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Explain the general rules for charting and the rules of electronic charting (Box 3-6).
- a. Chart accurately
- b. Document patient complaints and unusual behavior. Describe type, location, onset, and duration of pain or adverse reactions.
- c. Use correct spelling, grammar, and approved abbreviations
- d. Use present tense, never future, to describe care
- e. Avoid criticism
- f. Avoid documenting for others
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Interpret common symbols and abbreviations sometime encountered in the patient medical record and physician orders (Table 3-1).
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Explain the term medical record and list the functions.
- a. Medical records provide a standardized method of recording and collating information pertinent to the care and treatment of the hospitalized patient.
- b. Function of medical record:
- i. Serving as a database clinician can access for data collection and review
- ii. Provides legal record of all care and services provided
- iii. Establishing clear documentation of diagnosis and care provided for reimbursement
- iv. Offering a central location for interdisciplinary communication and documentation to monitor and improve patient outcomes
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Categorize the types of information that may be found in each of components of the patient medical record.
- a. Admission sheet
- i. Name, age, sex, admission date and time, attending physician, and other demographic information
- b. Admitting diagnosis
- i. Provides a starting point for the RC clinician to assess the patient:
- 1. Childbirth
- 2. Heart disease
- 3. Mental health issues
- 4. Malignant neoplasms
- 5. Pneumonia
- 6. COPD
- 7. Asthma
- 8. Stroke
- 9. Bone fracture
- 10. Osteoarthritis
- 11. Back problems
- 12. Septicemia
- 13. Diabetes mellites
- 14. Surgical procedure
- c. Physicians orders
- i. RC clinicians should carefully review the current physicians’ orders for medications, respiratory care and diagnostic testing
- 1. Medications:
- a. Antimicrobials
- b. RC medications
- c. Cardiac/cardiovascular agents
- d. Sedatives
- e. Systemic steroids
- f. Neuromuscular blocking agents
- g. Airway medication instillations
- h. Drugs that may cause methemoglobinemia
- i. Reversal agents
- d. Results of history and physical examinations
- e. Consultation report
- f. Diagnostic testing results
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Compare and contrast the advantages and disadvantages of electronic medical records (Box 3-2).
- a. Advantages:
- i. Facilitate effective quality assurance
- ii. Produce a legible record
- iii. Accessibility by multiple people at the same time
- iv. Expedite the transfer of data between facilities
- v. Reduce the number of lost records
- vi. Speed the retrieval of data and expedite billing
- vii. Provide analysis of practice patterns and research activities
- viii. Allow for a complete set of backup records at little or no cost
- ix. Easily identify patients due to preventative screenings or vaccinations
- x. Practice enhancers and a public relation toold
- b. Disadvantages:
- i. Initial high cost
- ii. Large training investment
- iii. Power failures
- iv. Hardware crashes and breakdowns
- v. Software glitches
- vi. Sabotage of the system by disgruntled employees and hackers
- vii. Unauthorized access
- viii. Reluctance of physicians to use tightly controlled note format
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List the information found on the patient admissions sheet, physician’s orders, and admitting diagnosis and/or problem list.
SEE QUESTION 22
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Explain the significance of do not resuscitate (DNR) orders in the patient chart.
a. When a patient suffers from a cardiac or respiratory arrest, the healthcare professionals will call a code alerting the code team to hurry to the site of the arrest to perform CPR and advanced life support. A DNR (do not resuscitate) is a form of advance directive by the patient or family stating that the patient does not wish to receive CPR or advanced life support in the event of a cardiac or respiratory arrest. These DNRs cannot be fought or gone againt.
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