Lecture 6

V550V550Medical DocumentationMedical DocumentationCharting & TerminologyCharting & Terminology

Richard E. Meetz, OD, MSRichard E. Meetz, OD, MS20082008

Medical RecordsMedical Records

A record of the patient’s care.A record of the patient’s care.

Basis for 3rd party reimbursement.Basis for 3rd party reimbursement.

Medical-Legal document.Medical-Legal document.

Medical RecordsMedical RecordsA record of patient careA record of patient careProvides essential information on Provides essential information on

the day of the exam.the day of the exam.Continuity of care from one Continuity of care from one

practitioner/visit to the next.practitioner/visit to the next.Allows evaluation of changes in a Allows evaluation of changes in a

patient’s health or condition.patient’s health or condition.

Medical RecordsMedical RecordsBasis for 3Basis for 3rdrd party reimbursement party reimbursement Shows the necessity for any procedures Shows the necessity for any procedures

and level of care.and level of care.– By counting Hx entries, numbers and types of By counting Hx entries, numbers and types of

tests and procedures, the complexity of the tests and procedures, the complexity of the case can be established and correctly billed case can be established and correctly billed for.for.

Supports claims in cases of reviews & Supports claims in cases of reviews & auditsaudits. . – Medicare/Medicaid, VSP, etc.Medicare/Medicaid, VSP, etc.

Medical RecordsMedical RecordsMedical-Legal RecordMedical-Legal Record The medical record provides a The medical record provides a legal record legal record

of careof care.. Defense of the doctor and staff in cases of Defense of the doctor and staff in cases of

malpractice claims.malpractice claims.

““In court, the medical record IS the care In court, the medical record IS the care rendered! rendered!

If it isn’t in the record, it never If it isn’t in the record, it never happened!”happened!”

Medical RecordsMedical RecordsMedical-Legal RecordMedical-Legal Record Should include all the vital information Should include all the vital information

needed to reconstruct the events of needed to reconstruct the events of the exam.the exam.

Should reflect the current standard of Should reflect the current standard of care.care.

Should Should NEVER be alteredNEVER be altered after care is after care is called into question for review or called into question for review or litigation. (See error correction)litigation. (See error correction)

Medical RecordsMedical Records ConfidentialityConfidentiality Records are confidential informationRecords are confidential information

– Patient’s written permission is necessary Patient’s written permission is necessary for record releasefor record release

– Records should not leave the clinic or Records should not leave the clinic or officeofficeMust be kept in secure location Must be kept in secure location

– Locked or restricted Locked or restricted

– Avoid discussing patient care issues in Avoid discussing patient care issues in public areaspublic areas

Medical RecordsMedical Records ConfidentialityConfidentiality Computerized/electronic records are new Computerized/electronic records are new

security/confidentiality issuesecurity/confidentiality issue– Hipaa: Health Information Portability and Hipaa: Health Information Portability and

Accountability ActAccountability ActStandardized how and when information is Standardized how and when information is

released and how transferred.released and how transferred.1st Requested by the insurance companies, 1st Requested by the insurance companies,

FTC took over FTC took over Strict rules on record keeping & rule for releaseStrict rules on record keeping & rule for releaseHAD to have sign copy of Hipaa policy in record HAD to have sign copy of Hipaa policy in record

in every officein every office

Medical RecordsMedical RecordsContent of Medical recordsContent of Medical records

All parts of the examinationAll parts of the examination– Intake Hx, exam forms, F/U forms, prescription Intake Hx, exam forms, F/U forms, prescription

copies, informed consents copies, informed consents Laboratory resultsLaboratory results

– Visual Field print outsVisual Field print outs CorrespondenceCorrespondence

– Referrals, forwarded recordsReferrals, forwarded records– Patient letters and telephone communicationsPatient letters and telephone communications

With date, time, “question” & instructionsWith date, time, “question” & instructions

Medical RecordsMedical RecordsContent of Medical recordsContent of Medical records

Billing informationBilling information

– Patient personal dataPatient personal dataAddress, phone contactAddress, phone contactPlace & Date of birthPlace & Date of birth

– Copies of past bills sentCopies of past bills sent– Patient releasesPatient releases

Medical ChartingMedical ChartingGuidelines for DocumentationGuidelines for Documentation

1. The patient’s full name 1. The patient’s full name MUSTMUST appear on appear on every page.every page.

2.The full date 2.The full date MUSTMUST appear on all pages. appear on all pages.– Entries with only a month and day are NO Entries with only a month and day are NO

better than a lost page.better than a lost page.

3. All Entries/exams 3. All Entries/exams MUSTMUST be signed! be signed!– By writer’s full name & degree.By writer’s full name & degree.


4. All entries 4. All entries MUSTMUST be in permanent ink. be in permanent ink.NO pencils or erasable pensNO pencils or erasable pensBest in black ink, best if ball pointBest in black ink, best if ball point..

5. All entries 5. All entries MUSTMUST be LEGIBLE! be LEGIBLE!

6. Entries should use only approved 6. Entries should use only approved terminology & abbreviations. terminology & abbreviations.


7. Entries should only be made on approved 7. Entries should only be made on approved forms.forms.

8. Entries should be made in the appropriate 8. Entries should be made in the appropriate sequence. sequence.

9. 9. NeverNever skip lines or leave blanks. skip lines or leave blanks.

10. Late entries should be marked as such.10. Late entries should be marked as such.

Medical ChartingMedical ChartingMiscellaneous DocumentationMiscellaneous Documentation

Patient intake formsPatient intake forms– Patient generated history forms.Patient generated history forms.– Must be signed by patient.Must be signed by patient.– Should be dated & initialed by Dr. indicating that it Should be dated & initialed by Dr. indicating that it

was reviewed.was reviewed.– Must be reviewed, updated and initialed at each visit.Must be reviewed, updated and initialed at each visit.

Laboratory resultsLaboratory results– Should be dated & initial indicating that it was read.Should be dated & initial indicating that it was read.– Documentation that the patient was notified of the Documentation that the patient was notified of the

results.results.

Medical ChartingMedical ChartingMiscellaneous DocumentationMiscellaneous Documentation

Telephone calls from patients regarding Telephone calls from patients regarding healthhealth– Documentation of date, time, “question” and Documentation of date, time, “question” and

instructions to patient.instructions to patient. Late entries -Late entries - Cancelled or missed appointmentsCancelled or missed appointments

– Also attempts to contact patient should be Also attempts to contact patient should be documenteddocumented

– Any returned postal notices (cards) are to be kept Any returned postal notices (cards) are to be kept in the record.in the record.

Medical ChartingMedical ChartingAdding to a recordAdding to a record

After a chart has been signed off, DO NOT After a chart has been signed off, DO NOT go back and alter it at a later date.go back and alter it at a later date.

Use the following procedure:Use the following procedure:DateDateTimeTime““Late entry to (date)”Late entry to (date)”Complete note and sign off as usualComplete note and sign off as usual

Medical ChartingMedical ChartingAdding to a recordAdding to a record

Late entries/same day:Late entries/same day:on a fill in the blank on a fill in the blank form, add to bottom of subject page (front)form, add to bottom of subject page (front)

– Addition to subjective CC: “pt. states he now Addition to subjective CC: “pt. states he now recalls skipping lines when reading.”recalls skipping lines when reading.”

Different dayDifferent day

– 11/3/04 Late entry to 9/2: XXXXXXXXXXXX 11/3/04 Late entry to 9/2: XXXXXXXXXXXX 9:00am9:00am XXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXX SignatureSignature

Medical ChartingMedical Charting

Documentation of procedures:Documentation of procedures: Who performed the procedure (if other than Who performed the procedure (if other than

the person charting)the person charting) How procedure was doneHow procedure was done How patient tolerated the procedureHow patient tolerated the procedure Any change in symptomsAny change in symptoms Condition/status of patient at time of releaseCondition/status of patient at time of release Signed release/informed consent in chartSigned release/informed consent in chart


Error CorrectionError CorrectionNever Cross out, overwrite or Never Cross out, overwrite or

blacken an error!blacken an error!Use a single lineUse a single line

Then:Then:– Your initialsYour initials– DateDate– Add correcting informationAdd correcting information

Medical ChartingMedical Charting Incorrect Error CorrectionIncorrect Error Correction

Correct Error CorrectionCorrect Error Correction

Medical ChartingMedical ChartingRecording the HistoryRecording the HistoryThings to avoidThings to avoid JoustingJousting

– Arguing, complaining, belittling, criticizing others Arguing, complaining, belittling, criticizing others to defend oneself.to defend oneself.

Stating opinions vs. factStating opinions vs. fact– Patient Patient isis intoxicated intoxicated

Vague statementsVague statements– Patient Patient appearsappears to be sleeping to be sleeping

Derogatory or frivolous commentsDerogatory or frivolous comments– Patient Patient is a rockis a rock


Recording the HistoryRecording the HistoryDefn: Jargon Defn: Jargon 9.9. Nonsensical gibberishNonsensical gibberish10.10.A hybrid languageA hybrid language11.11.Language or terminology peculiar to a Language or terminology peculiar to a

specific field, profession or group. To specific field, profession or group. To exclude outsiders.exclude outsiders.

Excessive use of abbreviations falls into this Excessive use of abbreviations falls into this categorycategory..

Medical ChartingMedical ChartingMedical AbbreviationsMedical Abbreviations The need for speed & to shorten record keeping The need for speed & to shorten record keeping

has greatly increased the use of abbreviations.has greatly increased the use of abbreviations.

However, they add convenience at the expense However, they add convenience at the expense of communication & safetyof communication & safety– Problems arise when an abbreviation has more than Problems arise when an abbreviation has more than

one meaningone meaning– Recent study found that abbreviations account for Recent study found that abbreviations account for

5% of medical errors5% of medical errors ““QD” most common error (means once daily) QD” most common error (means once daily) U for units next most common in errorU for units next most common in error


Medical AbbreviationsMedical Abbreviations THERE ARE NO UNIFORM ABBREVIATIONSTHERE ARE NO UNIFORM ABBREVIATIONS Abbreviations are site specific.Abbreviations are site specific.

EXAMPLE: LLLEXAMPLE: LLL

IUSO = Lids, lashes & Lacrimal (apparatus)IUSO = Lids, lashes & Lacrimal (apparatus)

IUHC = Left Lower Lobe (lung) IUHC = Left Lower Lobe (lung) Each site MUST have its own approved list.Each site MUST have its own approved list.

– Can be called in to court in in cases of Can be called in to court in in cases of malpracticemalpractice

– Support documentation in chart reviewsSupport documentation in chart reviews

Medical ChartingMedical ChartingMedical AbbreviationsMedical Abbreviations Problems: Abbreviations and symbols can Problems: Abbreviations and symbols can

be easily misread or interpreted in a be easily misread or interpreted in a manner not intended.manner not intended.

Example: OD usually means Example: OD usually means Right eyeRight eyeCould also mean Could also mean one dropone dropOr mean Or mean once dailyonce daily??

So... OD OD OD could mean:So... OD OD OD could mean:

One drop in the right eye once dailyOne drop in the right eye once daily. . NOT!NOT!


Medical AbbreviationsMedical Abbreviations Abbreviations with different Abbreviations with different LayLay meaning. meaning.

SOBSOB: : Short of BreathShort of Breath

BSBS:: Blood SugarBlood Sugar

FBSFBS: : Fasting blood sugar or Fasting blood sugar or

ASSASS: : Anterior superior spineAnterior superior spine

T&AT&A: : Tonsillectomy and adenoidectomyTonsillectomy and adenoidectomy

Common Medical Terms and Common Medical Terms and Their AbbreviationsTheir Abbreviations

Cerebrovascular accident Cerebrovascular accident CVA = Stroke CVA = Stroke

Myocardial infarctionMyocardial infarctionMI = Heart AttackMI = Heart Attack

HypertensionHypertensionHTN = High blood pressureHTN = High blood pressure

Diabetes MellitusDiabetes MellitusDM = high blood sugarDM = high blood sugarIDDM = Insulin dependant diabetesIDDM = Insulin dependant diabetesNIDDM = Non insulin dependant diabetesNIDDM = Non insulin dependant diabetes


Medical AbbreviationsMedical Abbreviations Abbreviations with more than one meaning.Abbreviations with more than one meaning.

– On average any abbreviation will have 2 to 3 On average any abbreviation will have 2 to 3 different meanings;different meanings;

BSBS can mean blood sugar orcan mean blood sugar orblind spotblind spot

FBSFBS can mean fasting blood sugar orcan mean fasting blood sugar or foreign body sensationforeign body sensation

OUOU can mean oculi unitas = both eyes orcan mean oculi unitas = both eyes or oculus uterque = each eyeoculus uterque = each eye

Medical TerminologyMedical Terminology


EtymologyEtymology Study of word origins from Latin, Greek or Study of word origins from Latin, Greek or

the earliest known use.the earliest known use. Study of the basic elements and their Study of the basic elements and their

applicationapplication Medical etymology based on “word roots”Medical etymology based on “word roots” If familiar with root words and general If familiar with root words and general

anatomy, you will usually be able to figure anatomy, you will usually be able to figure out the medical terminologyout the medical terminology


EtymologyEtymology 90-95% of medical & technical scientific 90-95% of medical & technical scientific

vocabulary comes from Greek and Latin vocabulary comes from Greek and Latin sourcessources

On average, learning one of these On average, learning one of these “building block” words will help you learn “building block” words will help you learn about 50 different medical wordsabout 50 different medical words

Just 500 Greek & 500 Latin word Just 500 Greek & 500 Latin word components account for the vast bulk of components account for the vast bulk of all the medical words you are likely to all the medical words you are likely to encounter in any single health fieldencounter in any single health field

Medical TerminologyMedical TerminologyEtymology: Word RootsEtymology: Word Roots

– The main part or stem of a word.The main part or stem of a word.– Frequently indicates a body part.Frequently indicates a body part.

Examples: Examples: – Kardia (heart) = cardiKardia (heart) = cardi– Gaster (stomach) = gastrGaster (stomach) = gastr– Hepar (liver) = hepatHepar (liver) = hepat– Nephros (kidney) = nephrNephros (kidney) = nephr– Osteon (bone) = osteOsteon (bone) = oste

Medical TerminologyMedical TerminologyEtymology: Combined formEtymology: Combined form

– Is a word root plus a vowel usually “o”Is a word root plus a vowel usually “o”– Usually indicates a body part.Usually indicates a body part.

Examples:Examples:– cardi +o = cardio (heart) cardi +o = cardio (heart) – gastr + o = gastro (stomach) gastr + o = gastro (stomach) – hepat + o = hepato (liver)hepat + o = hepato (liver)– nephr + o = nephro (kidney)nephr + o = nephro (kidney)– oste + o = osteo (bone)oste + o = osteo (bone)– phac + o = phaco (lens) phac + o = phaco (lens)

Medical TerminologyMedical TerminologyEtymology: Combined form-“Ocular”Etymology: Combined form-“Ocular”

Examples: Examples: – Amblyo = dull, dim Amblyo = dull, dim – Aqueo = waterAqueo = water– Blepharo = lidBlepharo = lid– Coreo = pupilCoreo = pupil– Dacryo = tear, lacrimal sacDacryo = tear, lacrimal sac– Kerato = corneaKerato = cornea– Cyclo = ciliary bodyCyclo = ciliary body– Irido = irisIrido = iris– Presbyo = old age Presbyo = old age

Medical TerminologyMedical Terminology Etymology: SuffixEtymology: Suffix

– Is a word ending. Is a word ending. – Usually indicates a procedure, condition, disease.Usually indicates a procedure, condition, disease.

Examples: Examples: – itis = inflammation itis = inflammation – megaly = enlargementmegaly = enlargement– plegia = paralysis condition plegia = paralysis condition – ia = condition ia = condition – osis = abnormal conditionosis = abnormal condition– opia = visionopia = vision– stenosis = narrowing conditionstenosis = narrowing condition

Medical TerminologyMedical TerminologyEtymology: Suffix; ProceduresEtymology: Suffix; Procedures

Examples: Examples: – ectomy = excision, removalectomy = excision, removal– centesis = puncturecentesis = puncture– plasty = surgical repairplasty = surgical repair– tomy = incision, cut intotomy = incision, cut into– lysis = separation, destruction, looseninglysis = separation, destruction, loosening

Medical TerminologyMedical TerminologyEtymology: PrefixEtymology: Prefix Is a word element at the beginning of Is a word element at the beginning of

a word. a word. When a medical word contains a prefix When a medical word contains a prefix

the meaning of the word is altered.the meaning of the word is altered. Usually indicates a number, time, Usually indicates a number, time,

position, direction, color or sense of position, direction, color or sense of negation.negation.

Medical TerminologyMedical TerminologyEtymology: Prefixes of PositionEtymology: Prefixes of Position Examples: Examples:

– ante, pre, pro = before ante, pre, pro = before – hyper = excessive or high (also of number)hyper = excessive or high (also of number)– hypo, infra, sub = under, below (also of #)hypo, infra, sub = under, below (also of #)– Intra = within*Intra = within*– Inter = between*Inter = between*– peri = aroundperi = around– medi, meso = middlemedi, meso = middle– retro = behind, backwardretro = behind, backward– Eso = inward / exo = outward, outsideEso = inward / exo = outward, outside

*most commonly confused ie. IOP*most commonly confused ie. IOP

Medical TerminologyMedical TerminologyEtymology: Prefixes of NumberEtymology: Prefixes of Number

ExamplesExamples – Bi = twoBi = two– Dipl, diplo = doubleDipl, diplo = double– Hemi = halfHemi = half– Mono, uni = oneMono, uni = one– Macro = largeMacro = large– Micro = smallMicro = small– Poly = manyPoly = many

Medical TerminologyMedical TerminologyEtymology: Prefixes of NegationEtymology: Prefixes of Negation

ExamplesExamples:: – a = without, not (used before a consonant)a = without, not (used before a consonant)– an = without, not (used before a vowel)an = without, not (used before a vowel)– im, in = in, notim, in = in, not

Medical TerminologyMedical TerminologyEtymology: Other PrefixesEtymology: Other Prefixes

ExamplesExamples: : – Anti, contra = againstAnti, contra = against– Brady = slowBrady = slow– Tachy = fastTachy = fast– Dys = bad, painful, difficultDys = bad, painful, difficult– Hetero = differentHetero = different– Pan = allPan = all

Medical TerminologyMedical TerminologyEtymology: RulesEtymology: Rules Two basic rules for building wordsTwo basic rules for building words..

1) a root word is used before a suffix that 1) a root word is used before a suffix that begins with a vowel.begins with a vowel.

– Example:Example:Scler (hardening) + osis (abnormal condition) Scler (hardening) + osis (abnormal condition)

= sclerosis (abnormal condition of hardening= sclerosis (abnormal condition of hardening

Medical TerminologyMedical TerminologyEtymology: RulesEtymology: Rules

2-1) a combining vowel is used to link 2-1) a combining vowel is used to link a root word to a suffix that begins a root word to a suffix that begins with a consonant.with a consonant.

– Example:Example:ophthalm (eye) + o + scopy (to view) = ophthalm (eye) + o + scopy (to view) =

ophthalmoscopy (visual examination of the ophthalmoscopy (visual examination of the eye interior)eye interior)

Medical TerminologyMedical TerminologyEtymology: RulesEtymology: Rules

2-2) a combining vowel is used to link 2-2) a combining vowel is used to link two word roots together.two word roots together.

– ExampleExample::oste (bone) + o + arthr (joint) + itis oste (bone) + o + arthr (joint) + itis

(inflammation) = osteoathritis (inflammation (inflammation) = osteoathritis (inflammation of the bone & joint)of the bone & joint)

Medical TerminologyMedical TerminologyEtymology: Defining wordsEtymology: Defining wordsThree steps:Three steps:1) Define the suffix, or last part of the 1) Define the suffix, or last part of the

wordword2) Define the prefix, or the first part of 2) Define the prefix, or the first part of

the wordthe word3) Define the middle3) Define the middle

Medical TerminologyMedical TerminologyEtymology: Defining wordsEtymology: Defining wordsExample: gastroenteritisExample: gastroenteritis

1) define the suffix, itis = inflammation1) define the suffix, itis = inflammation2) define the prefix, gastro = stomach2) define the prefix, gastro = stomach3) define the middle, enter = intestine3) define the middle, enter = intestine

Definition:Definition: inflammation of the stomach & inflammation of the stomach & intestineintestine

Medical TerminologyMedical TerminologyEtymology: Defining wordsEtymology: Defining wordsExample: polyarthritisExample: polyarthritis

1) define the suffix, itis = inflammation1) define the suffix, itis = inflammation2) define the prefix, poly = many2) define the prefix, poly = many3) define the middle, arthr = joint3) define the middle, arthr = joint

Definition:Definition: inflammation of many jointsinflammation of many joints

Medical DocumentationMedical DocumentationCharting & TerminologyCharting & Terminology

ReferencesReferencesBates’ Guide to Physical Examination and Bates’ Guide to Physical Examination and

History TakingHistory Taking, 8th Ed., Chap 1&2, 8th Ed., Chap 1&2

The Record That Defends its FriendsThe Record That Defends its Friends, all, all

Medical Terminology; A Systems ApproachMedical Terminology; A Systems Approach, , 4th Ed., chap 1-4 & 164th Ed., chap 1-4 & 16

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Health & Medicine

Lecture 6