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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?
- REFERRALS
- INSURANCE
- PATIENT INFORMATION
What does the Right side of the chart consist of?
- PROGRESS NOTES
- LABS
- X-RAYS/EKG
- HOSPITAL
- CORRESPONDENCE
What does the Referrals section contain?

Current referrals
What does the Insurance section contain?
- Expired and current cards
- All HIPPA related documents
- Financial Agreements
- Insurance verification sheet
What does the Patient Information section contain?
- Patient information sheet
- Patient history form
- Prescription/Prescription refills
- Living Will
- Phone Messages
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
- Mammogram results
- Echo reports
- Ultrasound reports
What does the Hospital section contain?
- Emergency Room reports
- Hospital admissions
- Surgical/Operative reports
- Discharge Summary
What does the Correspondence section contain?
- Records from other physicians
- Letters
- Requests for medical records

Author

shaketarenae

49306

Card Set

MOPS

Description

Preparing a Patient Medical Record/Chart

Updated

2010-11-13T22:54:04Z

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