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The document discusses patient medical records, including what they are, their purposes, standard chart information, and roles in documentation. Medical records provide a record of a patient's medical history and care as documented by physicians and other healthcare professionals. They serve both clinical purposes like supporting patient care and non-clinical purposes such as administrative, legal, and financial functions.

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Sahan SahA
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85 views26 pages

1st Lecture Improved

The document discusses patient medical records, including what they are, their purposes, standard chart information, and roles in documentation. Medical records provide a record of a patient's medical history and care as documented by physicians and other healthcare professionals. They serve both clinical purposes like supporting patient care and non-clinical purposes such as administrative, legal, and financial functions.

Uploaded by

Sahan SahA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Introduction To

Patient Medical Records


HTTPS://WWW.YOUTUBE.COM/WATCH?
V=KL3_HNMPP_W
LEARNING OUTCOMES

1 EXPLAIN WHAT IS MEDICAL RECORD ?


2 PURPOSES OF THE MEDICAL RECORD
3 STANDARD CHART INFORMATION
4 ROLES OF DOCUMENTING THE MEDICAL RECORDS
WHAT IS MEDICAL RECORD ?
• It is a legal document providing a record of a patient's medical history and
care.
WHO CAN DOCUMENT THE MEDICAL REPORT?
• Physicians, nurse practitioners, nurses and other members of the health
care team may make entries in the medical record.
WHAT DOES IT INCLUDE?
• The medical record includes a variety of types of "notes" entered over
time by health care professionals, recording observations and
administration of drugs and therapies, orders for the administration of
drugs and therapies, test results, x-rays, reports, etc.
PURPOSES OF THE MEDICAL
RECORD
• There are 2 major purposes of the medical record:
• 1. Clinical purposes
• 2. Non clinical purposes
1. Clinical purposes
1. Clinical purposes about the patient whether admitted to the
hospital or treated as an outpatient or an emergency patient.

This is the PRIMARY purpose is to support the continuous patients


medical care by documenting sufficient information about:
• Diagnostic procedures
• Diagnoses
• Prognoses
• treatment
1. Clinical purposes
It supports excellent medical care by:
• Aiding in identification of the patient
• It helps in generating an effective diagnostic and treatment plan
o Physical exam findings
o Diagnostic procedures and tests to be performed
o Records the doctors' differential diagnoses ideas
o Documents patients responses to treatment
o Supports continuity of care
o It documents communication with the patients
2. Non clinical purposes

a. Administrative : demographic and socioeconomic data such as the name of the patient
(identification), sex, date of birth, place of birth, patient’s permanent address, and medical
record number
b. Legal data: a signed consent for treatment by appointed doctors and authorization for the
release of information
c. Financial data: the patient whether admitted to the hospital or treated as an outpatient or
an emergency patient.
APPLY YOUR KNOWLEDGE
What is the purpose of documentation in a patient’s
medical record?
ANSWER: Documentation in the medical record
provides evidence of appropriate care. If a procedure is
not documented, it is considered not done.
Patient Charts: Standard Chart Information
Patient Registration Form
1. Personal Identification Information
. Name
. Record Number
. Date
. Patient demographic information
• * Age, DOB
• * Address
. Insurance / financial information
. Emergency contact
This information varies from one hospital to another depending on the
policy and requirement of each hospital.
PATIENT CHARTS:
STANDARD CHART INFORMATION (CONT.)
2. Diagnostic supporting information:

• A. Past medical history


• Illnesses, surgeries, allergies, and current
medications
• Family medical history
• Social history (diet, exercise, smoking, use
of drugs and alcohol)
• Occupational history
• Current patient complaint recorded in
patient’s own words
PATIENT CHARTS:
STANDARD CHART INFORMATION (CONT.)
B. Physical examination results

C. Results of laboratory and other tests

D. Records from other physicians or hospitals

E. Doctor’s diagnosis and treatment plan

F. Operative reports, follow-up visits, and


telephone calls
Patient Charts:
Standard Chart Information (cont.)

G. Informed consent forms


H. Hospital discharge summary forms
I. Correspondence with or about the patient
J. Information received by fax
• Request an original copy; if not available, make a photocopy of the fax
K. Dating and initialing
DOCUMENTATION OF MEDICAL
RECORDS - OVERVIEW
• With documentation of medical records, particular emphasis must be placed on the six
factors that improve the quality and usefulness of charted information:
1. Clarity
2. Accuracy
3. Completeness
4. Stability of Quantities and Measurements
5. Timeliness
6. Confidentiality
1. CLARITY
• All documents and forms must
include identifiable data In a clear
way that prevent the confusing or
mixing between the different
patients.
2. ACCURACY

• Each individual medical record MUST be written correctly and


accurately.
• All the information about the patient, his condition and about the
provided health care and his response MUST be written correctly
and accurately.
• Inaccuracies (either commission or omission) lead to improper
medical advice being provided in error and may result in adverse
healthcare outcomes or in legal proceedings.
3. COMPLETENESS

• ALL documentation, including that from the outpatient clinics, emergency, medical
laboratory and radiology departments of the hospital must be included in medical record.
4. STABILITY OF QUANTITIES AND
MEASUREMENTS
• Quantities and measurements must be specified and
unified in the documentation between the health care
providers.
• The documentation criteria or amount of recorded data
should be unified for all the patients.
5. TIMELINESS

Timeliness
Record all findings as soon as they are
available

For late entries, record both original date


and current date

Record date and time of telephone calls and


information discussed

Retrieve file quickly in event of an emergency


6. CONFIDENTIALITY
• Medical records are confidential and protected by authority of
the Privacy.
• Don’t leave patient-identifiable information on your computer
screen or exposed in your work area.
• Don’t talk about patients or families in hallways, elevators, or
in other public places.
• Don’t release medical record information without the patient’s
consent.
APPLY YOUR KNOWLEDGE

What section of the patient record contains information


about smoking, alcohol use, and occupation?
ANSWER: Information about smoking, alcohol use, and
occupation is part of the patient’s past medical history.
WHO OWNS THE MEDICAL RECORD?

• Medical records in hospitals or other public facilities are owned by the hospital or health
authority, while the information included are owned to the patient.
• The patient has the right to access the records if he need information for insurance or
Medicare funding purposes.
FUNCTIONS OF A MEDICAL
RECORD DEPARTMENT
1. Admission and Discharge procedure, and completion of medical w records after an
inpatient has been discharged or died.
2. Collecting:
• To collect and document all the administrative, medical and technical forms about the patient
, including his identification and the development and maintenance of the master patient
index (MPI).
2. Organizing:
• Means the process of arranging the documents inside the patient's medical record,
abstracting the essential information from them, classify, code and take the necessary data to
facilitate the process to bring up to it in an easy, practical way with less time and effort as
possible.
FUNCTIONS OF A MEDICAL
RECORD DEPARTMENT – CONT.
4. Storage:
Medical records should be stored in a safe and secure environment. The
department must develop records management protocols to regulate who may
gain access to records and what they may do according to their role,
responsibilities, and develop a protocol to make it easy handled if needed. Also
to make a proper process to store any inactive record.
5. Retrieval:
To retrieve the medical records for patient care and other authorized use.
6. Dissemination:
By providing the required information for any internal or external side.

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