Chapter 4 Notes: The Medical Record

Medical Records The medical record is a ______________________________________________________________ that records a single

patient’s medical history over time.o Some things you might find in a medical record include:

Past medical history Past and current _____________________________________________________________________ Past and current medications Physician observations X-rays and other test results

o Regulations and legal considerations State and federal agencies regulate the ____________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

What does it mean when we say the medical record is a legal document? Who has access to it?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Correcting Medical Records• How to correct an error made in a medical record:

• If a mistake is made in a handwritten entry it should be identified by __________________________

___________________________________________________________________________ addition to the following;• Date of correction• The abbreviation ____________________• Initials and credentials of person making corrections

**Never use ____________________________________________________________________________________________**

Common records used in documenting the care of a patient History and Physical (H & P)

o Document of medical history and findings from the physical examinationIncludes:

Subjective Information à ________________________________________________________

________________________________________________________________________________________

Objective Information à _________________________________________________________

________________________________________________________________________________________

Would each of the following be considered subjective or objective information?

o Patient complains of sore throat and drainage for 4 dayso Patient has a blood pressure (BP) of 130/85o Physician reports patient has a fever of 102 Fo Patient has 4 small children ages 2-12

History (Hx)o Record of the patient’s personal medical history including past injuries, illnesses,

operations, defects and habits

Includes: __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________

• History (Hx) Abbreviations

________ Chief Complaint or _________ complains of• Brief description of why patient is seeking care

________ Present Illness or _________ History of present illness• Notation of duration and severity of complaint. How bad is it? How long have

they had it?

________Symptom• Evidence of illness that the patient reports

________Past History or __________ Past Medical History• Notation of surgeries, injuries, physical defects, medications and allergies

_______________ usual childhood diseases

_______________ no known allergies

_______________ no known drug allergies

_______________ Family History• Notes about the state of health of immediate family members

Example: FH: father, age 58, mother, age 54, brother, age 32, all L&W

_____________ alive and well

_____________ living and well

_____________ Social History• Recreational interests, hobbies, use of tobacco/drugs

_____________ Occupational History• Work habits that may involve work related risks

_____________ Review of Systems or _____________ Systems Review• Questions related to function of the body systems

• Physical Exam (Px or PE)o Document of physical examination of a patient including notations of positive and negative

findings

Includes: ___________________________________________________________________________________________ Signs, or objective evidence of the disease, is documented and further diagnostic test

are ordered if necessary

• Physical Exam (Px or PE) Abbreviations

_______________ head, eyes, ears, nose, throat

_______________ pupils equal, round and reactive to light and accommodation

_______________ no acute distress, no appreciable disease

_______________ within normal limits

_______________ assessment• Identification of a disease or condition after evaluation of all subjective and

objective information

_______________ impression

_______________ diagnosis

_______________ rule out• A differential diagnosis is noted when one or more diagnosis are suspected

Example: Dx: R/O pancreatitis R/O gastroenteritis

• Requires further testing to verify or eliminate each possibility

SOAP notes• Progress notes made after the initial history and physical is recorded. The letters represent

the order in which progress is noted:

S subjectiveà __________________________________________________________________________________

O objectiveà ___________________________________________________________________________________

_________________________________________________________________________________________________

A assessmentà ________________________________________________________________________________

P planà ________________________________________________________________________________________

Common Hospital Records• History and Physical• Physician’s orders

• Directions for care• Diagnostic tests/laboratory reports• Nurse’s notes• Physician’s progress notes• Consultation report

• Included if the case is difficult enough to call in a specialist• Operative report• Pathology report• Anesthesiologist’s report• Discharge summary

• Summary of patient’s hospital care, including date of admission, diagnosis, course of treatment, final diagnosis and date of discharge

Common Patient Care Abbreviations• Individual medical facilities provide their own list of acceptable terms and abbreviations

that may differ from site to site. Therefore, use only those acceptable to the specific workplace.

______________________ emergency facility

______________________ place to recover after surgery

______________________ inpatient

______________________ care before surgery

______________________ patient

______________________ well developed, well nourished

______________________ bathroom privileges

______________________ shortness of breath

______________________ treatment

_____________________ increase

_____________________ decrease

_____________________ degree or hour

_____________________ pound or number sign

_____________________ vital signs

_________ temperature

_________ pulse

_________ respiration

_________ blood pressure

Error Prone Abbreviations and Symbols• Medical errors caused by illegible entries and misinterpretations have led health care

agencies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), to require that medical facilities publish lists of authorized abbreviations for use by all personnel, including a list of those unacceptable

___________ every day• Risk: mistaken for q.i.d when period after the “q” is sloppily written to look like an I

• Preferred use: _______________________________________________________________________________________

___________ every other day• Risk: mistaken for q.d when the “o” is mistaken for a period

• Preferred use: _______________________________________________________________________________________

___________ discharge, discontinue• Risk: “discharge” could be mistaken for “discontinue” when followed by medications

prescribed at the time of discharge

• Preferred use: ________________________________________________________________________________________

______________________ left ear, right ear, both ears• Risk: mistaken for each other

• Preferred use: ________________________________________________________________________________________

______________________ left eye, right eye, both eyes• Risk: mistaken for each other

• Preferred use: ________________________________________________________________________________________

______________________ subcutaneous• Risk: mistaken for SL (sublingual) or “5 every”

• Preferred use: ________________________________________________________________________________________

Pharmaceutical abbreviations and symbols• Metric

• cc (cubic centimeter)• cm (centimeter)• g or gm (gram)• kg (kilogram)• L (liter)• mg (milligram)• ml,mL (milliliter) Note: 1cc = 1 mL• mm (millimeter)• cu, mm (cubic millimeter)

• Apothecary• fl oz (fluid ounce)• gr (grain)• gt (drop)• gtt (drops)• dr (dram)• oz (ounce)• lb or # (pound)• qt (quart)

Medication Administration—Drug forms• Solid and Semisolid Forms

• _________________________________________________________

• _________________________________________________________

• _________________________________________________________

• Liquid Forms• Fluid• _________________________________________________________________________________________• Cream, lotion, ointment• Other delivery systems

• Transdermal• ________________________________________________________________________________________

_• Implant

• Imbedded in the body to ____________________________________________________________

Parenteral Drug Administration

The Prescription• A prescription is a written direction for dispensing or administering a medication for a patient• Must be written in a specific format

• _______________

• Symbol at beginning of prescription• Stands for recipe

• Includes ______________________________________________________________________________________________

Drug names• ___________________________________________à assigned to drug at the time it is formulated to describe

the molecular structure of the drug

• ___________________________________________ à the official name given to a drug

• ___________________________________________ à the manufacturer’s name for a drug

For example:Chemical name: 1-[[3-(6,7-dihydro-1-methyl-7oxo-3-propyl-1H-pyrazolo[4,3-pyrimidin-5-yl)-4-ethoxyphenyl]sulfonyl]-4-methylpiperazine citrate

Generic name: sildenafil

Trade or Brand name: Viagra

Recording Date and Time• The date and time are usually required for all entries in a medical record.

Date• Always include the month, day, and year

Time• Military time is often used