Mix
The purpose of a Medical Record
To keep track
Numeric seniority units are filled BLANK alphabetic
Before
Example:
•Edward Lee Smith II is filed BEFORE Edward Lee Smith Jr
•George Lee Curtis IV BEFORE George Lee Curtis Sr
Where is the HPI (History of present illness) located?
In the H&P (History and physical report)
What type of document is an x-ray report?
Radiology & Imaging report
If the patient expires during the hospital stay, the report will be labeled as a
death summary
Describes the gross & microscopic exams performed on organs, lesions, tissue samples, or body fluid removed during a surgical procedure
Pathology Report
How should Joellen M. de la Vara be indexed?
Delavara, Joellen M.
What is the document's name that may include, sponge count & instrument inventory?
Operative Report
If the patient is transferred to another facility, such as a skilled nursing facility, the report is labeled as a
transfer summary
State law requires an autopsy be performed in the following situations:
●Sudden, unexpected death,
●when someone dies unattended
●Crime or suspicion of crime
●reason for admission
●description of what transpired while in the hospital
●final diagnosis
●follow up instructions
●discharge medications
●patient's condition at time of discharge
●prognosis for recovery
How should Prof. Marcia Tai Lewis be indexed?
Lewis, Marcia Tai Prof
(Lewis is unit 1)
(Marcia is unit 2)
(Tai is unit 3)
(Prof is unit 4)
What is included in Demographics or “Facesheet"?
Includes patient name, address, phone number, email, health insurance info, marital status, emergency contacts, historical and future clinic appointments, etc.
Often, Health Insurance Cards and Identification Cards accompany this information in the chart.
Radiology reports are filed by date or BLANK rather than date of BLANK
service, dictation
What is the name of Joellen's black lab?
Major
How would you file patient charts with identical names?
Use/Reference other identifiers such as:
• DOB, SS #, Address, or phone #
How should Brenda C. Hughes-Callahan be indexed?
Hughes-callahan, Brenda C.
A method that serves as a reminder that some future action is needed
Tickler Files
What is an autopsy report?
documents findings of exam to determine cause of death, & to ascertain or confirm presence of disease. May also be called an autopsy protocol, necropsy report or medical examiner report.
Documents the patient's history of a hospital admission
Discharge Summary
Who owns the patient record?
The law states that medical records are the property of the one creating them
Using INDEX Rules to create and sustain accurate medical records is important: What are the index units?
Unit 1- Patient’s last name
Unit 2-Patient’s first name
Unit 3-Patient’s middle name or initial
For an autopsy: Temporary anatomic diagnosis should be placed in the medical report within BLANK hours, and the report should be completed within BLANK days
72, 60
What is a consultation report?
A report that is generated when one healthcare provider requests the services of another provider in the care & treatment of a patient.
What does SOAP stand for
S - Subjective impressions
O – Objective impressions
A - Assessment or Diagnosis
P - Plans for further studies, treatment, or management