Chp 1Chp 1Managing Medical Managing Medical RecordsRecordsLesson 1:Lesson 1:Managing Medical RecordsManaging Medical Records

Categories and Reports Found in Categories and Reports Found in a Medical Record (pg 6)a Medical Record (pg 6)Health hx

reportPhysical exam

reportOffice notesProgress notesPathology

resultsAdmin.

documents

Medication record

Physician ordersRadiology

reportsLaboratory

reportsOperative

reportsECGsMiscellaneous

Sections of the Medical RecordSections of the Medical Record

DatabaseProblem listTreatment plan

Progress notes

SOAP ChartingSOAP Chartingfour parts (see page 29)

“S”◦subjective information gathered from the patient –usually the CC

“O” ◦Objective data gathered during the visit -measurable

SOAP ChartingSOAP Charting“A”

◦assessment, physician’s preliminary diagnosis

◦“P”◦plan of care for this patient

Information that SHOULD Information that SHOULD NOTNOT be be Included in a Patient’s ChartIncluded in a Patient’s Chart

Your opinions

Internal office problems

Subjective comments

Contents that SHOULD BE Contents that SHOULD BE Included in the Medical RecordIncluded in the Medical Record

Factual (objective) statements

Everything….Legible writing in black ink only

Study Guide (aka Study Guide (aka workbook)workbook)Evaluation of Learning

◦Page 5◦Questions 1-10◦Write in book!

Steps for Adding Items to a Steps for Adding Items to a Patient’s ChartPatient’s ChartAdd item as soon as it is found that the item was omitted

Locate the last entryUsing a pen with black ink, place the current date

On the same line, after the date, write, “Late entry”

Steps for Adding Items to a Steps for Adding Items to a Patient’s ChartPatient’s Chart

Enter the information that was originally omitted

Sign the entry with your full name and credentials

Responsibilities of the MA Responsibilities of the MA

Document clearly

Be accurate Keep up to date

easily accessible

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