Primary And Secondary Health Records Paper

Primary And Secondary Health Records Paper

M05_GART2674_01_SE_C05.QXD 5 8/10/09 9:52 AM Page 98 Healthcare Records LEARNING OUTCOMES After completing this chapter, you should be able to: 䊏 Discuss the functions that healthcare records serve H primary and secondary health records 䊏 Explain the difference between 䊏 Identify different forms used I to record patient information 䊏 Discuss standard data elements and standard data sets G 䊏 Explain how health records assist in the continuity of care G 䊏 Define a RHIO 䊏 Describe the various formsSof telemedicine 䊏 Explain an E-visit , ACRONYMS USED IN CHAPTER 5 S H Acronyms are used extensively in both medicine and computers. The following A acronyms are used in this chapter Primary And Secondary Health Records Paper.

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ALOS Average Length of Stay N NCVHS CDC Centers for Disease Control I and Prevention National Committee on Vital Health Statistics NHIN National Health Information Network OASIS Outcome and Assessment Information Set CMS CPR CT Centers for MedicareC and Medicaid Services Q Cardiopulmonary Resuscitation U Computed Tomography (also A CAT, Computerized Axial PACS OR PAC SYSTEM Picture Archiving and Communication System Tomography) PET Positron Emission Tomography DEEDS Data Elements for Emergency Department Systems 1 PHI Protected Health Information PHR Personal Health Record DNR Do Not Resuscitate RAI Resident Assessment Instrument RHIO Regional Health Information Organization SNF Skilled Nursing Facility SOAP Subjective, Objective, Assessment, Plan UACDS Uniform Ambulatory Care Data Set ECG EEG EHR EKG HEDIS 1 Electrocardiogram (also EKG) 0 Electroencephalogram 5 Electronic Health Record T ECG) Electrocardiogram (also Health Plan EmployerS Data and Information System HPI History of Present Illness IDN Integrated Delivery Network LOS Length of Stay MDS Minimum Data Set MPI Master Patient Index MRI Magnetic Resonance Imaging NCDB National Cancer Data Base UAMCMDS Uniform Ambulatory Medical Care Minimum Data Set UCDS Uniform Clinical Data Set UHDDS Uniform Hospital Discharge Data Set 98 Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Primary And Secondary Health Records Paper

Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 99 HEALTHCARE RECORDS 99 Understanding Healthcare Records Healthcare records have many purposes, the most important of which is to help healthcare providers with patient care. The patient health record is the repository of data and information about the patient, the condition of the patient’s health, the care and treatments the patient received, and the outcome of that care. This chapter will familiarize you with some of the contents of health records and how they are used. The term patient health record has replaced the term patient medical record because it encompasses a holistic view of patient care. Though the terms are used almost interchangeably, an acute care patient record is usually concerned with one stay or episode, whereas an outpatient medical record is usually limited to one group or clinic. Later in this chapter we will discuss efforts to overcome these limitations by regional providers sharing records electronically and the growing interest by patients in maintaining lifelong personal health records. In Chapter 4 the term data was used to differentiate the H information the computer processes from the software application. In this and future chapters theIword data does not just mean computer information, but rather the information in a health record. Additionally, the term health data G is sometimes used herein for what is technically health information. In a more precise definition, data and information are not the same thing. Data are records G of facts. Information is data in a useful form that conveys meaning. For example, the numeric values 68, 70, 72 are data. S 䊏 䊏 If the data represent height in inches, they may be used to plot an adolescent’s growth rate. , If the data represent a patient’s pulse, they are used to provide information about the patient’s heart rate measured at different intervals. Health information, therefore, is not just the patient dataS but the presentation of this data in a useful form and the association of other relevant details with H it. Figure 5-1 shows a standard form used in pediatric practices. When patient height is recorded on this form, the doctor can easily see A a boy’s height to the general popthe rate of growth over time. Curved lines on the form compare ulation at the same age. In this chapter we will examine some N typical health information forms and further explore the concepts of data elements and data sets introduced in the previous chapter. I C Functions of Healthcare Records Q U A patient’s health record provides accurate information not only about the patient’s treatment, but also about the patient’s health history and previous treatments. A As such, it serves as the primary communication document among various providers who might care for the patient at different times in different departments Primary And Secondary Health Records Paper.

The patient record also provides the basis for all billing 1 and reimbursement. Coding professionals review the record of the patient visit and determine 1 what codes to put on the insurance claim. CMS and other health insurance auditors follow the dictum that “if it isn’t documented, it wasn’t done,” meaning that medical claims will not be paid0if the patient record does not have enough detail about the encounter or treatment to support the5claim. The health record is a legal document. Should a question arise as to the cause of a disease or injury, or to determine if a medical error was made, relevant T portions of the patient’s record may become evidence in a court of law. S Healthcare records provide the basis for improvements in health. Individually, a patient’s record is evaluated and used to develop care plans for the patient. Collectively, health records can be used by the healthcare facility to improve the quality and processes of healthcare delivery. Public health departments, Homeland Security, and law enforcement officials use information from health records to track births, deaths, communicable diseases, effects of exposure to hazardous materials, bioterrorism threats, gunshot wounds, child abuse, and other crimes. Researchers use patient records from clinical trials to monitor the effectiveness and safety of new drugs. De-identified health records are analyzed by researchers to find health trends in our society and measure which treatments seem to have the best outcomes. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 100 8/10/09 9:52 AM Page 100 CHAPTER 5 2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles Mother’s Stature Date Father’s Stature Age Weight Stature BMI* NAME RECORD # 12 13 14 15 16 17 18 19 20 cm AGE (YEARS) 95 90 75 50 25 in 62 S T A T U R E 60 58 56 54 52 50 48 46 44 42 40 38 cm 3 4 5 6 7 8 9 H I G G S , 160 155 150 145 140 135 130 125 S H A N I C Q U A 120 115 110 105 100 95 36 90 34 85 32 80 30 80 W E I G H T 70 60 50 40 30 lb 10 5 10 11 35 30 25 20 15 10 kg 2 3 4 5 6 7 8 9 1 1 0 5 T AGE (YEARS) 10 11 S12 13 190 185 180 175 170 165 160 155 150 in 76 74 S T A T U R E 72 70 68 66 64 62 60 105 230 100 220 95 90 95 210 90 200 85 75 80 75 50 25 10 5 190 180 170 160 70 150 W 65 140 E I 60 130 G 55 120 50 110 H T 45 100 40 90 35 30 25 20 15 10 kg 14 15 16 17 18 19 20 80 70 60 50 40 30 lb Published May 30, 2000 (modified 11/21/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts FIGURE 5-1 Pediatric Growth Chart of Boys’ Stature for Age and Weight for Age. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 101 HEALTHCARE RECORDS 101 Primary and Secondary Records Health information professionals classify health records as primary or secondary records: 䊏 䊏 Primary records are those that are gathered directly from the patient and his or her providers, as well as records obtained from devices and diagnostic tests performed on the patient Primary And Secondary Health Records Paper.

Primary records are used for patient care and as legal documents. Secondary records are those that are created later, by analyzing, summarizing, or abstracting from the primary records. Secondary records are used in billing, research, and quality improvement. Types of Primary Health Records Primary records may be electronic medical records or paper forms, but what they have in comH mon is that they document the patient’s history and state of health, the clinician’s observations and actions, and all tests, treatments, and outcomes. As such,Ithe patient’s health record at a given facility is actually a collection of documents or computer records, G descriptions of which are provided later in this chapter. G As you have learned in previous chapters, there are differences between inpatient and outpatient facilities. The type and quantity of information they keep also varies by the type of facility. S For example, primary health records are generated and maintained by patients, doctors, nurses, , chiropractors, and others. home health providers, hospitals, rehabilitation facilities, dentists, The following examples illustrate some of the differences between health records at different providers’ locations: S 䊏 䊏 䊏 䊏 Acute care hospital charts contain admission and discharge reports, nursing notes, physician examination notes, all orders, test results, operativeHreports, pathology and radiology reports, and administrative and demographic forms. However, A in nearly all cases these are concerned with the current stay. N Ambulatory care facilities (physician offices) tend to keep a single chart per patient, combinI ing documents from all previous visits, medical history, consults, lab results, and reports from other providers. The principal document is the physician’sCnote, which details the observation and findings, but often includes the physician’s orders and plan of treatment. In addition to demographic and social history information, many officesQkeep records of communications with the patient and their insurance plans in the chart as well. U Home care agency records are uniquely centered on a physician’s orders for treatment at A home. CMS has standardized the details that are required about a patient’s home care. The nurses or therapists visiting the patient at home keep notes from each visit concerning the services performed and the patient’s progress. These are1updated in records maintained by the home care agency Primary And Secondary Health Records Paper.

1 Dental records generally contain very abbreviated notes about the treatments and proce0 ever had with the practice includdures performed, but usually cover all visits the patient has ing dental hygienists and other dentists. Also, because dental 5 x-rays are small, most offices store them in the patient’s chart. This is different from medical facilities where x-rays and other diagnostic images are typically stored in a separateTlocation or computer system. S Types of Secondary Health Records Secondary health records are those that are created by abstracting relevant details from the primary records. These secondary records are used for reimbursement (insurance claims), quality improvement at the facility, reporting to accreditation and government agencies, and research. The following are some examples of secondary health records: 䊏 Health insurance claims are created by selecting information from the patient record, such as procedures and diagnoses, assigning codes to them, and assembling them with information from the patient’s demographic and insurance information. These are then submitted to the insurance plan for payment. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 102 8/10/09 9:52 AM Page 102 CHAPTER 5 䊏 䊏 The master patient index (MPI) is typically a computerized system intended to prevent duplicate registrations for the same patient. By taking key identifying facts from patient demographic information such as full name, date of birth, gender, and sometimes Social Security number, a list is created of all the patients registered anywhere in the healthcare facility. By checking the MPI first, registration clerks can see if the patient is already registered and thereby avoid creating duplicate records in the system. Aggregate data is collected by gathering selected items of information from many patients’ charts and then analyzing it. For example, in Chapter 1 we discussed ALOS or average length of stay. By extracting the LOS of all of the patients in the hospital last month, the hospital can calculate the average. Similarly, aggregate data can be analyzed to determine the case mix or for quality improvement purposes. Case mix will be described further in Chapter 9. Transition from Paper to Electronic H Records Many social forces and practical reasons I are causing healthcare providers to change from paper health records to electronic health records (EHRs). Social reasons include an increasingly mobile G doctors more frequently. Additionally, many patients society where patients move and change today see multiple specialists for theirG care. This means their medical record no longer resides with a single general practitioner who provides their total care Primary And Secondary Health Records Paper.

Thus, the ability to share examination records and test results is increasinglySimportant to the patient’s continuity of care (discussed later in this chapter). , Practical reasons for the move to EHRs include the fact that paper records cannot be easily accessed or shared, the charts must be copied and faxed or transported from one office to another, and handwritten portions of the record S are often abbreviated, cryptic, or illegible. Finally, searching the contents of paper charts requires manually opening every chart and reading it. H Chapter 7 will cover ways EHR systems can be used to help improve patient health, the quality of care, and patient safety by Aproviding access to complete, up-to-date records of past and present conditions. Though many facilities are moving toward electronic health records, the N transition will take several years. I C Contents of Health Records Q Although the types of documents or data contained in medical records differ between inpatient U and outpatient facilities, many of them serve a similar purpose. However, clinical records are not the only items stored in a patient’s chart. A For example, many ambulatory offices store nearly any document concerning a patient in the patient’s chart. Figure 5-2 compares a list of some typical records in an inpatient and outpatient chart. Additional information and samples of many of the 1 forms are provided later in this chapter. 1 Data Administrative and Demographic Whether health records are paper or0electronic, certain administrative documents tend to originate as paper forms. Generally this5is the registration information provided by the patient or relative and certain legal documents that the patient must sign. In an all-digital facility these T paper documents are subsequently scanned as images and stored in the electronic record Primary And Secondary Health Records Paper.

When a patient is first registered, demographic data such as name, address, phone numbers, S next of kin, and emergency contact information is recorded. Registration will also record information used for billing such as account guarantor and insurance plans. Though some facilities allow the patient to enter this information directly using a web page, most facilities employ a registrar to enter the data into a computer. In a paper-based facility the patient demographics form is called the face sheet. In facilities that are still transitioning from paper to electronic records, the information may be entered into the computer then printed out to create a face sheet for the paper chart. Demographic and billing information is verified and updated if necessary for each return visit. Patients’ insurance cards may also be photocopied or scanned into the computer during registration. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 103 HEALTHCARE RECORDS Comparison of Contents of Patient’s Chart Acute Care Hospital Registration Record Consent Forms, Authorizations, Property list, Advance Directives Medical History (Admitting Doctor) Physical Examination (Admitting Doctor) Doctor’s Office 103 FIGURE 5-2 Contents typical of acute care versus ambulatory patient charts. H RegistrationIForm G Authorizations, Advance Consent Forms, Directives G Medical History (From Patient) S Doctor’s Notes , from each visit. (Complaint, Symptoms, History, Review of Systems, Vital Signs, Physical Exam, Assessment, Plan of Care) Physician Orders S orders and Test Results Diagnostic Test Clinical Observations: Doctors’ notes, Nurses’ notes, Therapy notes Flow sheetsH (specialty specific—pediatric, obstetric, etc.) Surgery Report/Anesthesia Record Medical Records from other providers Consultation Reports Test Results Discharge Summary Patient Discharge Instructions A N ConsultationI Reports Problem List C Medication Q List Immunization U Record Correspondence A Authorization forms to Disclose PHI Copies of Insurance Cards 1 1 Consent and Directives 0 A number of legal documents signed by the patient are included in the medical record. In some 5 cases these are simple permission statements included on the patient information form; in other T filed in the chart or scanned into facilities the patient signs many individual forms, which are then the computer. Some typical examples include the following. S The patient acknowledges receipt of the Notice of Privacy Practices discussed in Chapter 3. This consent or acknowledgment may be included on the registration form or combined with another consent form. HIPAA CONSENT TO USE AND DISCLOSE PHI CONSENT TO TREATMENT A general consent to be treated by the healthcare practice or facility is usually included in the registration form. Additional informed consent forms are required for each operation or special procedure (discussed below). CMS requires that patients be given a statement of their rights under Medicare. Patients will sign an acknowledgment that they have received the statement and their rights have been explained. MEDICARE PATIENT RIGHTS STATEMENT Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 104 8/10/09 9:52 AM Page 104 CHAPTER 5 ASSIGNMENT OF BENEFITS In order for a healthcare facility to be reimbursed by Medicare and other insurance plans, the policy holder must sign a form permitting the plan to pay the provider directly. This is called the assignment of benefits, and may be part of the insurance portion of the registration form or may be a blank insurance claim form signed by the policy holder. Note that a CMS-1500 paper insurance form has two signature blocks; one authorizes the patient’s medical information to be sent to the plan and the other authorizes the assignment of benefits to the provider. (Refer to Chapter 10, Figure 10-4, to view an example of this form.) Written consent forms are signed by the patient or patient’s legal representative before any operation or special procedure. The informed consent describes what is going to be done, the expected outcome, any risks associated with it, and possible alternatives to the procedure. This is done to ensure the patient has a complete understanding before going forward. Figure 5-3 shows a two-sided informed consent form. INFORMED CONSENT H A patient may elect not to have a medically necessary procedure I done. In such a case, a form documenting that the consequences of the decision are fully understood by the patient is signed and G added to the chart. REFUSAL OF TREATMENT An advance Gdirective is sometimes called a living will and permits patients to provide instructions regarding resuscitation and life-prolonging procedures in the S event the patient should become terminally ill or injured and unable to communicate his or her , wishes. The advance directive or separate document may also grant another person the power to make medical decisions on the patient’s behalf should the patient become incapacitated. The advance directive may include instructions not to resuscitate the patient in the case of death. When this is the case, inpatientSfacilities create a special order in the chart and clearly mark it DNR (do not resuscitate). If a DNR Horder is not present, consent to perform cardiopulmonary resuscitation (CPR) is presumed. ADVANCE DIRECTIVES A If a patient has agreed to donate organs or other tissues upon death, this is also N specifying an organ donor status, the patient’s family noted in the record. If a patient dies without must be given the opportunity to authorize organ donation. I ORGAN DONOR PERSONAL PROPERTY LIST Inpatient Cfacilities may create a list of personal property brought to the facility by the patient such as jewelry, eyeglasses, hearing aids, and dentures. The form, signed by the patient, may release theQfacility from responsibility for loss or damage to the items. A similar disclaimer may absolve the Ufacility of responsibility for a patient’s vehicle parked on the premises while staying there. A As discussed in Chapter 3, HIPAA requires any disclosure of PHI for purposes other than treatment, payment, or operations of the facility to be tracked and 1 authorizations permitting release of partial or complete recorded. In addition, copies of signed medical records are kept by the HIM 1 department, sometimes with the health record itself. DISCLOSURE RECORDS 0 5 As you would expect, most of the information in the patient’s medical record will be of a clinical nature. In both paper and electronicTsystems, diagnostic images are stored separately from the chart documents or data; however, some EHR systems may provide seamless access to images, S within one system. In paper systems x-rays films are giving the appearance that they are located Clinical Documents stored separately, usually in another part of the hospital. The following are clinical documents typically found in the health record. The primary source of a patient’s medical history is the patient or a relative. A medical history at an acute care facility will be obtained through an interview of the patient by the admitting doctor or a nurse Primary And Secondary Health Records Paper.

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At an ambulatory facility the history typically originates as a paper form that is filled out by the patient in the waiting room, though some modern medical practices allow patients to enter this data themselves on a computer using medical history software. A sample paper history form is shown in Figure 5-4. MEDICAL HISTORY Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 105 HEALTHCARE RECORDS 105 H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 5-3a Informed Consent (front side). Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 106 H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 5-3b Informed Consent (back side). Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 107 HEALTHCARE RECORDS 107 Date: ______________ Patient Name: ________________________________________________________ Date of Birth: Race: ______________ ❒ Male ❒ Female Family Practice Medical Center Anytown, USA What is the reason you are here today? ___________________________________________________________________________________________________________________________________________________ Please check any of the following conditions which you have had General ❒ Serious Infections (e.g. pneumonia) ❒ ❒ ❒ ❒ HEENT ❒ Glaucoma ❒ Allergies “hay fever” ❒ Frequent Ear Infections ❒ Frequent Sinus Infections Diabetes Mellitus Rheumatic fever HIV Infection Cancer Respiratory Cardiovascular ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ High Blood Pressure Congestive Heart failure Heart Murmur Heart Valve Disease Angina Heart Attack High Cholesterol Abnormal Heart Rhythm Blood Clot in Veins Blocked Arteries in Neck Blocked Arteries in Legs ❒ ❒ ❒ ❒ Asthma Emphysema Blood Colt in Lungs Sleep Apnea Musculoskeletal / Extremities ❒ ❒ ❒ ❒ ❒ ❒ Osteoporosis Rheumatoid Arthritis Degenerative Joint Disease Fibrmyalgia Neck Pain (herniated disk) Back Pain (herniated disc) GI/GU ❒ Stomach Ulcers ❒ Ulcerative Colitis ❒ Crohns Disease ❒ Bleeding from Intestines ❒ Diverticulitis ❒ Colon Polyps ❒ Irritable Bowel Disease ❒ Hepatitis ❒ Cirrhosis of the liver ❒ Liver Failure ❒ Pancreatitis ❒ Gallstones ❒ Kidney Stones ❒ Kidney Failure ❒ Prostate Disease ❒ Endometriosis ❒ Sex Transmitted Infection H I G G S , S H A Please check any of the following major illnesses in your family members: N❒ Kidney Disease ❒ Tuberculosis ❒ Diabetes Mellitus ❒ Emphysema ❒ Thyroid Disease I❒❒ Epilepsy ❒ Heart Disease ❒ Anemia Neurological Disorder ❒ High Blood Pressure ❒ Hemophilia C❒ Liver Disease ❒ Osteoporosis ❒ Other _____________________ ❒ Other _____________________ Q U If you have had surgery please indicate the year: Year Surgery Year Surgery Year Surgery A Neurosurgery _____ Angioplasty _____ Colonoscopy _____ _____ _____ _____ _____ _____ _____ Appendectomy Back or Neck Surgery Bladder Surgery Carotid Artery Surgery Carpal Tunnel Surgery Chest/lung Surgery _____ _____ _____ _____ _____ _____ Coronary Bypass Ear Surgery Gallbladder Hip Surgery Inguinal Hernia Knee Surgery _____ _____ _____ _____ _____ _____ 1 1 0 Please indicate when you had the following preventative services: Date Immunizations Date T ests Date 5 _____ Flu Vaccine _____ Chest X-ray _____ _____ Hepatitis Vaccine _____ EKG _____ T _____ Pneumonia Vaccine _____ Echocardiogram _____ _____ Tetanus Booster _____ Stress Test _____ S _____ Other _____ Cardiac _____ Angiogram S inus Surgery S tomach Surgery Thyroid Surgery T onsillectomy Trauma Related Surgery Vascular Surgery T ests / Exams Colon Cancer Stool Test Flexible Sigmoidoscopy, R ectal Exam Barium Enema Prostate Cancer Blood Test Lymphatic / Hematologic ❒ Thyroid Goiter ❒ Over Active Thyroid ❒ Under Active Thyroid ❒ Transfusions ❒ Anemia Skin / Breast ❒ ❒ ❒ ❒ Acne Eczema Psoriasis Fibrocystic Breast Disease Neurological / Psychiatric ❒ ❒ ❒ ❒ ❒ ❒ ❒ Chronic Vertigo (Meniere’s) Peripheral Nerve Disease Migraine Headaches Stroke Multiple Sclerosis Depression Anxiety ❒ ❒ ❒ ❒ ❒ Breast Cancer Ovarian Cancer Colon Cancer Prostate Cancer Other _____________________ Year _____ _____ _____ _____ _____ _____ _____ Date _____ _____ _____ _____ _____ Surgery Tubal ligation C-Section Hysterectomy Ovary Removed Breast Surgery T hyroid Surgery Other T ests / Exams Breast Exam Mammogram P ap Smear B one Density Test Date of last Physical Exam Personal Habits Tobacco ❒ Never ❒ Previous user ❒ Current user # packs per day __________ FIGURE 5-4 Alcohol ❒ Never ❒ Previous user ❒ Current user # drinks per day __________ Caffeine ❒ Never ❒ Previous user ❒ Current user # cups per day __________ Illicit Drugs ❒ Never ❒ Previous user ❒ Current user Outpatient History Form (paper version). Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 108 8/10/09 9:52 AM Page 108 CHAPTER 5 The patient’s history for an ambulatory visit includes: 䊏 䊏 䊏 䊏 䊏 䊏 Chief complaint (principal reason for the visit) History of present illness Past medical history, including previous illnesses, operations, serious injuries, childhood diseases, drug and environmental allergies, and immunization records Social history concerning living conditions and habits such as smoking, drinking or drug usage Family history to determine if close relatives have certain chronic diseases or allergies that may be hereditary Review of systems, which involves questions about one or more of 11 body systems Primary And Secondary Health Records Paper.

The patient’s medical history will be reviewed and updated for each outpatient visit. H PHYSICAL EXAM Detailed records are I made of each physical exam; these are generally encompassed in the physician’s note along with the medical history discussed above. The physician’s note is sometimes called the SOAPG note, which is an acronym for a recommended format for physician notes. SOAP stands for: G Subjective: S 䊏 The patient’s description of symptoms and the chief complaint , Objective: 䊏 The findings of the physical exam and diagnostic tests S H A Plan: N 䊏 Physician’s orders and plan of care for the treatment of the condition. I Generally a history and physical are conducted at every outpatient visit. Cnotes are used to document the patient’s condition and After the initial exam, progress response to treatment and any modifications to the plan of care or additional orders. Physician Q progress notes may follow the SOAP format as well. Inpatient rules require a historyU and physical within 30 days prior to admission or no more than 24 hours after admission. A Assessment: 䊏 The physician’s diagnosis Nursing progress notes for inpatients will usually be grouped elsewhere in a nursing notes section of the chart (discussed later in this chapter.) 1 Each order for a medication, lab work, or other 1 diagnostic test will be recorded in the patient’s chart. Orders are also recorded for ancillary 0 and occupational therapy. services such as respiratory, physical, Orders must be dated and signed 5 (or electronically signed) by an authorized person. Generally this is a physician, physician assistant, or certified nurse practitioner. A sample order T form is shown in Figure 5-5. In hospitals, physicians often give S or change orders verbally. The order is then entered and DIAGNOSTIC AND THERAPEUTIC ORDERS signed by a person authorized to receive verbal orders (usually a licensed nurse.) Inpatient orders may also concern dietary restrictions, restraint, seclusion, and so on. Inpatient facilities also require a discharge order when the patient leaves. Outside the hospital, orders are also required for medical equipment, devices, and home health services Primary And Secondary Health Records Paper.

For each test or diagnostic study ordered, the chart should also contain a report of the results. X-rays and other radiology studies will be interpreted by a radiologist who will dictate a report; laboratory work will generate a lab results report or pathology report. DIAGNOSTIC AND THERAPEUTIC REPORTS Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 109 HEALTHCARE RECORDS 109 H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 5-5 Form for Orders Following Surgery. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 110 8/10/09 9:52 AM Page 110 CHAPTER 5 Physical, occupational, respiratory, speech, and other types of therapists record the patient’s progress and the outcome of the ordered therapy. These too are part of the patient record. A nutritional or dietary plan will be part of inpatient records. The actual images or data captured from ordered tests is retained as part of the patient record Primary And Secondary Health Records Paper.

These are generally stored separately from the chart, though in an electronic medical record they may appear integrated. If an x-ray is taken on film, the films are stored in large envelopes called jackets, usually in a separate file room. Many hospital radiology departments have eliminated film and either capture the x-ray directly into the computer, or scan the film during processing and store the image electronically. Radiology departments generally store images on a Picture Archiving and Communication System (PACS). These include x-rays, CT scans, PET scans, and MRIs. Other diagnostic tests may produce images that are stored in the medical record, but not on the PAC system. Examples of these are EKGs, EEGs, and ultrasound H images. DIAGNOSTIC IMAGES I Surgical procedures require records of the anesthesia, the actual proceedings in the operating room (intraoperative records), the period in the recovery room, and G a postoperative progress note. An informed consent for the procedure signed by the patient or legal representative is required and isG usually grouped with the operative records. If the operation involves organ transplantation, additional S transplant records are required. Refer to Figure 5-3 to view an informed consent form. OPERATIVE RECORDS , Information gathered by nurses on an outpatient visit may include the chief complaint, past medical history, family history, and social history, and the vital signs. In an Skept as separate nursing notes, but rather made a part of the outpatient setting these are usually not physician’s SOAP note. H In an inpatient facility, nurses provide most of the care and record most of the information about the patient. Nursing notes areA therefore grouped separately by most systems. In addition to recording the patient’s medical, social, N and family history upon admission, nurses document the administration of medications, therapies, oxygen, and other treatments ordered by the I physician. Nursing notes are the key to continuity of care for the inpatient. Nurses document not only C the treatment interventions but the patient’s response to treatment, and record observations on Q changes in the patient’s status or deviations from the plan of care. Any abnormal conditions or new complaints that arise are recorded by the nurses. In addition to frequent monitoring of vital U signs, nurses also record the level of pain the patient is experiencing and the input and output of A fluids by the patient. A nursing assessment of the patient is performed at each work shift and all nursing notes are signed by the nurse. Because nurses provide most of the direct treatment to the patient, nursing 1 notes usually make up the largest portion of an inpatient medical record. Figure 5-6 shows a method for1recording nursing notes using a flow sheet. A flow sheet records data in columns and rows, making it easy to compare changes in values recorded over 0 multiple intervals of time. NURSING NOTES 5 Specialists may be asked to see a patient or review a case Primary And Secondary Health Records Paper.

In both T inpatient and outpatient settings, consulting physicians will provide a document of their findings for the patient’s medical record. A S copy of the attending physician’s request for the consult, called a referral, may be kept in the medical record as well. Some insurance programs require a formal preauthorization for outpatient referrals; in such cases, a copy of that preauthorization is also placed in the patient’s chart. REFERRAL CONSULTS CASE MANAGEMENT Case managers and social workers document care planning, coordination of care, and discharge plans in an inpatient facility medical record. DISCHARGE SUMMARY Inpatient stays of longer than 48 hours are concluded with a discharge summary report created by a physician. Shorter stays may have a final discharge progress note or short-stay report used in place of the discharge summary. A final physical exam is conducted. It Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 111 HEALTHCARE RECORDS 111 H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 5-6 Nursing Flow Sheet chart used in a neonatal unit Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.qxd 112 10/5/09 7:43 PM Page 112 CHAPTER 5 H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 5-7 A Discharge Summary Form Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:53 AM Page 113 HEALTHCARE RECORDS 113 may be recorded with the discharge summary or as a separate physician note. An example of a discharge summary form is shown in Figure 5-7. Elements in the discharge summary include: 䊏 䊏 䊏 䊏 䊏 䊏 Principal diagnosis and other diagnoses Brief history justifying the need for hospitalization Summary of laboratory, radiology, and other diagnostic results Significant treatments and procedures as well as the patient’s response to them Patient’s condition at the time of discharge Plan of care: follow-up visits, dietary restrictions, referrals to other providers, prescriptions and orders for medications and durable medical equipment such as a wheelchair or crutches, and orders for home oxygen or therapy.  Primary And Secondary Health Records Paper