Alliyah EvangelistaHIM 1 - Chp. 3-5, The Purpose and the Content of the Health Record
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Define the two purposes of a health record.
Primary - to support direct patient care
Secondary - environment in which the services are performed
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List examples of a primary purposes
- patient care delivery
- patient care management
- patient care support processes
- financial and other administrative purposes
- patient self-management
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List examples of secondary purposes
- education
- regulation
- research
- public health
- policy making and its support
- industry
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Why is health record documentation important to the primary purpose of patient care?
Because it supports the direct care for patients. For example, it allows communication between health providers for ongoing care and treatment and provides information to monitor the quality of care.
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Why is health record documentation important to the secondary purposes of patient care?
It supports the environment around the services. For example, records could be used to educate future providers on the standards for a health record as well as provide information if it's required by law.
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Why is data collection so important?
Can be used for administrative and clinical decision-making and are critical for use in planning, management and research.
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What are the two types of data present in a health record?
- Clinical: medical condition, diagnosis, procedures and treatment
- Administrative: demographic and financial information, consents and authorizations; patient identity
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When does the collection of clinical data begin?
Before admission: because it also checks for medical history, admitting diagnosis, physical exams, etc.
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Why is a person's medical history important?
Their past, family and surgical history might help in diagnosis their current complaint. In the case of family history, they might've inherited something from their family.
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What does a physical exam report?
- physician's assessment of current health status
- addresses major body systems
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What is in a a diagnostic and therapeutic report?
Should have physician's orders; which include admission and discharge orders. They should be legible, dated and signed by the physician.
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What are the two types of diagnostic and therapeutic orders? Define them.
Standing orders: written instructions on how to treat a patient
Verbal orders: instructions given orally, not as reliable
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What are progress notes (PGN's) and who writes them?
They are the chronological report of the patient's condition and their response to the administered treatment. Written by physicians, nurses, and others.
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What is in a diagnostic report?
- lab tests
- pathology exams
- imaging reports
- monitors of body functions
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What is in procedure and surgical documentations?
- pre-op notes by surgeon anesthesiologist
- patient consent
- anesthesia record
- operative report
- post-anesthesia
- pathology report
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What must the physician ensure in regards to patient consent?
They must ensure that the patient understands the procedure, alt. treatments, the risks ,complications, and the benefits of it to truly get their consent.
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What are the 3 types of consent and explain?
Written: must be signed on a document
Implied: implied, something that isn't explicitly said, but implied. Ex: patient pulls out arm for physician to insert needs without saying anything.
Expressed: verbally spoken, "yes, i consent."
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What do the procedure and operative reports describe?
- diagnoses
- description of the procedures performed
- normal and abnormal findings
- patient's medical condition before, during and after
- blood loss
- specimens removed
- complications if any
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What must the procedure and op reports have to have?
- names of the surgeons and their assistants
- date and duration of the operation
