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A Medical Record is:
a written document of information describing a patient and his or her health care.
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A Medical Record contains:
dates, observations, medical and surgical interventions, and treatment outcomes provided during hospitalization or visit to a doctor's office.
It includes: symptoms, medical history, exam results, x-ray reports and lab tests, diagnoses, and treatment plans
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Information from medical records could influence...
one's credit, admission to educational institutions, employment, and one's ability to obtain health insurance.
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What does HIPAA stand for?
Health Insurance Portability and Accountability Act
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When was HIPAA passed and what is it?
1996; HIPAA is a set of rules that doctors, hospitals, and other health care providers must follow to help insure that all medical records, billing, and patient accounts meet certain consistent standards with regard to documentation, handling, and privacy.
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What does PHI stand for?
Protected Health Information
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What is Microfilm?
photographs of records in a reduced size
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What is microfiche?
sheets of microfilm
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What does EMR stand for?
Electronic Medical Record
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What does EHR stand for?
Electronic Health Record
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What are the general components that of a patient's chart?
- 1. Patient Information Form 9. Consultation Reports
- 2. Medical History 10. Misc. Reports
- 3. Physical Exam 11. Tests/ Lab Reports
- 4. Consent Form 12. Operative Report
- 5. Informed Consent Form 13.Anesthesiology Report
- 6. Physician's Orders 14. Pathology Report
- 7. Nurse's Notes 15. Discharge Summary
- 8. Physician's Progress Notes
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What does SOAP stand for?
Subjective, Objective, Assessment, Plan
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What is Subjective?
- Patient's description of how patient feels/ symptoms. Includes chief complaint (CC)
- Ex: pain, nausea, dizziness, tightness in chest, lump in throat, weakness in legs, butterflies in stomach
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What is Objective?
- Symptoms that can be observed (seen, heard, felt, smelled, or measured). Includes: vitals, data from Physical Exam (PE), general appearance, and condition of all body systems.
- Ex: Rash, sweating, shakes, dilated pupils
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What is Assessment?
Interpretation of subjective and objective findings. Includes diagnosis or the ruling out a disease or condition.
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What is Plan?
- Management and treatment regimen for patient
- Ex: lab test, diagnostic tests, physical therapy, diet therapy, medications, medical and surgical interventions, patient referrals, and follow-up directions
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