request an accounting of the transfer of their information for purposes other than treatment, payment, or health care operations. Definition. It can even be embarrassing. A physical therapist might help a football player with a knee injury to regain normal functioning of the knee or assist a patient recovering from a stroke to use his or her legs to walk again. Does the note include the date of your entry, your reasons for refusing to modify the entry, and your signature? Most of these documents are preprinted forms or computer templates that contain specific information entered by a physician or other health professionals. 6.Business associates to whom the medical office may disclose PHI must respect the HIPAA Privacy Rule. Categories of Medical Record Documents An operative report (Figure 36-9) must be completed for all patients who have had a surgical procedure. A diagnostic procedure is a type of procedure performed to assist in the diagnosis, management, or treatment of a patients condition. A patient's medical record serves as a critical piece of care, communication, and legal processes. orignal copy is retained in the clinic and request honored with a photocopy of a complete record or summary, EMR software being used determines the back-up processand storage requirements, closed or inactive files are those ofclients no longer being seen, active records shoud be in the readiness for providers, professionals must know the limits for the state in which they are employed, once limits of retention are reached procedures have to be followed to purge aged data, a destruction log is developed to keep track of all destroyed medical records, log must include date and method of destruction a statement and the signature of the persons who witnessed the destruction, one method of destruction is picking an service that specializes in destruction, Click here to study/print these flashcards. List and describe the seven sections of the health history. Hospital Documents Start here: Advice, support and assistance at your fingertips. 8. All health care providers, health plans, and health care clearinghouses (e.g., billing services) that use, store, maintain, or transmit health information must comply with this rule. Speech therapy refers to treatment for the correction of a speech impairment resulting from birth, disease, injury, or previous medical treatment. Clinics On the first occasion a patient is seen, records should include: Printouts from monitoring equipment. health-care professionals adds to the chart in a particular place in the same manner. PMC . The medical assistant must always keep in mind that the information contained in a patients medical record is strictly confidential and must not be read by or discussed with anyone except the physician or medical staff involved with the care of the patient (see Highlight on the HIPAA Privacy Rule). providing interoffice and intraoffice communication of client-related data. A patients written consent is not required for the use or disclosure of PHI for the following: Billing services List the general functions of electronic medical record (EMR) software. List the guidelines that should be followed in recording the chief complaint. work for the benefit of the patient and the medical staff. It does not affect the discoverability of other information held by the organization. MH 92:02. Explain the difference between a PPR and an EMR. Activities permitted Legal Health Record Definition and Role The legal health record serves to identify what information constitutes the official business record of an organization for evidentiary purposes. A therapeutic service report documents the assessment and treatment designed to restore a patient's ability to function 4. 16. Refills (prescription medications only) Outcome Documentation that the consultant examined the patient Patients name and date of birth a medical record that is accurate,complete,and concise encourages quality medical care. On examination, there were no findings indicative of an underlying physical problem. Progress notes serve to document the patients health status from one visit to the next. Case Study 1 var windowOpen; Minor everyday occurrences may be cause for litigation if the outcome is unacceptable to the patient. problem The https:// ensures that you are connecting to the Social security number An example of the latter is a physician attending a patient at an urgent care center or in the emergency department of a hospital. Hospital documents are dictated by the attending physician and transcribed at the hospital. A medication record form for recording the patients prescription and OTC medications includes the following: Date the patient began taking the medication, Frequency of administration of the medication, Refills (prescription medications only), Date the patient stopped taking the medication. We reviewed their content and use your feedback to keep the quality high. Address of responsible party INTRODUCTION TO THE MEDICAL RECORD The procedure may be performed by a physician, the medical assistant, or a technician specially trained in the procedure. Law firms Medical treatment: Examples: Most Colleges and privacy commissioners generally recommend or require that electronic health records management systems have an "audit trail" that tracks who made the change and when the change was made. 16. Physical therapy involves the use of therapeutic exercise, thermal modalities, cold, hydrotherapy, electrical stimulation, massage, and other physical agents to restore function and promote healing after an illness or injury. Once a tort claim is filed, the information contained within the subject patient's EHR must be electronically locked and or stored to prevent alteration or loss of evidence. PHI stands for information about protected health. A Holter monitor report is a narrative description of the interpretation of a 24-hour ambulatory ECG, including the evaluators impressions. PROCEDURES The medical office is required to put in place appropriate administrative, physical, and technical security safeguards to protect the privacy of PHI from accidental use or disclosure or violation of the above-listed requirements. Transcription services Therapeutic Service Documents The patient, who was infuriated by this diagnosis, became intimidating and declared that the physician, who was not a psychiatrist, could not possibly make such a diagnosis. True. [1] Description of the technique and procedures used during surgery Search for various available grantsto drive the translation of basic research to advance human healthcare, and to increase the translational and clinical research capabilities of public hospitals, research institutions and medical researchers. In general, records that are adequate for continuity of care are also sufficiently comprehensive for legal use. A symptom is any change in the body or its functioning that indicates the presence of disease. They also had a history of depression and were under the care of a psychiatrist. Handwritten notes Speech Therapy The physical examination report is a summary of the physicians findings from the assessment of each part of the patients body and includes the following: Progress notes involve updating the medical record with new information each time the patient visits or telephones the medical office. Spirometry Report Examination findings, including important negatives Examples of common diagnostic imaging procedures include ultrasonography, computed tomography (CT) scan, and magnetic resonance imaging (MRI). The HIPAA Privacy Rule is outlined here as it relates to the medical office: Components of the Medical Record Sigmoidoscopy Report What Would You Not Do? 4. Avoid deleting the original entry, though. Differential diagnosis 11. A diagnostic imaging report is a narrative description of a diagnostic imaging procedure (Figure 36-6). Science Medicine Health Computing Chapter 38: The Medical Record 5.0 (5 reviews) List three functions of the medical record. 1. I asked him what was wrong. Health care operations: Examples: A medical record is a confidential compilation of pertinent facts of an individual's health history, including all past and present medical conditions, illnesses and treatment, with emphasis. Correspondence regarding a patient may be received from various individuals or facilities, such as the patients insurance company, the patients attorney, and the patient himself or herself. Individually Identifiable health Information that is transmitted ot maintained in any medium including oral statements. Types of Medical Records Manufacturer, lot number, and expiration date of the medication The emergency department report is a record of the significant information obtained during an emergency department visit (Figure 36-12). Harefuah. The medical office is required to put in place appropriate administrative, physical, and technical security safeguards to protect the privacy of PHI from accidental use or disclosure or violation of the above-listed requirements. He replied, You guys are doing a great job with our collection rate. The operative report must include the following: Names of primary surgeon and assistants, Full description of the findings at surgery (normal and abnormal), Description of the technique and procedures used during surgery, Numbers of packs, drains, and sponges used, Condition of the patient at the completion of surgery. The medical record documents the results of treatment and the patients progress. A large variety of forms or templates are available; the type of form or template used is based on the specific requirements of each medical office. Missing or adulterated documents may harm either the claimant's case or the government's case, depending on the circumstances. Identify the information contained in each of the following medical office clinical documents: health history report, physical examination report, progress notes, medication record, consultation report, and home health care report. Figure 36-8 Hospital history and physical examination report. The original document is filed in the patients hospital medical record, and a copy is sent to the patients regular physician. There is evidence that the use of electronic medical records can reduce the costs associated with tort claims and malpractice judgments. Privacy legislation also prescribes certain requirements when correcting a medical record. 2 PRETEST True or False I I. Although the College was satisfied with the care provided, it found the method by which the changes were made to the record was not acceptable, despite the physician's intention to make the chart complete and accurate. Although abbreviations are undoubtedly a great time-saver, you should take care to use them only where their meaning is unambiguous and would be easily understood by your colleagues. Medical office administrative documents include the patient registration record and patient-related correspondence. Introduction to the Medical Record Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window) If we make careful documentation a regular feature of our charting, it will become automatic. It is important that the date and time be included with each progress note, along with the signature and credentials of the individual making the entry. return false; The physician believed the patient's symptoms were manifestations of their depression. Acta Otorhinolaryngol Ital. Progress notes 5. Operative report 4. Legs and feet eCollection 2022 Jan. Legal review: AIDS patient records--legal issues of access and disclosure. The legal health record is generally used when replying to formal medical record request for legal purposes. 2. It is also important to record your opinion at the time regarding, for example, diagnosis. False All OTC medications taken by patient should be documented on the medication record form. Hospital documents are prepared by the physician responsible for the care of a patient while at the hospital; this physician is known as the attending physician. A review of College guidelines and provincial and territorial privacy statutes suggests that the following should be considered when correcting your entry in a patient's medical record: If in doubt, consider contacting the CMPA for further advice before amending a medical record. Please enable it to take advantage of the complete set of features! Home health care is the provision of medical and nonmedical care in a patients home or place of residence. A decrease in the amount of water in the body is known as edema. Mouth and pharynx The College recognized that "there may be some patient interactions that result in emotional confrontations that may be challenging for the physician to manage. An accurate and complete medical record serves several purposes. If the patient or the patient's living relative (with proper clearance) requests to review the sequestered original records, he/she may do so only in the presence of a service unit employee. The NPP form is then filed in the patients chart. List and define the four subcategories included in the progress notes of a problem-oriented record (POR). The following websites contain current information on HIPAA: The medical record serves as a legal document True The purpose of progress note is to update the medical record with new information True The patient registration record consists of a list of the problems associated with the patient's illness. Breasts With a paper-based patient record (PPR), the original patient registration record is then usually placed in the front of the patients medical record. The providerT, 2a privacy nootice should address the following topics? HIPAA is a federal law consisting of several components, one of which contains provisions to protect a patients privacy, known as the HIPAA Privacy Rule.
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