Define: charting diagnosis discharge summary report electronic medical record health history report Informed consent medical record medical record format

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  • 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

  • Correcting errors

  • 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!

  • Go to Lesson 2

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