Define:chartingdiagnosisdischarge summary reportelectronic medical recordhealth history reportInformed consent
medical recordmedical record formatpaper-based patient recordphysical exam reportprognosissubjective symptoms
Chp 1Managing Medical RecordsLesson 1:Managing Medical Records
Lesson ObjectivesUpon completion of this lesson, students should be able to Define and spell the terms to learn for this chapter.Discuss the problem-oriented medical record.Describe the four components of the SOAP charting method.
Categories and Reports Found in a Medical Record (pg 6)Health hx reportPhysical exam reportOffice notesProgress notesPathology resultsAdmin. documentsMedication recordPhysician ordersRadiology reportsLaboratory reportsOperative reportsECGsMiscellaneous
Sections of the Medical RecordDatabaseProblem listTreatment planProgress notes
SOAP Chartingfour parts (see page 29)
Ssubjective information gathered from the patient usually the CC
O Objective data gathered during the visit -measurable
SOAP ChartingAassessment, physicians preliminary diagnosis
Pplan of care for this patient
Practice SOAP ChartingProblem list form
Critical Thinking QuestionWhat types of information should not be included in the patient chart, and why?
Information that SHOULD NOT be Included in a Patients ChartYour opinionsInternal office problemsSubjective comments
Contents that SHOULD BE Included in the Medical RecordFactual (objective) statements Everything.Legible writing in black ink only
Study Guide (aka workbook)Evaluation of LearningPage 5Questions 1-10Write in book!
How to Correct an Error in the Medical RecordDo not erase or scribble out the original error NO White OutDraw a single line through the errorInitial above the single lineDate entrywrite in the correction
Steps for Adding Items to a Patients ChartAdd item as soon as it is found that the item was omittedLocate the last entryUsing a pen with black ink, place the current dateOn the same line, after the date, write, Late entry
Steps for Adding Items to a Patients ChartEnter the information that was originally omitted
Sign the entry with your full name and credentials
Responsibilities of the MA Document clearly Be accurate Keep up to dateeasily accessible
Study Guide (aka workbook)Evaluation of LearningPage 6Questions 20-27Write in book!
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