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U N I T 3

Records
Ma na ge me nt

153
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CHAPTER 7 Patients’ Medical


Records

O B J E C T I V E S

After reading this chapter and learning step-by-step procedures to gain job skills,* you should be able to:

Learning Objectives
❚ List reasons for maintaining medical records.
❚ Explain the difference between a medical record and a medical report.
❚ Name three basic types of medical record systems.
❚ State the functions of a flowchart.
❚ Describe the operation of an electronic medical record system.
❚ Name various titles the physician may have in the treatment of patients.
❚ List contents of a patient’s medical record file.
❚ State the differences between a manual, an electronic, and a digital signature.
❚ Describe two types of documentation formats.
❚ Distinguish subjective from objective information.
❚ Define terms and common abbreviations in medical reports and chart notes.
❚ Name basic elements of a patient encounter included in the medical record.
❚ Understand the contents of a history and physical examination report.

P e r f o r m a n c e O b j e c t i v e s ( J o b S k i l l s ) i n T h i s Te x t b o o k
❚ Prepare and compile a medical record for a new patient.
❚ Correct an entry in a medical record.
❚ Abstract data from medical records.

*This textbook and the accompanying Workbook meet the educational components of the American Association of Medical Assistants Role
Delineation Study of 2003 for administrative procedures and general skills.
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CHAPTER 7 Patients’ Medical Records 155

P e r f o r m a n c e O b j e c t i v e s ( J o b S k i l l s ) i n t h e Wo r k b o o k
❚ Write definitions for chart note abbreviations.
❚ Enhance spelling skills by learning new medical words.
❚ Prepare a patient record from a patient information form.
❚ Prepare a patient record from information received in an interview.
❚ Decode abbreviations in medical records and know their meaning.
❚ Record telephone messages.
❚ Make proper correction entries in chart notes.
❚ Abstract information from a patient medical record.
❚ Organize the contents of a history and physical examination report.

CMA AREAS OF COMPETENCE

Administrative General (Transdisciplinary)


Administrative Procedures Communication Skills
❚ Perform basic clerical functions ❚ Receive, organize, prioritize, and transmit
information
Clinical ❚ Use medical terminology appropriately
Patient Care Legal Concepts
❚ Obtain patient history and vital signs ❚ Prepare and maintain medical records
❚ Coordinate patient care information with ❚ Document accurately
other health care providers ❚ Follow federal, state, and local legal
guidelines

RMA AREAS OF COMPETENCE

❚ Manage complete patient medical records ❚ Record laboratory results and patient com-
system munication in charts
❚ Arrange contents of patient charts in ❚ Use computer for data entry and retrieval
appropriate order and perform audits for
accuracy

KEY TERMS
abstract consulting physician
attending physician diagnosis
audit laboratory report
case history medical record
CHEDDAR medical report
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156 UNIT 3 Records Management

objective sign
ordering physician SOAP
POR subjective
prognosis symptom
progress report treating or performing physician
referring physician x-ray report

HEART OF THE HEALTH CARE PROFESSIONAL and state programs. A medical report is a permanent,
legal document in either letter or report format that
Service formally states the elements performed and the results
Those working with medical records of an examination and recommended treatment.
serve patients by respecting their pri-
vacy and keeping personal information confi-
dential. Consider the medical record as a diary MEDICAL RECORD SYSTEMS
put in your care, and have a high regard for it. With the onset of documentation guidelines and the
increase of internal and external audits, it is impor-
tant that a proper medical record system be used. A
MEDICAL RECORDS good medical record system is a key to quality care. It
assists with accessing patient records and protecting
A patient’s medical record is a handwritten or type-
against liability suits. The day is fast approaching
written recording of information that documents facts
when medical record information will be available
and events during the administration of patient care.
through data retrieval systems providing computer
The legal task force of The American Health Informa-
readouts so that traditional patient charts can be
tion Management Association (AHIMA) defines the
updated constantly.
legal health record (LHR) as “the documentation of
Three basic types of record systems used by most
healthcare services provided to an individual, in any
physicians’ offices are:
aspect of healthcare delivery by a healthcare provider
• Problem-oriented record
organization.” The principal reasons for maintaining
medical records are: • Source-oriented record
• Integrated record
1. To aid in the diagnosis and treatment of a patient
2. To provide written documentation of directed
patient care Problem-Oriented Record System
3. To verify that services were medically necessary During the 1960s, Dr. Lawrence Weed developed a
problem-oriented record system (POR). The system has
4. To assist in the research of disease and injuries so been modified for use by individual disciplines, includ-
other patients may benefit from previous patient ing the medical profession (Figure 7-1 and Figure 7-2).
care The example in Figure 7-1 illustrates a flow sheet
5. To substantiate procedure and diagnostic code that indicates allergies, the patient’s blood type, and
selections for appropriate reimbursement lists in tabular form all of the patient’s problems, each
6. To comply with federal and state laws one numbered with the dates that they were treated
and resolved. The patient’s continuing medications
7. To defend the physician in the event of a lawsuit
are cross-referenced (by number) to the problem for
Patient records are also used in completing various which they were prescribed, along with dosage infor-
reports required by law, such as reports on communi- mation and the start and stop dates of the medication.
cable diseases, child abuse, gunshot wounds, stabbings The example in Figure 7-2 illustrates identifica-
from criminal actions, diseases and illnesses of new- tion data with several flow sheets in the bottom
borns and infants, and injury or illness that occurs in portion of the form. One flow sheet lists immuniza-
the workplace. In addition, they are used to assist in tions and the dates that they were received. Another
the preparation of insurance claims for private, federal, one lists consultations with the date, type, and con-
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CHAPTER 7 Patients’ Medical Records 157

Morani, Betty
00621 A Codeine, Sulfa

1 10/98 Hypertension - essential


2 10/98 Diabetes mellitus (Type 2 )
3 1/99 L Retinopathy see below
4 4/00 Atherosclerosis with
cerebral vascular insuffic.
5 4/00 Hearing loss
6 1/02 HBPNon-compliance 2/02
3 1/02 Bilat. Grade II Retinopathy

1 Sinoserp 1 mg. b. i. d. 10/98 10/00


2 Orinase 0.5 gm. daily 10/98 10/00
1 Hydrodiuril 50 mg. A.M. 10/00
2 1500cal. diet low Na hi K 2/02

10/98 1/99 4/00 1/02

Figure 7-1. Problem-oriented medical record preprinted inside the jacket of a patient’s chart. Left side with
space for problem descriptions, continuing medication, and allergies and sensitivities. (Reprinted with permission
of Hollister, Inc., Libertyville, IL, 1988)

sulting physician’s name; the type of problem is cross- used to record blood sugar levels for diabetics, blood
referenced by number to the problem list shown in pressure readings for hypertensive patients, pro-
Figure 7-2. The last flow sheet contains hospitaliza- thrombin levels for patients taking blood-thinning
tion dates and the reasons for admission. agents (e.g., Coumadin), weight for obese or under-
Some data are hard to track in narrative progress nourished patients, as well as medication refills. They
notes; on the other hand, flow sheets, charts, or can be developed for any type of continuous problem,
graphs allow the physician to quickly find information for example, cardiovascular cases (see Example 7-1).
and perform comparative evaluations. These, how- Using a medical record system helps the physician
ever, do not replace documentation in the progress retrieve information quickly and handle large patient
notes in the medical record. In addition to the types of workloads. The POR system permits evaluation of the
flow sheets previously mentioned, they are commonly physician’s reasoning in assessing patients’ conditions.
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158 UNIT 3 Records Management

Figure 7-2. Problem-oriented medical record preprinted inside the jacket of a patient’s chart. Right side with
space for identification data, immunizations, consultations, hospitalizations, educational status, and special
notes. (Reprinted with permission of Hollister, Inc., Libertyville, IL, 1988)

There is less reliance on the physician’s memory so ple, history and physical section, progress notes, labo-
errors are reduced, and the patient receives more effi- ratory, radiology, surgical operations, and so forth.
cient, continuous care. The disadvantage of this Some SOR systems use color laminated tab dividers for
format is the time it takes to develop the problem list each section, which make locating information quick
and to do the necessary repetitious recording. and easy. The information in each section is sequenced
in chronological order, with the most recent on top.
Sequencing of the sections varies from practice to
Source-Oriented Record System practice. The disadvantage of the SOR system is the
The source-oriented record system (SOR) is the most lack of an overall picture of the patient’s health or
common paper-based management system. Docu- problem because documentation related to these
ments are arranged according to sections, for exam- issues is filed in different sections of the record.
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CHAPTER 7 Patients’ Medical Records 159

EXAMPLE 7-1
Cardiovascular Flow Sheet
Patient's name: Clare McDonald Physician: F. Practon, MD

Normal Values 135–199 30–85 <130 L = < 3.7 35–160


ABC Lab M = > 3.7
H = > 4.7

Date Cholesterol HDL LDL Cardiac Risk Ratio Triglycerides

1/18/1998 204 59 116 3.5 145


2/3/1999 232 61 160 3.80 57
2/17/2000 245 55 142 4.5 242
10/9/2000 256 62 178 4.1 80
2/16/2001 277 59 181 4.7 186
5/4/2002 266 50 186 5.3 Start Zocar 40 mg/d 149
9/14/2002 187 70 102 2.7 99

Integrated Record System COMPLIANCE


The integrated record system files all documents in
chronological order without regard to their source. The Health Insurance Portability and
Trying to compare information from the same source, Accountability Act (HIPAA) of 1996
for example, laboratory test results, is difficult because requires health insurance reform and
they are scattered throughout the record. Some med- administrative simplification. One of
ical practices keep progress notes on top and other the provisions directs federal government
documents, such as radiology and laboratory reports, programs to adopt national electronic stan-
in separate sections. dards for automated transfer of certain health
care data among health care payers, plans,
and providers. This eliminates nonstandard
Electronic Medical Record System formats and encourages offices to convert to
The use of legal, financial, clinical, and other business an electronic recordkeeping system.
data has generated an ever-expanding volume
of required forms, documentation, and reporting
procedures. These data take more office time to docu-
ment and require more storage space when a paper EXAMPLE 7-2
chart system is used.
In an electronic medical record (EMR) system, a Computer Template Questions
template on the computer screen is brought up and Chief complaint: Fever. The questions
the medical assistant enters the reason for the appearing in a pop-up screen might ask,
patient’s visit (see Example 7-2). A series of questions “How long has the patient had a fever? What
designed to find more information about the patient’s is the highest temperature reading?” “What
complaint are then answered. other symptoms (chills, sweats, nausea,
There is one screen that may contain ongoing data vomiting, rash, headache, pain) accompany
about a patient, including allergies and past history of the fever?”
complaints. There may be a history and physical
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160 UNIT 3 Records Management

screen with two different templates. For example, one COMPLIANCE


may be for a well-child visit and one may be for an ill-
child visit. When the examination has been completed, It is imperative that an electronic
the software program may prompt the physician medical record system provides secu-
through a series of templates and screens to assist in rity for both data and the system.
the assignment of procedural codes. When the diagno- Data security offers protection from
sis has been determined, a diagnostic screen appears. improper disclosure or unauthorized or unin-
There are usually several diagnostic codes listed— tended alteration of information. System secu-
those that were previously assigned and those relating rity incorporates safeguards to protect the
to the current problem. The physician selects the system and its resources and data from
appropriate one according to the description. With this defined threats. A protected system would
data input, it is then possible for the system to generate include personal identification and user verifi-
either a paper claim for mailing or an electronic claim cation such as passwords, access codes, key
for transmission. cards, and biometric identification. It would
Electronic systems may also generate prescrip- also provide audit trails limiting user access
tions, laboratory requisition forms, or specific written and locating suspicious patterns of access.
instructions for the patient to take home. There is less The computer architecture must be designed
chance for error in reading or misinterpretation to prevent users from gaining access to unau-
because all documents are legible. thorized data and to prevent tampering. It must
In an electronic system, every examination room incorporate encryption that permits interpreta-
has either a computer or a physician handheld per- tion of data only with the appropriate key.
sonal digital assistant (PDA). The physician can
choose the typical language for normal findings
sealed and separate from the medical record, then a
already stored in the unit or mark an insertion point
special file should be established for those cases, for
for edited remarks and later dictate that section of the
example, HIV, alcohol and substance abuse, and so on.
report. There may be a workstation in the hallway or
See Chapter 9 (Filing Procedures) for further discus-
at the physician’s desk to finish notes after leaving the
sion about this topic.
patient. The physician can release the report to be
finalized by the medical transcriptionist, who reviews
and edits it for accuracy of grammar and spelling, RECORDKEEPING
enters any information that has been dictated, and
returns the report to the physician for final review and Recording Data
signature. With this system, the doctor does not have With the appearance of computers and communica-
to spend time redictating each component of the tion equipment, there are a variety of ways to record
report for each patient. data. Each medical practice may use one or more.
Computers play a role in storing medical records Physician enters data. Entries in the patient’s
for statistical purposes and for retrieval and review; for record are handwritten. Physicians have been held
example, when a physician wants to evaluate data on liable in a hospital setting when medication has been
the effectiveness of a treatment plan or follow the given to a patient in error as a result of handwritten
course of several patients who have the same diagno- notes that were incorrectly read.
sis. But remember, confidentiality of the medical
COMPLIANCE
information must be safeguarded. Some states have
laws that require human immunodeficiency virus
Entries in the patient’s record must
(HIV) test results to be entered in the medical record,
be legible.
whereas other states do not. The inclusion of HIV test
results in a medical record is not considered disclo-
sure, and results may be disclosed to those employed
in medical offices and who are involved in patient care Physician dictates. Although some physicians
and treatment without breaching confidentiality or prefer to handwrite, the majority dictate their notes or
the law. If a medical practice is in a state where laws comments. Dictation terminals may be available at the
require certain confidential information to be kept physician’s desk, in the treatment room, or at office
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CHAPTER 7 Patients’ Medical Records 161

workstations. Portable equipment may be used by the Attending physician refers to the medical staff
physician when off site. The transcriptionist listens to member who is legally responsible for the care
voice recorded data and keys the information using a and treatment given to a patient.
typewriter, word processor, or computer. The record or
Consulting physician is a provider whose opin-
report is then reviewed and signed by the physician.
ion or advice regarding evaluation and/or man-
Physician keys data. Data are entered via a terminal
agement of a specific problem is requested by
that is available in every examination room where the
another physician.
physician can key in information about the patient’s
visit. This information can be printed in the form of a Ordering physician is the individual directing the
progress note or medical report. selection, preparation, or administration of tests,
Medical assistant enters data. A checklist, form, or medication, or treatment.
template is used with common problems and proce-
Referring physician is a provider who sends the
dures specific to the medical practice. The assistant
patient for testing or treatment. It may also be the
fills in blanks or circles an abbreviation that represents
provider who transfers the management of a
phrases or complete sentences as the physician nar-
patient to another physician.
rates findings and recommendations. The advantage
of this system is that the medical record is completed Treating or performing physician is the provider
before the physician leaves the examination room. The who renders a service to a patient.
physician can review the input before leaving the
room or at a later time (Figure 7-3).

Documenters
All individuals who provide health care services may
be known as documenters because they chronologi- STOP AND THINK
cally record facts and observations about the patient
and the patient’s health. There are instances when the Attending, Consulting, Ordering,
physician’s title may change, depending on the spe- Referring, Treating, or
cialty and services rendered. Because this can be a Performing Physicians
confusing issue and because it is important when sub-
mitting insurance claims, clarification of these vari- Scenario: Kay Lenzer has been under the
ous roles is detailed here. care of Dr. Practon for her annual physical
examinations. She falls at home, suffering a
compound fracture of her left tibia. Dr.
Practon determines that the fracture requires
treatment by a specialist and sends her to Dr.
Skeleton, an orthopedic surgeon, who orders
x-rays and performs surgery to stabilize the
fracture. During the recovery phase, Ms.
Lenzer develops a peculiar skin rash and Dr.
Skeleton sends her to a dermatologist, Dr.
Cutis, for an opinion about the skin ailment.
Critical Thinking: What roles do Dr. Practon,
Dr. Skeleton, and Dr. Cutis play in this sce-
nario? What titles would be given to each of
these physicians?
Response/Discussion: Remember, a physi-
Figure 7-3. A medical assistant is shown checking cian can wear more than one hat and take on
with the physician to clarify information about a more than one role. Determine your answer
patient’s condition before recording it in the medical and justify your reasoning.
record.
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162 UNIT 3 Records Management

Authentication of Documents SOAP Format


Figure 7-4 shows a progress note in a problem-
Manual Signatures
oriented medical record, which is divided into four sec-
Typed entries made during the continuing care of the tions using the SOAP format. The acronym is derived
patient should be signed or initialed by the attending from the following:
physician. For a chart to be admissible as evidence in
court, the physician who dictated or wrote the entries S: Subjective—statements about how the patient
must attest that the entries were true and correct at feels and symptoms experienced. This would
the time of writing; thus, stamped signatures are not include comments by the patient about the his-
allowed. A physician’s signature or initials after the tory of present illness, responses to review of sys-
typed notes indicates this fact. If the physician is away tems, and statements about the past, the family,
from the office after dictating a document and the cor- and social history.
respondence is urgent, there are two choices: O: Objective—data from laboratory reports, x-rays,
other diagnostic tests, and physical findings on
1. The assistant can sign the physician’s name with
examination by the physician. All objective data
his or her own initials after it.
are seen (inspection and observation), heard
2. A photocopy of the record (letter) may be sent, (auscultation), felt (palpation), or measured as in
stating that the physician will sign and forward diagnostic testing.
the original upon his or her return.
A: Assessment—analysis of the subjective and objec-
tive portions of the chart note.
Electronic Signatures P: Plan—therapeutic treatment plan and instruc-
In hospitals and large clinics, documents generated tions to the patient by the physician. This includes
via computer may contain either electronic signatures further testing, medications, return visit, and
or digital signatures. An electronic signature refers to a outlook or prognosis of the case.
method of authenticating documents by the insertion
of a facsimile of a person’s actual handwritten signa- CHEDDAR Format
ture or typed name that is affixed electronically at the This format breaks down in further detail each
end of a document. Because it can be altered, deleted, element of the patient encounter. The CHEDDAR
or forged by anyone with access privileges, an elec- acronym is derived from the following:
tronic signature creates obvious problems.
A digital signature is secure because it cannot be C: Chief complaint stated by the patient as the main
forged or altered without detection, and if the content reason for seeing the doctor. This is usually a sub-
of the signed document is altered, the signature is jective statement.
invalidated. To authenticate portions of the medical H: History of the present illness, including social his-
record, an individual has computer access and uses an tory and physical symptoms as well as contribut-
identification encryption system such as a series of let- ing factors.
ters or numbers (alphanumeric computer key entries), E: Examination by the physician.
an electronic writing, or a biometric system (voice
D: Details of problems and complaints.
print, hand or fingerprint transmissions, facial, iris, or
retinal scans). D: Drugs and dosages of the current medications the
patient is taking.
A: Assessment of the diagnostic process and the
Documentation Format impression (diagnosis) made by the physician.
Documentation in a patient’s medical record can
R: Return visit information or referral to a specialist for
become voluminous. An organized system to dictate
additional tests.
and record enables the physician and staff to locate
certain sections quickly and find information. The fol-
lowing methods are used by physicians and have Documentation Guidelines
enjoyed some popularity because they were developed The following guidelines should be adhered to in
from acronyms that can be remembered easily. maintaining each patient’s medical record. If a med-
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Morani Betty A 6 16 45 1209

2
#1 12/8/xx Pt returns for scheduled visit following neg. work up
for primary causes of recently diagnosed hypertension.
No new symptoms since last visit of 11/10/xx. Pt relieved
that all tests were neg. & is very anxious to start therapy
for control.
BP 150/105 RA&LA sitting. Recheck of heart
& lungs normal.
essential hypertension asymptomatic.
Prescribed Esidrix 25 mg Tabs #2
Tabs 1 after breakfast & dinner.
Retn 1 wk. Follow low sodium & high
potassium diet. Given diet slip #3 MS
Discussed side effects. If dizziness or
lightheadedness occur on standing,
reduce Esidrix to i after dinner.
Pt. advised alcohol & barbituates
may worsen side effects.
G. Practon, MD

Figure 7-4. Progress note from a problem-oriented medical record with an example of the SOAP format.
(Courtesy of Bibbero Systems, Inc., Petaluma, CA. Telephone: (800) 242-2376; Fax: (800) 242-9330; Web site:
http://www.bibbero.com)

ical assistant is aware of documentation deficiencies, mentation to describe test results or condi-
it is his or her responsibility to bring them to the tions as “normal,” “abnormal,” or “within
physician’s attention in a tactful manner. normal limits.”
1. Record the patient’s name and date (month, day, • The plan for care
and year) for each entry. • The date and legible identity of the observer
2. List each patient encounter in complete form, leg- 4. Use standard, approved abbreviations.
ibly, accurately, and in chronological order. 5. List all allergies and history of adverse reactions.
3. Enter all documentation in a timely fashion; state 6. Record all immunizations or injections given to
information objectively and be specific, including: the patient.
• The reason for the encounter, with relevant 7. Prominently display the patient’s problem list,
history, physical examination findings, and and document significant illnesses and medical
prior diagnostic test results conditions so the list is kept current.
• The assessment, clinical impression, or diag- 8. Present rationale for ordering diagnostic and
nosis. Avoid generalizations (e.g., patient other ancillary services; if not stated, docu-
doing well). It is considered inadequate docu- mented rationale should be easily inferred.
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164 UNIT 3 Records Management

22. Document any sample drugs that are given to the


EXAMPLE 7-3 patient and the patient’s agreement to accept the
samples.
Elements of History of Present Illness
23. Indicate patient education and instructions.
If a patient has chest pain, the physician may
24. Verify that each entry is signed or initialed by the
describe (1) the location of the pain (e.g.,
author and include professional credentials.
midsternal), (2) the quality of the pain (e.g.,
dull, sharp, stabbing), (3) the severity of the 25. Make all corrections using standard technique
pain to further define the magnitude of the (see Figure 7-6 on page 173).
problem usually using a scale of from 1 to 10,
(4) the duration of the pain (when the symp- COMPLIANCE
tom first occurred), (5) the timing or relation-
ship to a specific place or time of day, (6) the Verify that each entry is signed or ini-
context or when the pain occurs, (7) all tialed by the author with his or her title
remedies and interventions that have been or position. A signature log should be
tried to resolve the pain (modifying factors), retained in the office policy handbook
and (8) any associated signs and symptoms. consisting of all staff members’ names, job
titles, signatures, and approved initials.
9. List the reasons for deviations from standard
treatment. Medicare Documentation Guidelines
10. Have past and present diagnoses accessible to the In November 1994, the American Medical Association
treating or consulting physician. (AMA) and the Centers for Medicare and Medicaid
11. Identify appropriate health risk factors. Services (CMS), formerly the Health Care Financing
Administration (HCFA), developed documentation
12. Include the patient’s past medical history (serious guidelines for the Medicare program. They are referred
illnesses, accidents, and operations). to as the 1995 guidelines. Subsequently newer guide-
13. Document smoking habits and/or history of alco- lines were developed in 1997. These policies affect
hol or substance abuse. reimbursement for procedure codes used for evalua-
tion and management services.
14. Note the patient’s medical condition on each
visit, consisting of pertinent history, examina- COMPLIANCE
tion, assessment, and plan of action, including
necessary follow-up by the attending physician. Medicare has an obligation to those
15. Document all telephone conversations with or enrolled to ensure that services paid
regarding the patient. for have been provided and were
medically necessary. Documentation
16. Document the patient’s progress, response to and
must support the level of service and each
changes in treatment, and revision of diagnosis.
procedure.
17. Support procedure and diagnostic codes reported
on the health insurance claim form or billing state-
Physicians may use either the 1995 or 1997
ment with documentation in the medical record.
guidelines but there is no formal requirement. How-
18. File the results of laboratory, x-ray, electrocardio- ever, Medicare claims processors and auditors may
gram (ECG), and other tests with the most recent use them when reviewing documentation to deter-
report on top. mine that the reported services were actually rendered
19. Read through written entries to verify that every- and that the level of service was provided.
thing is legible. A variety of formats of documentation (e.g.,
SOAP or CHEDDAR notes) are accepted by Medicare
20. Photocopy prescriptions written for the patient. fiscal intermediaries as long as the information is dis-
21. List the names of the staff members who assisted cernible. Some physicians do not like to use printed
in any procedure. forms; they prefer blank or ruled sheets for this pur-
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CHAPTER 7 Patients’ Medical Records 165

pose, especially if they dictate the history and physical Likewise the term negative as in “chest x-ray, nega-
examination findings for transcription purposes. tive” does not indicate what service the physician pro-
Figures 7-5A and B show a complete, detailed medical vided. Instead state details such as “PA and lateral
history and physical examination. chest films were reviewed and no abnormalities were
Other physicians prefer that the medical assistant seen.”
interview patients and take the medical histories. When describing the status of a condition, that is,
Steps should be taken so that conversations of this acute or chronic, the word acute refers to a condition
nature are private and not overheard by others in the with a sudden onset that runs a short but relatively
reception room or throughout the office. The data severe course. The word chronic means a condition per-
may also be obtained by questionnaire or checkoff list sisting over a long period of time. However, the word
structured with specific questions or in outline form to recurrent may be preferred for certain ailments instead
be completed by the patient. These forms, however, do of chronic. For example, “chronic asthma” is listed in
not take the place of narrative documentation in the the diagnostic code book as “recurrent asthma.”
medical record. Documentation guidelines say “describe” so if the
If a patient is to be admitted to the hospital, a his- physician states “controlled hypertension” or “con-
tory and physical (H&P) from the office visit may be trolled diabetes,” this is stating a fact that describes the
used for the hospital documentation provided it was state of the diabetes and the reason for the visit (chief
performed one week before admission. complaint). However, the patient should be questioned
When significant aberrant reporting patterns are about blood sugar level results or diet, and the physi-
detected by Medicare fiscal intermediaries, then a cian should document the response; then a finding
review is conducted. Because these federal guidelines has been identified supporting the state of the chronic
affect reimbursement, many medical practices have condition.
begun using these documentation policies for
Medicare patients as well as those under private or
managed care plans. Acronyms and Abbreviations
In medical records, it is acceptable to use standard
Documentation Terminology acronyms and abbreviations that are commonly under-
Accurate words or phrases are of utmost importance stood by the general medical community. Do not invent
when determining what charges to bill or verifying an abbreviation. Each medical office should develop a
services that have been billed. Often a physician will list of standard abbreviations applicable to the specialty.
list a normal situation or negative result by either To assist in this task, each local hospital has its own list
dictating or writing “noncontributory” or “within of abbreviations acceptable in its facility that might be
normal limits (WNL).” Such phrases cannot be used available to staff physicians on request.
when referring to an affected body area or to deter- Abbreviations and symbols appear in chart notes
mine a diagnostic code assignment. These terms because physicians need to document quickly and
should not be used if the patient was not questioned or eliminate long words. In many instances, it would be
no examination was performed on the body part. difficult for a layperson to interpret a chart because of
the physician’s shorthand. The medical assistant
needs to be familiar with all the abbreviations and
EXAMPLE 7-4 symbols used by the physician.
Official American Hospital Association policy is
Documentation for Examination of that “abbreviations should be totally eliminated from
Extremities the more vital sections of the record, such as final
diagnosis, operative notes, discharge summaries, and
A statement such as “All extremities are within descriptions of special procedures.” Many physicians
normal limits” does not indicate how many are, however, unaware of this policy, and the final
extremities or which extremities were examined. diagnosis may yet appear with abbreviations on the
Documentation must indicate which limb was patient’s record.
examined and what it was examined for. For The current trend is to omit periods with special-
example,“The left lower extremity was examined ized abbreviations, acronyms, and metric abbrevia-
for skin rash, and no abnormalities were found.” tions as well as physicians’ academic degrees (e.g.,
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166 UNIT 3 Records Management

Larson, Vivian P.
80-02-41
February 12, 20XX

HISTORY
CHIEF COMPLAINT:
Pain and restriction of motion of the right arm and a cut on the head.
PRESENT ILLNESS:
This 65-year-old Caucasian female was walking on the street when she slipped on some loose gravel and
fell, landing on her right arm and striking her head against the curb. She sustained a laceration of her
scalp and an injury to her right shoulder. She went home to change her clothes and started experiencing
dizziness and blurred vision. She then went to the University Hospital Emergency Room by automobile
where an x-ray of her right arm revealed a fracture involving the greater tuberosity of the humerus and
a CAT-Scan of her head revealed a subdural hematoma.

PAST HISTORY:
The patient states that her general health has always been good except that in recent years she has
suffered from spastic colitis. She had a flare-up of this condition about six months ago. Operations: T
& A at age 13. A total abdominal hysterectomy in 1956. Social History: She smokes cigarettes occa-
sionally and drinks alcohol socially only. Allergies: No known allergies.

FAMILY HISTORY:
Her father died at age 72 of a cerebrovascular accident. Her mother died at age 74 of a myocardial infarc-
tion. Three brothers, all deceased, two with cancer (age 67 and 71), and one with heart disease (age 60).
Two sisters, alive and well, one has heart problems. No family history of tuberculosis or diabetes.

REVIEW OF SYSTEMS:
GENERAL: No fever, no chills, no night sweats, or weight loss.
HEENT: Blurred vision, headache, and head pain. No earaches, deafness, sore throats, hoarseness, or
difficulty in swallowing.
CR: No chest pains, tachycardia, or ankle edema. No shortness of breath, chronic cough, or wheezing.
GI: Appetite good, slight nausea, no vomiting, diarrhea, constipation, or melena.
GU: No dysuria, hematuria or pyuria.
CNS: Dizziness reported. No fainting or seizures.
GYN: No spotting since her hysterectomy.

PHYSICAL EXAMINATION
GENERAL
This patient is a well-nourished, well-developed, 65-year-old Caucasian female who is awake, alert,
and experiencing head pain, headache, dizziness, blurred vision, and slight nausea. She also is experi-
encing pain in her right shoulder when she attempts to move her right arm. Height 5’8”. Weight: 155
lb. Blood pressure: 170/90. Temperature: 99°. Pulse: 100. Respirations: 20.

HEENT:
The pupils are dilated, equal, and react slowly. Extraocular movements are normal. Nasopharynx is
clear. Upper and lower dentures. Ears are clear. There is a laceration measuring 2.3 cm on occipital
region of scalp. (continues)

Figure 7-5A. The first page of a medical history and results of a physical examination typed in full block report
style
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CHAPTER 7 Patients’ Medical Records 167

Larson, Vivian P.
80-02-41
February 12, 20XX
Page 2

NECK:
Supple with a full range of painless motion. Thyroid is not enlarged. No lymphadenopathy and no
venous engorgement.

CHEST:
Symmetrical with normal expansion. Breasts: No atrophy and no masses. Lungs: Clear to auscultation.
Heart: Normal sinus rhythm, no murmurs, and no enlargement.

ABDOMEN:
Soft and nontender and somewhat obese. Liver, kidneys, and spleen are not palpable.

GENITALIA:
Normal external female.

RECTAL:
Deferred.

NEUROLOGICAL:
No motor deficits. Dizziness experienced without relation to head movement. Patient is oriented to
person, place, and time. Slight drowsiness occurring.

MUSCULOSKELETAL:
There is a small bruise over the anterior aspect of the left knee. The hips, knees, and ankle joints are
otherwise normal. Good peripheral pulses. The right upper arm is moderately swollen and discolored.
There are no other gross deformities. The patient has considerable pain with any attempt at either
active or passive movement of the right shoulder.

DIAGNOSIS:
1. Laceration—occipital region of scalp measuring 2.3 cm.
2. Subdural hematoma.
3. Relatively undisplaced fracture proximal right humerus (greater tuberosity).
4. Hypertension.

TREATMENT PLAN:
Suture scalp wound. Fracture treatment (without manipulation) with right arm placed in a long arm
fiberglass cast. Admit patient to hospital observation unit directly from Emergency Department. Place
patient under head trauma precaution and monitor blood pressure every hour.

Gerald Practon, MD
Gerald Practon, MD
mtf
D: 2-12-XX
T: 2-13-XX

Figure 7-5B. The second page of a medical history and results of a physical examination typed in full block
report style
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168 UNIT 3 Records Management

MD). Latin abbreviations are typed in lowercase letters lesions. Avoid using terms such as small, medium, or
with periods (e.g., b.i.d., a.m.), and many of these are large. Documentation should consist of the location
pharmaceutical abbreviations (see Chapter 8). The and site(s), the size(s), the number(s) of lesions
patient care abbreviations are listed in Table 7-1. The treated, the method of destruction, and any extenuat-
medical assistant can use a medical dictionary to look ing circumstances. Reimbursement is affected by the
up abbreviations not included in this table. size or area documented and subsequently reported
on insurance claims.
Illustrations Burns are listed by
Illustrations may be used by the physician to docu- 1. Type (e.g., chemical)
ment an area of the body where a problem occurs. 2. Depth (first, second, or third degree)
They may depict a finding, symptom, or procedure 3. Site (face, arm, leg, trunk)
and may help educate the patient or verify a com-
4. Percentage of total body surface (TBS) affected
pleted service. Physicians may either purchase or
hand draw and label their illustrations. Illustrations
that are used for some aspect of a patient encounter CORRECTING A MEDICAL
should be kept in the chart and must be legible, dated,
and signed. Include the patient’s name and date of
RECORD
birth on the drawing. To alleviate confusion and prevent medicolegal prob-
lems, it is important to know how to correct chart
Digital Images notes as well as other records. Never erase or use cor-
rection fluid on handwritten or typed entries. If cor-
Some physicians (e.g., plastic surgeons, oral surgeons)
rections need to be made on a patient’s medical record,
may take photographs of the patient that become part
draw a line neatly through the incorrect entry so it
of the medical record. These may be digital images
remains readable. If there is adequate room above or
that are imported while transcribing medical reports.
below the original entry, insert the correct information
These images may also consist of scans of various
there. Otherwise it may be inserted in the margin or
body organs or radiographic x-rays. A graphic may
after the conclusion of the note. The person making
help the physician determine what corrective meas-
the correction writes “Corr.,” the date, and his or her
ures to take and also makes it easier for patients
initials in the margin of the page as shown in Figure
to understand their condition or disease because it
7-6. If the correction is inserted at the end of the chart
gives more comprehensive detailed documentation.
note, the person making the correction enters the date,
Microsoft Word or Corel WordPerfect word processing
writes or types “correction to chart note of 8-10-20XX
software has a feature that allows digital images to be
(date of note being corrected),” enters the correction,
imported into a document. If the document is an elec-
and initials or signs at the end of the notation.
tronic medical record, the image can be attached so
It is permissible when typing a chart note or med-
other physicians can view it. If photographs are part
ical report to use correction fluid or tape on typo-
of the medical record, be sure to label them with the
graphical errors at the time of typing, but one never
patient’s name, date of birth, and date taken. Remem-
obscures, erases, or puts self-adhesive typing strips
ber that if a patient’s digital image is requested for
over an original entry to correct the note later. When
publication, the authorization form must contain
the physician discovers a notation, such as a progress
wording that indicates the digital image is to be used
note has been inserted into the wrong record or is
in this manner.
missing, or needs to make a correction after an entry
has been typed, it must be added as an addendum or
Measurements corrected in the specified manner. For further infor-
Measurements that pertain to lacerations, lesions, mation on making corrections, see Chapter 10.
burns, nerve and skin grafts, neoplasms, tattoos, When making a correction in a computerized docu-
cysts, injection material, and so forth, commonly ment, maintain the original entry in the electronic file.
appear in patients’ medical records and operative Note the section in error by using highlight, underline,
reports. Most of the time, the metric system (e.g., cen- or score-through features found under “Tools.” Enter
timeters) is used when measuring skin lacerations and the correct information as an addendum along with the
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CHAPTER 7 Patients’ Medical Records 169

Table 7-1. Patient Care Abbreviations


A allergy; abortion Cauc Caucasian
AB antibiotic CBC complete blood count
abdom abdomen cc cubic centimeter
abt about CC chief complaint
Acc, acc accommodation CDC calculated date of confinement
AD, a.d. right ear chem chemistry
adm admit; admission; admitted CHF congestive heart failure
adv advice chr chronic
aet. at the age of CI color index
AgNO3 silver nitrate cm centimeter
AIDS acquired immune deficiency syndrome CNS central nervous system
alb albumin CO, C/O complains of
ALL allergy CO2, CO2 carbon dioxide
a.m., AM before noon comp comprehensive
AMA American Medical Association compl complete
ant anterior Con, CON, Cons consultation
ante before Cont. continue
A&P auscultation and percussion COPD chronic obstructive pulmonary disease
AP anterior posterior; anteroposterior CPX, CPE complete physical examination
AP & L anteroposterior and lateral C section cesarean section
approx approximate CT computerized tomography
apt apartment CV cardiovascular
ASA acetylsalicylic acid CVA costovertebral angle; cardiovascular
asap, ASAP as soon as possible accident; cerebrovascular accident
ASCVD arteriosclerotic cardiovascular disease CXR chest x-ray
ASHD arteriosclerotic heart disease Cysto cystoscopy
asst assistant D&C dilatation and curettage
auto automobile dc discontinue
Ba barium DC discharge
BI biopsy del delivery
BM bowel movement Dg, Dx, dx diagnosis
BMR basal metabolic rate diag. diagnosis, diagnostic
BP, B/P blood pressure diam. diameter
Brev Brevital diff. differential
BUN blood urea nitrogen dilat dilate
Bx, BX biopsy disch. discharged
DNA does not apply
C cervical; centigrade; celsius
DNS did not show
C&S culture and sensitivity
DOB date of birth
Ca, CA cancer, carcinoma (continues)
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170 UNIT 3 Records Management

Table 7-1 (continued). Patient Care Abbreviations

DPM Doctor of Podiatric Medicine GU genitourinary


DPT diphtheria, pertussis, tetanus (vaccine) Gyn, GYN gynecology
Dr. Doctor H hospital call
drsg dressing HA headache
Dx, Dg, dx diagnosis HBP high blood pressure

E emergency HC hospital call; hospital consultation


ECG electrocardiogram; electrocardiograph HCD house call, day

ED emergency department HCl hydrochloric acid


EDC estimated date of confinement; due HCN house call, night
date for baby hct hematocrit
EEG electroencephalogram; HCVD hypertensive cardiovascular disease
electroencephalograph HEENT head, eyes, ears, nose, and throat
EENT eye, ear, nose, and throat Hgb, Hb hemoglobin
EKG electrocardiogram; electrocardiograph hist history
epith. epithelial H2O, H2O water
ER emergency room hosp hospital
ESR erythrocyte sedimentation rate H&P history and physical
est. established; estimated HPI history of present illness
etiol. etiology hr, hrs hour, hours
EU etiology unknown HS hospital surgery
Ex, exam. examination Ht, ht height
exc. excision HV hospital visit
ext external HX history
F Fahrenheit; French (catheter) HX PX history and physical examination
FACP Fellow, American College of I injection
Physicians
I&D incision and drainage
FACS Fellow, American College of Surgeons
IC initial consultation
FH family history
i.e. that is
FHS fetal heart sounds
IM intramuscular
fluor fluoroscopy
imp., IMP impression
ft foot; feet
inc include
FU follow-up
inf, INF infected
Fx fracture
inflam., INFL inflammation
G gravida (number of pregnancies) init initial
g, gm gram inj., INJ injection
GA gastric analysis int, INT internal
GB gallbladder intermed intermediate
GC gonorrhea interpret interpretation
GGE generalized glandular enlargement IPPB intermittent positive pressure
GI gastrointestinal breathing (continues)
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CHAPTER 7 Patients’ Medical Records 171

Table 7-1 (continued). Patient Care Abbreviations

IQ intelligence quotient OC office call


IV, I.V. intravenous occ occasional
IVP intravenous pyelogram O.D., o.d. right eye

JVD jugulovenous distention ofc office


OH occupational history
K35 Kollmann (dilator)
O.L. left eye
KUB kidneys, ureters, bladder
OP, op. operation, operative, outpatient
L left; laboratory; living children; liter OPD outpatient department
lab., LAB laboratory OR operating room
L&A, l/a light and accommodation orig. original
L&W living and well O.S., o.s. office surgery; left eye
lat, LAT lateral OT occupational therapy
lbs pounds OTC over the counter
LLL left lower lobe OV office visit
LLQ left lower quadrant
P pulse; preterm parity or deliveries
LMP last menstrual period before term
lt., LT left PA posterior anterior, posteroanterior
ltd. limited P&A percussion and auscultation
LUQ left upper quadrant PAP, Pap Papanicolaou (test)
M medication; married Para I woman having borne one child
MA mental age (Para II, two children, and so on)

med., MED medicine PBI protein-bound iodine

mg milligram(s) PC present complaint

MH marital history PD permanent disability

ml milliliter(s) PE physical examination

mm millimeter(s) perf. performed

MM mucous membrane PERRLA, PERLA pupils equal, round, react to light


and to accommodation
mo month(s)
pH hydrogen ion concentration
N negative PH past history
NA, N/A not applicable Ph ex physical examination
NaCl sodium chloride phys. physical
NAD no appreciable disease PI present illness
neg. negative PID pelvic inflammatory disease
NP new patient p.m., PM after noon
NPN nonprotein nitrogen PMH past medical history
N&V nausea and vomiting PND postnasal drip
NYD not yet diagnosed PO, P Op postoperative; phone order
O2, O2 oxygen pos. positive
OB obstetrical, obstetrics post. posterior
(continues)
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172 UNIT 3 Records Management

Table 7-1 (continued). Patient Care Abbreviations

postop postoperative Smr, sm. smear


preop preoperative SMWD single, married, widowed, divorced
prep prepare, prepared SOB shortness of breath
PRN, p.r.n. as necessary sp gr specific gravity
prog prognosis SQ subcutaneous
P&S permanent and stationary SR suture removal; sedimentation rate
PSP phenolsulfonphthalein STAT, stat. immediately
Pt, pt patient STD sexually transmitted disease
PT physical therapy strab strabismus
PTR patient to return surg. surgery
PX physical examination Sx. symptoms
R right; residence call; report T temperature; term parity or deliveries
RBC, rbc red blood cell at term
rec recommend T&A tonsillectomy and adenoidectomy
re ch recheck Tb, tbc, TB tuberculosis
re-exam, reex reexamination TD temporary disability
reg. regular temp. temperature
ret, retn return TIA transient ischemic attack
rev review TMs tympanic membranes
Rh- Rhesus negative (blood) TPR temperature, pulse, respiration
RHD rheumatic heart disease Tr. treatment
RLQ right lower quadrant TTD total temporary disability
RO, R/O rule out TURB transurethral resection of bladder
ROS review of systems TURP transurethral resection of prostate
rt. right TX, Tx treatment
RT respiratory therapy U unit
RTC return to clinic UA, U/A urinalysis
RTO return to office UCHD usual childhood diseases
RUQ right upper quadrant UCR usual, customary, and reasonable
Rx, RX, * prescription; any medication or UGI upper gastrointestinal
treatment ordered UPJ ureteropelvic junction or joint
S surgery UR, ur urine
SD state disability URI upper respiratory infection
SE special examination UTI urinary tract infection
sed rate sedimentation rate vac vaccine
Sep. separated VD venereal disease
SH social history VDRL Venereal Disease Research Laboratory
SLR straight leg raising (test for syphilis)
slt slight W work; white
(continues)
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CHAPTER 7 Patients’ Medical Records 173

Table 7-1 (continued). Patient Care Abbreviations


WBC, wbc white blood cell or count; well baby c_, /c, w/ with
care P_ after
WF white female s_, /s, w/o without
wk. week; work c_c, c_/c with correction (eyeglasses)
wks weeks s_c, s_/c without correction (eyeglasses)
WM, W/M white male + positive
WNL within normal limits –, o_ negative
WR Wassermann reaction ± negative or positive; indefinite
Wt, wt weight L left
X x-ray(s); multiplied by m murmur
XR x-ray(s)
R right
yr year
7 male
Symbols 6 female
* birth µ micron

date, time, and your initials. Never delete or key over instructions regarding the overpayment. In some situ-
incorrect data in a computerized medical record file. ations you must submit a corrected claim along with
If the correction made to the medical record the explanation of benefits document and the cor-
involves overpayment of an insurance claim, contact rected chart note, operative note, or other medical
the insurance carrier, report the error, and ask for record document.

Michael Otani

February 22, 20xx The patient is a Japanese-American male, age 32,


who came in complaining of rectal discomfort, rectal bleed
ing, and severe itching. PE revealed multiple soft external
internal
hemorrhoids.
Corr.
DIAGNOSIS: Multiple internal hemorrhoids. 36 fp 4/8/XX
TX: Rx Americaine Suppositories #24 + a.m. & p.m. and fp

after each bowel movement and 1 oz Americaine ointment


appl. sm amt a.m. and p.m. Pt. to return in 2 weeks for a re–
examination

Fran Practon, MD
mtf Fran Practon, MD

Figure 7-6. Typed chart note with examples of corrections made by physician Fran Practon (FP) on the day she
read and signed entries
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174 UNIT 3 Records Management

JOB SKILL 7-1

Correct a Medical Record you do not want to suggest any altering or


obliteration of a medical record.
Objective: To insert a correction entry
in a medical chart note using standard 2. Write or type the correct information either
procedures. above or below the line wherever there is
adequate room. If there is no space, the
Equipment/Supplies: Patient’s medical
correction must be made on the next avail-
record, reference documents for making
able section of the sheet. Refer to the date
correction (transcribed notes, telephone
of the chart note being corrected (e.g.,“cor-
notes, physician’s comments, correspondence),
rection to chart note of 8-10-20XX”), enter
and pen.
the correction, and initial or sign at the end
Directions: Follow these step-by-step proce- of the notation. If the correction requires an
dures, which include rationales, to learn this attached document, note in the record “see
job skill. An exercise is presented in the Work- attached document X” and indicate where
book to practice this skill. the corrected information can be found.
1. Draw a line neatly through the incorrect 3. Write “Corr.,” the date, and your initials in
entry. It should remain readable because the margin of the page.

ELEMENTS OF A MEDICAL RECORDS AND OTHER


RECORD DOCUMENTS
Patient records consist of a variety of documents, Laboratory Reports
such as a patient information form and a medical his-
Laboratory tests may be performed in the physician’s
tory questionnaire, a history and physical, progress
office laboratory (POL) or by an outside or hospital
notes, physiology reports (e.g., electrocardiography
laboratory, which sends test results to the physician’s
[ECG], laboratory reports, x-ray films and radiology
office. In the report, when normal value ranges are
reports), and other medical reports. If a patient has a
indicated, the medical assistant can circle, underline
durable power of attorney for health care or a living
in red, or highlight those of the patient’s values that
will and wishes to donate organs at the time of death,
appear higher or lower than the norms, thus calling
this information should be flagged in the patient’s
them to the physician’s immediate attention. Other
chart. The patient’s account or ledger, which contains
laboratory reports may present abnormal values that
financial information, is also considered part of the
can be easily identified (Figure 7-7). Then the labora-
record but is not filed with the patient record; it is
tory report, along with the patient’s chart, may be
maintained in a separate file. It is the medical assis-
placed on the physician’s desk. The medical assistant
tant’s responsibility to assist the physician in keeping
should never interpret a laboratory report to the
the records current and accurate.
patient in person or over the telephone. The physician
must initial all laboratory reports before they are filed
Patient Information Form in patients’ medical records.
As explained in Chapter 4 and shown in Figure 4-8,
the patient information form is used to obtain demo-
graphic and insurance information. It is primarily a Laboratory Log
business record but also helps acquaint the physician When patients or their specimens are sent to an outside
with a patient’s personal data and becomes part of the laboratory, it is important to be sure that the test has
medical record. been done, the report has been received, the physician
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CHAPTER 7 Patients’ Medical Records 175

PATIENT: PETER, JAMES B.

Figure 7-7. Example of a laboratory report showing the names of each test and an indication of whether the
results are low, in the expected normal range, or high
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176 UNIT 3 Records Management

1/6/XX Kim Chang CBCc Sed Rate ABC Lab 1/7/XX 1/9/XX ✓
1/6/XX Bruce Johnson UGI College Hosp. 1/4/XX 1/17/XX
1/7/XX Joe Felipe 3 hr GTT College Hosp. 1/8/XX 1/11/XX ✓
1/8/XX Lori Carr SerumBetaHCGQuan ABC Lab 1/10/XX

ORDER #74-9052 BIBBERO SYSTEMS,INC., PETALUMA, CA TO REORDER CALL TOLL FREE (800) BIBBERO (800/242-2376) OR FAX (800) 242-9330

Figure 7-8. Example of entries made to a test log showing when tests have been ordered and reports received

has read it, and the proper response has been made (i.e., PATIENT MEDICAL HISTORY
file it or have the physician telephone the patient if
there are abnormal results). Maintaining a log in a The levels of evaluation and management (E/M) ser-
notebook, calendar book, or using a preprinted form vices are based on four types of history: problem
with columns is quick and easy—more importantly, it is focused (PF), expanded problem focused (EPF),
imperative if trying to identify which patient’s labora- detailed (D), and comprehensive (C). E/M services is a
tory results are pending (see Figures 7-8 and 7-9). Enter phrase used for various types of office visits when
each report that is received and identify if a report is referring to procedure codes in the Current Procedural
missing.

Radiographs (X-Ray Films)


Some physicians take x-rays in their offices and store
the x-ray films in a separate file because of their size.
Other physicians send their patients to a radiology
group or hospital radiology department to have films
taken, and these films are kept by the facility. The find-
ings are sent to the physician in the form of an x-ray
report to be included in the patient’s medical record. If
the physician takes the films and dictates the findings,
the results may be included in the patient’s initial his-
tory and physical examination report, progress note,
or dictated in letter form.

Electrocardiograms
Some offices perform electrocardiograms (ECGs or
EKGs) on patients. Special cards are available to
mount the strips of paper on which ECGs are recorded.
The original ECG record may be included with a
patient’s chart or if there is a great number, because of
the bulk, a separate folder may be used. If a separate
folder is used, a copy of the ECG and written interpre- Figure 7-9. Example of entries made on the page of
tation is placed in the patient’s record. a flip calendar
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CHAPTER 7 Patients’ Medical Records 177

JOB SKILL 7-2

Prepare and Compile a Medical the patient’s record is in the filing cabinet or
Record for a New Patient drawer. Colored labels aid in filing and
locating lost charts because if misfiled,
Objective: To prepare and compile a the color stands out from neighboring
medical record for a new patient. file folders.
Equipment/Supplies: File folder, patient infor- 4. Add a current year label either to the end
mation form, file folder label, labels for special or top tab of the file folder for a new patient.
information (current year, allergies, insurance To update an established patient’s record,
information), typewriter or computer, forms add a year label the first time the patient
(flow sheet, progress notes, laboratory reports, comes in for an appointment for the current
and so forth), two-hole punch, and pen. year. This helps when having to purge
Directions: Follow these step-by-step proce- inactive files.
dures, which include rationales, to learn this job 5. Adhere an allergy label and indicate all
skill. An exercise is presented in the Workbook allergies or if there are no known allergies,
to practice this skill. write NKA. Allergy labels alert all staff mem-
bers and help avoid adverse reactions.
1. Type or key a label for the patient’s file
folder with the last name followed by the 6. Adhere an insurance label indicating the
first name and middle initial. Charts are filed type of plan. Labels identify patients who
by last name; however, if the office uses a are in specific insurance categories (e.g.,
numeric filing system, insert a number on HMO, PPO).
the label.
7. Insert blank forms used by the medical
2. Select a file folder. practice into the patient’s file folder. Label
each sheet with the patient’s name or
3. Adhere the label to the tabbed edge of the
record number. This helps identify each
file folder, which may be located at the right,
page of the record.
left, or middle top portion of the folder or on
the side. If a color-coded filing system is 8. Punch holes in the sheets if necessary and
used, select the colored letters for the first affix them to the folder. This will secure
two letters of the patient’s last name. In pages and help position information that
larger offices additional labeling may be may otherwise fall out.
required. This label must be visible when

Terminology code book. When a patient comes in with problem, condition, or other factor that is the reason for
a complaint of symptoms describing how he or she the encounter. If more than one, list them in the order
feels, this is called subjective information. The history of importance. The CC is required for all levels of history.
of the present illness is based on this subjective infor- Complaints can also be objective; if a patient complains
mation. It is drawn from the patient’s own words about of something that can be seen, felt, heard, or measured
the chief complaint (CC) and his or her response to (e.g., a rash or a bump), it is objective information.
questions asked. Depending on the specialty of the
physician and the subjective symptoms, the medical
history may vary. Each type of case history includes
History of Present Illness
some or all of the following elements: The chief complaint is followed by a detailed account
of how the patient was injured or when he or she first
noticed the illness, called history of chief complaint or
Chief Complaint history of present illness (HPI or PI). The HPI is a
The chief complaint (CC) is a concise statement, usually chronological description of the development of the
in the patient’s own words, describing the symptom, patient’s present illness from the first sign or symptom
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178 UNIT 3 Records Management

or from the previous encounter to the present. It patient is a female. Sexual activity along with the
includes the following elements: location, quality, number of pregnancies, living children, and abortions
severity, duration, timing, context, modifying factors, are noted. For example, gravida 3, para 2, aborta 1.
and associated signs and symptoms (see Example 7-3 The onset of menses (menarche) and the last men-
on p. 164). When a symptom is demonstrable to an strual period (LMP) are entered into the record along
observer upon examination, it is an objective symptom, with any problems associated with the menstruation.
or, more generally, a sign.
If the patient has been treated by another physi-
cian for the same or a similar problem, this will be Review of Systems
discussed, along with the possible diagnosis and treat-
A review of systems (ROS), systemic review (SR),
ment prescribed.
functional inquiry, or inventory by systems is an
inventory of body systems obtained through a series of
Past, Family, and Social History oral questions seeking to identify signs or symptoms
(PFSH) the patient might be experiencing or has experienced
that may reveal information related to the present ill-
The PFSH consists of a review of the following areas:
ness. The ROS should not be confused with the exami-
nation of body systems, which will follow. The ROS
Past History (PH) begins at the top of the body and continues down
The past history is a personal history, including usual through each body system.
childhood diseases (UCHD), previous illnesses, physi- The physician may dictate ROS data with sub-
cal defects, operations, accidents or injuries, treat- headings or as a single paragraph without subhead-
ments, medications, drug reactions, and allergies. ings. The medical assistant must be able to recognize
Medications include listing drugs the patient has the body part and divide the information as it is dic-
taken recently or is currently taking. Allergies include tated. The following material contains descriptions of
any reactions the patient may have to drugs, food, or body systems and examples of words and phrases after
the environment. Allergies should be underlined in each heading or subheading that may assist a medical
red in the medical record and placed on the front of assistant when keying or typing a history and physical
the chart, boldly visible. Some medical practices list examination report. Abbreviations that are com-
allergies at the top of each page in the patient’s monly used and accepted are given where they are
progress notes. Because allergies may appear as indi- appropriate in the breakdown of systems and observa-
viduals age, questions should be asked each time a tions that follows:
patient is seen for an appointment.
Constitutional Symptoms—Physical makeup of a body
and include the methods the body uses to function,
Family History (FH) actions of metabolic processes, manner and degree of
The family history is a review of medical events in the reactions to stimuli, and power of resistance to disease
patient’s family, including diseases that may be hered- organisms. For example, symptoms may consist of
itary or place the patient at risk. Notations are made fever, weight loss or weight gain, or hot flashes.
regarding whether the mother and father are living
Eyes—Assessment of the patient’s perception of his
and well (M & F, l & w), ages at death, cause of death,
or her vision functions. Symptoms and conditions
and similar information for siblings and grandparents.
concerning the eye and ocular adnexa are evaluated.
The place and circumstances of the patient’s birth
These may include vision difficulties and problems
might also be noteworthy.
such as lazy or wandering eye; glaucoma; scotoma;
conjunctivitis; trachoma; pain; discharge; redness;
Social History (SH) limitation of visual fields; use of glasses, contact
The social history is an age-appropriate review of past lenses, or intraocular lenses; blurring; double vision;
and current activities and occupational history (OH), seeing spots or rings around lights; watering; itching;
habits, diet, alcohol, drugs, tobacco, marital history abnormal sensitivity to light; infection of the meibo-
(MH), exercise, and recreational interests. Sometimes mian gland on the eyelid; tear duct problems; and
gynecologic problems may be a subtopic when the so on.
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CHAPTER 7 Patients’ Medical Records 179

Ears, Nose, Throat—Because of intercommunication on menarche (onset of menses), menstrual flow, Pap
between the structures of the upper respiratory tract, smear, obstetric history (pregnancies, deliveries, abor-
the ears, nose, mouth, and throat are often reviewed tions), use of contraceptives. Female symptoms might
together. include irregularity of menses, pain during intercourse,
bleeding unrelated to menses, or problems associated
Ears—Includes testing of the hearing and condi-
with the onset of menopause; dysmenorrhea; menor-
tions such as hearing loss, discharge, dizziness,
rhagia; metrorrhagia, dyspareunia; and leucorrhea.
syncope, tinnitus (ringing in ears), and pain.
Male symptoms might include impotence, white patches
Nose—Includes the sense of smell and conditions on the glans penis, and painful injury to the testes.
such as discharges, colds, allergies, chronic sinus
congestion, and epistaxis (nosebleed). Musculoskeletal (MS)—System composed of the mus-
cles, bones, and joints. Symptoms include pain, strains,
Mouth and Throat—Includes condition of teeth, sprains, stiffness, painful or swollen joints, limitation of
dental hygiene, dentures, thyroid gland, move- movement, dislocations, fractures, and arthritis.
ment of the neck, position of the trachea, and
problems such as tender gums, sensitive tongue, Integumentary (Skin and Breast)—System that pertains
difficulty in swallowing, hoarseness, sore throat, to the covering of the body (skin, hair, nails, sebaceous
postnasal drip, and choking. glands). Breasts are listed with this system because
mammary glands are part of the integumentary
Cardiovascular (CV)—System that includes the heart system. Lumps found on self-examination and secre-
and blood vessels. Symptoms include chest pain, tions from the nipples are symptoms of concern. Other
angina, tachycardia, bradycardia, heart murmurs, symptoms include comments on eruptions, rashes,
palpitations, heart attacks, pitting or pedal edema, itches, scaling, dryness, and discolorations.
cool extremities, varicose veins, high blood pressure,
hypotension, and so forth. Hair—Symptoms include notes on changes in the
hair texture and distribution, hair loss, and exces-
Respiratory—Exchange of oxygen is the main function sive hair.
of the lungs and respiratory system. Symptoms may
include comments on dyspnea, orthopnea, two-pillow Head—Symptoms include lumps, bumps, tender-
orthopnea, shortness of breath on exertion, wheez- ness, swelling, or other abnormalities.
ing, pneumonia, hemoptysis, and paroxysmal noctur- Neurological—Pertains to the central and peripheral
nal dyspnea (PND). nervous system. Symptoms might include loss of
Gastrointestinal (GI)—System that mechanically and sensation (paresthesia) to a particular body part. Cen-
chemically breaks food down to molecular size for tral nervous system disorders produce more severe
absorption into the bloodstream to be used by the symptoms such as headaches, vertigo, loss of conscious-
cells. The liver and gallbladder are also included in this ness, seizures, convulsions, paralysis, ataxia, or aphasia.
system. Symptoms include comments on hemateme-
Psychiatric—System that deals with the interaction
sis, appetite, indigestion, melena, icterus, jaundice,
between the mind and body. Symptoms include com-
anorexia, nausea, vomiting, flatus, borborygmus, flat-
ments on the emotional state of the individual (sad-
ulence, coffee-ground vomitus, stool color (black tarry
ness, anxiety, depression, or thoughts of suicide).
or clay-colored), hematochezia, diarrhea, obstipation,
dysphagia, change in weight or diet, change of bowel Endocrine—System composed of glands and the inter-
habits, and constipation. action of hormones. Symptoms include over or under
functioning of a gland and its hormone(s). For exam-
Genitourinary (GU)—Review of the organs with urinary
ple, hypersecretion of thyroid hormone would pro-
and reproductive functions. Symptoms include com-
duce symptoms of weakness, wasting, tremulousness,
ments on urinary flow, incontinence, stress inconti-
palpitations (cardiac arrhythmia), or bulging eyes.
nence, burning and frequency during urination,
dysuria, pyuria, nocturia, hematuria, oliguria, enuresis, Hematologic/Lymphatic—Blood, blood-forming struc-
sexually transmitted diseases (such as gonorrhea and tures, and the lymphatics comprise this system. Symp-
syphilis), urgency or hesitancy during urination, drib- toms include edema, swollen or tender lymph nodes,
bling, discharge, lumbar pain, and stones. Female: Notes easy bruising, frequent infections, and fatigue.
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180 UNIT 3 Records Management

Allergic/Immunologic—Ability to fight disease is the Medicare Levels of Examination


focus of the immune system. Symptoms include aller-
For patients under the Medicare program, the levels of
gic reactions, frequent infections, allergic rhinorrhea
E/M services are based on four types of examination
(runny nose), seasonal allergies, and allergies to food
that are defined as follows:
or medication or drugs.
• Problem focused (PF): A limited examination of
the affected body area or organ
PHYSICAL EXAMINATION • Expanded problem focused (EPF): A limited exam-
General Guidelines ination of the affected body area or organ
system and other symptomatic or related body
The physical examination (PE or PX) is objective (O)
areas or organ systems.
in nature; that is, it consists of findings the physician
can discover by examination or through tests. The • Detailed (D): An extended detailed examination
thoroughness of the examination and the determina- of the affected body area or organ system and
tion of what body systems will be covered depend on other symptomatic or related body areas or
the patient’s illness or injury and on the specialty of organ systems.
the physician. Sometimes a checkoff list is used by the
• Comprehensive (C): A general multisystem
physician as each system is reviewed, and notes are
examination or complete examination of a
made on a pad, printed form, or keyed into a personal
single organ system and other symptomatic or
digital assistant (PDA). Then the physician dictates the
related body areas or organ systems.
entire physical examination for the patient’s medical
record. Rubber stamps or stencils showing different The extent of the examination and what is docu-
parts of the anatomy may be used by the physician to mented depends on clinical judgment and the nature
make notes and draw arrows to various organs. These of the presenting problem or problems. They range
stamps can be purchased from printing firms and can from limited examinations of single body areas or
be used at the time of the initial visit as well as when complete single organ system examinations to general
progress notes are made. multisystem examinations.
If the patient is going to be admitted to the hospital Table 7-2 lists the body areas and organ systems
and has had a physical examination one week before that are recognized for purposes of examination.
admission, the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) permits a copy of
the physical examination to become part of the hospital Body Areas and Organ Systems of
record instead of a new history and physical (H&P) on Physical Examination
the date of admission. If the patient has had any new Constitutional—Includes assessing the patient’s vital
development or changes between the examination date signs (sitting, standing, or supine blood pressure)
and the admission date, then these are noted in the hos- pulse rate and regularity, respiration, temperature,
pital record when the patient is admitted to the hospital. age, height, weight, race, and general appearance
During the PE, the physician goes through four (development, nutritional state, body habitus, defor-
basic procedures: mities, grooming, and emotional condition of the
1. Inspection, or observation, of the patient’s physi- patient).
cal characteristics and body parts. Eyes—Includes inspection of the patient’s vision,
ocular adnexa (area around the eye), conjunctivae,
2. Palpation, or touching and feeling, various parts
lids; examination of the pupils and irises (reaction to
and organs of the body.
light and accommodation, size, and symmetry); oph-
3. Percussion, or striking, parts of the body with thalmoscope examination of optic disks (size, C/D
short, sharp blows, during which attention is ratio, appearance, and posterior segments [e.g., vessel
fixed on the resistance of the tissues under the changes, exudates, hemorrhages]); extraocular move-
fingers and on the sound elicited to determine ments (EOMs); and fundi (back portion of the interior
tissue size, density, and location. of the eyeballs).
4. Auscultation, or listening, to sounds of the internal Ears, Nose, Mouth, and Throat—Includes inspection
parts of the body with the aid of a stethoscope. of the external auditory meatus (external ear canals);
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CHAPTER 7 Patients’ Medical Records 181

Table 7-2. List of Body Areas and Organ Systems for Purposes of Examination

Body Areas Organ Systems


Head, including the face Constitutional (vital signs, general appearance)
Neck Eyes
Chest, including the breasts and axillae Ears, nose, mouth, and throat
Abdomen Respiratory
Genitalia, groin, buttocks Cardiovascular
Back, including the spine Gastrointestinal
Each extremity Genitourinary
Lymphatic
Musculoskeletal
Skin
Neurologic
Psychiatric

EXAMPLE 7-5 EXAMPLE 7-7


Constitutional Examination Examination of Ears, Nose,
In this section of the physical examination, Mouth, and Throat
dictation might include comments such as
“appearing the stated age” or “appearing Dictation about ears may indicate presence of
younger” or “appearing older than the stated otitis media, tinnitus, cerumen (earwax); ear
age”; description of whether the patient is a discharge; and hearing. Comments on nose,
well-developed and well-nourished male or mouth, and throat would include if there is a
female; body type; alertness; general state of patent airway, a deviated nasal septum,
health; whether in acute distress, in no dis- whether there is rhinorrhea, or allergic
tress, conscious, coherent, euphoric, lethar- rhinitis. Inspection of teeth would mention
gic, distracted, well oriented, or agitated. whether edentulous or presence of dentures
(upper and lower plates) or carious; tongue
midline and whether uncoated or coated.

tympanic membranes (TMs—eardrums); ossicles;


airway, nasal septum, lips, gums, oral hygiene; tongue;
EXAMPLE 7-6 oral and buccal mucosa, salivary glands; tonsils,
Eye Examination palate, uvula, and posterior pharynx.
Dictation may include description of the scler- Neck—Includes inspection of contour; mobility
ae, cornea, conjunctivae, and lids; whether (whether supple, crepitus) or any limitation of motion
pupils and irises are equal, round, react to of the cervical spine; examination of the thyroid (size,
light, and accommodation (PERRLA or PERLA); shape, enlargement, tenderness, mass, or nuchal
whether there are silver wire arterioles; pres- rigidity); position of the trachea (midline, mobile); and
ence of Keith-Waggoner I or II (KW I or II) carotid pulses (full, equal bilaterally).
changes; any retinopathy, hemorrhages, exu- Respiratory—Includes assessment of respiratory
dates, papilledema, or arteriovenous (AV) nick- effort (intercostal retractions, use of accessory mus-
ing; disc margins (whether flat or choked); cles, diaphragmatic movement), auscultation of lungs
scotoma, diplopia, arcus senilis, and aphakia. (breath sounds, adventitious sounds, rubs, rhonchi,
wheeze, stridor), percussion of chest (dullness,
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182 UNIT 3 Records Management

Chest—Inspection of breasts (shape, whether sym-


EXAMPLE 7-8 metrical, nipple discharge); palpation of breasts and
axillae (masses or lumps, tenderness), expansion
Neck Examination (whether equal), thorax (whether bony).
Dictation may describe the presence of Gastrointestinal (Abdomen)—Examination of
enlarged lymph nodes (whether shotty), any abdomen; palpation of liver, spleen, and kidneys (LSK);
cervical lymphadenopathy, euthyroidism, hernia (absence or presence) symmetry, shape, and
thyromegaly, any carotid bruit, venous dis- contours; scaphoid. Examination (when indicated) of
tention, hepatojugular reflux (jugular vein anus, perineum, and rectum, including sphincter tone,
distention), and venous engorgement. presence of hemorrhoids, rectal masses. Obtain stool
sample for occult blood test when indicated.

EXAMPLE 7-9 EXAMPLE 7-11


Examination of Respiratory System Gastrointestinal (Abdomen) Examination
Dictation would mention whether lungs are Dictation may include statements about
clear to inspection, palpation, percussion presence of masses, rebound tenderness,
and auscultation (IPPA); whether rales are rigidity, guarding, any ascites; peristalsis;
sibilant, musical, bubbling, or coarse; and bowel sounds (tinkles, gurgles, rushes,
whether at base or apex. borborygmus); any suprapubic tenderness,
costovertebral angle (CVA) tenderness
flatness, hyperresonant or hyporesonant), palpation or tenderness at McBurney’s point; any
of chest (tactile fremitus), lung fields, and bron- visceromegaly, hepatosplenomegaly, or
chovesicular and vesicular function. organomegaly; any hernias (whether
Cardiovascular—Includes palpation of the heart inguinal, reducible, femoral, ventral, incision-
(location, size, thrills); auscultation of the heart with al, umbilical); right costal margin; left costal
notation of abnormal sounds and murmurs; assess- margin; liver (two fingerwidths below the
ment of rhythm, either normal sinus rhythm (NSR) costal margin); quadrants (right upper, left
or regular sinus rhythm (RSR); borders; silhouette; upper, right lower, left lower).
heart rate; rubs, gallops, heaves, lifts; examination of
carotid arteries (pulse, amplitude, bruits), abdominal
aorta (size, bruits), femoral arteries (pulse amplitude, Genitourinary/Male—Examination of scrotal con-
bruits), pedal pulses (pulse amplitude), and extremi- tents, penis, digital rectal examination of prostate
ties for edema or varicosities. gland.

EXAMPLE 7-10 EXAMPLE 7-12


Cardiovascular Examination Genitourinary Male Examination
Dictation for this section may contain words Dictation may include comments on whether
and phrases, such as A2 to P2 point of maxi- testes is descended, penis is circumcised or
mal impulse (PMI) at the fifth intercostal uncircumcised, whether prostate is tender,
space; midclavicular line (MCL); left border boggy, firm, nodular, enlarged; whether scro-
of cardiac dullness; systole, asystole, dias- tum contents show hydrocele, spermatocele,
tole; arrhythmia; murmurs grades II through tenderness of cord, or testicular mass.
VI (ejection, faint diastolic, harsh, soft blow-
ing, and apical low-pitched); any physiologi-
cal splitting of P2; precordium; any palpita- Genitourinary/Female—Pelvic examination (with
tion or opening snap. or without specimen collection for smears and cul-
tures), examination of external genitalia (general
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CHAPTER 7 Patients’ Medical Records 183

appearance, hair distribution, lesions), vagina (gen-


eral appearance, estrogen effect, discharge, lesions, EXAMPLE 7-15
pelvic support, cytocele, rectocele), examination of
urethra (masses, tenderness, scarring), examination Musculoskeletal Examination
of bladder (fullness, masses, tenderness), cervix (gen- Dictation may include comments about fingers
eral appearance, lesions, discharge), uterus (size, con- and nails, such as clubbing, cyanosis, inflamma-
tour, position, mobility, tenderness, consistency, tion, petechiae, ischemia, infection, and nodes.
descent or support), and adnexa/parametria (masses, Examination of these areas includes inspection
tenderness, organomegaly, nodularity). and palpation, range of motion, dislocation or
subluxation or laxity, muscle strength and tone
(e.g., flaccid, cog wheel, spastic), atrophy,
EXAMPLE 7-13 abnormal movements; color; temperature; any
Genitourinary Female Examination edema (whether pitting, pedal, pretibial); vari-
cosities, clubbing, or cyanosis; pulses (pedal,
Dictation may include comments on external peripheral, radial, femoral, popliteal, dorsalis
genitalia (vulva, labia, perineum); vaginal dis- pedis); and any intermittent claudication or sta-
charge; size and motion of cervix (i.e., sis dermatitis. Examination of the spine would
retroflexion or anteflexion); uterine size; render a description of any scoliosis, lordosis,
adnexal masses; whether parous, nulli- or kyphosis.
parous, or marital introitus; results of
bimanual or speculum examination; adnexal
regions; uterine fundus; any cystocele or
urethrocele; condition of Bartholin’s duct, EXAMPLE 7-16
urethra, and Skene’s duct (BUS), whether Examination of the Skin
well epithelialized.
Dictation may include description of the
skin—warm, dry, moist; turgor; pallid, jaun-
Lymphatic—Examination by palpation of two or diced, icteric, cyanotic, rashes, lesions,
more areas (neck, axillae, groin, other). ulcers, induration, subcutaneous nodule,
tightening. Description of the head includes
shape (whether normocephalic [normal,
EXAMPLE 7-14 without lumps] or exostotic [with bumps]);
color and texture of the skin and hair (e.g.,
Lymphatic System Examination whether there is alopecia [balding]).
Dictation includes comments about lymph
nodes on palpation in neck (cervical), arm pit Neurologic—Test of cranial nerves with notations
(axillary), and groin (inguinal). of any deficits for cerebral and cerebellar function;
examination of deep tendon reflexes (DTR) (biceps, tri-
ceps, knee jerk, ankle jerk); examination of sensation
Musculoskeletal—Examination of gait and station; (touch, pin, vibration, proprioception).
inspection and palpation of digits and nails; examina-
tion of joints, bones, and muscles of one or more of
the following six areas: (1) head and neck; (2) spine,
EXAMPLE 7-17
ribs, and pelvis, (3) right upper extremity; (4) left Neurologic Examination
upper extremity; (5) right lower extremity; and (6) left
Dictation may include notation of pathological
lower extremity. Examination of the spine (cervical,
reflexes (Hoffman, Babinski, Brudzinski, Gonda,
C1 to C7; thoracic, or dorsal, T1 to T12; lumbar, L1 to
Hoffmann, Kernig, Romberg, Homan, Strunsky);
L5; sacrum, S1 to S2), lumbosacral spine, sacrococ-
ankle clonus; any lingual, facial, or palatal
cygeal spine, and coccyx.
weakness; clear sensorium; station; and gait
Skin—Inspection and palpation of the skin and
(e.g., whether broad-based, ataxic gait).
subcutaneous tissues.
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184 UNIT 3 Records Management

Psychiatric—Description of patient’s judgment Diagnosis


and insight; assessment of mental status, including
The diagnosis is an impression, assessment, or final
orientation in all three spheres to time, place, and
conclusion based on history, physical examination
person, recent and remote memory, mood, and affect
findings, and, sometimes, diagnostic tests such as
(depression, anxiety, agitation).
x-rays, laboratory tests, or electrocardiogram (ECG).

COMPLEXITY OF MEDICAL Treatment


DECISION MAKING This is a recommended plan or treatment for the diag-
nosis. It might include admission to the hospital, phys-
Medical decision making is the thought process that the
ical therapy, additional tests, medication to be given
physician goes through. It refers to the complexity of
with dosage, and scheduling a future appointment.
establishing a diagnosis and selecting a management
option. For Medicare patients, the levels of E/M services
recognize four types of medical decision making: Prognosis
Prognosis is a probable outcome of the disease or
• Straightforward (SF)
injury and the prospect of recovery. It includes an esti-
• Low complexity (LC) mate of partial or total disability in an accident or
• Moderate complexity (MC) industrial case.
• High complexity (HC)
The following three elements are considered to
PROGRESS OR CHART NOTES
qualify for a level of decision making: After the initial visit, the history and physical exami-
nation are recorded on the chart, and each subse-
1. Number of Diagnoses or Management Options: This
quent patient visit is documented with progress notes
is based on the number and types of problems
chronologically entered in the medical record during
addressed during the visit, the complexity of
the visit or as soon as possible after the patient leaves
establishing a diagnosis, and the management
the office (see Figure 7-6 and Figure 7-10). For clarity
decisions made by the doctor.
and readability, it is preferred that progress notes be
2. Amount and Complexity of Data to Be Reviewed: typed and not be handwritten. Chart notes contain
This is based on the amount and complexity of information documenting each patient encounter,
diagnostic testing ordered or reviewed. A decision whether in the office, at home, in a skilled nursing
to obtain and review old medical records or to facility, in the emergency room, or at the hospital. The
obtain history from sources other than the medical assistant must check with the physician daily
patient increases the amount and complexity of to find out if patients have been seen at other sites, so
data to be reviewed. patient records can be pulled, entries can be made,
and charges can be posted. Prescription refills need to
3. Risk of Significant Complications, Morbidity, Comor-
be noted in the record, specifying frequency and
bidities, or Mortality: The level of risk is based on
dosage. If a patient is referred for a consultation, this
(1) significant complications, (2) other conditions
must be stated. Telephone conversations are noted if
associated with the presenting problem(s) (mor-
medical advice is requested or given. Appointment
bidity), (3) underlying diseases or other conditions
cancellations or no-shows and the refusal of a patient
present at the time of the visit (comorbidity), (4)
to cooperate with instructions should also be docu-
the risk of death associated with the problem
mented on the patient’s chart.
(mortality), (5) the diagnostic procedure(s), and
Chart notes, as part of the record, may be seen by
(6) the possible management options (treatment
attorneys, other physicians, and insurance compa-
rendered—surgery, therapy, drug management,
nies, and may be used as evidence during litigation;
procedures, and supplies).
therefore, they must be neat, accurate, and complete.
The final section of the history and physical Notes must be current, with no omissions, dated, and
examination report consists of stating the diagnosis, signed or initialed by the physician. They should be
the recommended treatment, and the prospect of typed single-spaced or handwritten, with a line at the
recovery. end of the note for the physician’s signature or initials.
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CHAPTER 7 Patients’ Medical Records 185

Goldberg, Arlene

1-7-XX CC: Malaise, anorexia, epigastric pressure with sensation of fullness, nausea,
headache, vertigo, and vomiting.
PE: Abdomen tender and rigid; esophagitis with pain and dysphagia; and severe
epigastric pain.
Dx: Acute gastritis.
Rx: DC alcohol, IM inj Prochlorperazine, 10 mg.
Gave Rx for 20 Meperidine, 50 mg, q4h, orally. Retn 4 days.
Gerald Practon, MD
mtf Gerald Practon, MD

Figure 7-10. Typed chart note signed by the physician

Self-Adhesive Chart Notes name, address, birth date, height, weight, marital his-
tory, social history, objective findings on physical
Some companies manufacture pressure-sensitive
examination, laboratory results, x-ray findings, diag-
paper in single sheets or as continuous sheets that are
nosis, anticipated further treatment, and prognosis.
perforated at various intervals. A series of chart notes
For industrial or work-related injuries or illnesses,
for different patients can be typed on the paper. Take
initial medical reports and subsequent progress
care in separating the notes for placement because
reports are submitted until the patient has fully recov-
brief notes can easily be placed on the wrong patient’s
ered, or until the condition is declared permanent and
chart. The notes are then placed on the physician’s
stationary.
desk for initialing. Finally, each note can be carefully
separated at perforations or cut apart. The backing is
peeled off and each note is secured in the next available
blank space of the patient’s progress sheet so informa- AUDIT OF MEDICAL RECORDS
tion previously entered is not obliterated. This elimi- Internal Review
nates the time-consuming work of obtaining each
medical record and locating the proper page to type in To perform an audit of medical records is to periodi-
the information. cally examine or review a group of patient records.
When done by the medical office staff, this process is
called an internal review, and records may be picked at
Electronic Progress or Chart Notes random. The purpose of the review is to verify that
In electronic record management, chart notes may be good recordkeeping is in place, that documentation is
dictated or transcribed directly into the computer valid for the level of service provided and billed, and
system. New chart notes are printed, signed, and that proper medical care is being provided. There are
added to the previous notes. If passwords are used for two types of internal reviews: the prospective review,
restricted access, electronic or digital signatures may which is done before billing is submitted, and the ret-
be acceptable. rospective review, which is done after billing insurance
carriers. Worksheets may be used, which separate the
components of the medical record to check off various
ABSTRACTING FROM MEDICAL items and to simplify and expedite the process.
RECORDS Table 7-3 presents some of the important and
most error-prone areas when reviewing documents
An abstract of data is required to complete reports, during the process of performing an internal review.
forms, and insurance claim forms. During this process,
information is extracted from various places in the
medical record and used to answer questions, fill in External Audit
blanks on forms, or compose a summary. The sum- Government programs, managed care organizations,
mary should include such information as the patient’s and private insurance carriers that have a contract
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186 UNIT 3 Records Management

JOB SKILL 7-3

Abstract Data from a Medical b. What is the patient’s diagnosis?


Record c. Was any medication prescribed?
Objective: To abstract data from a d. Does the patient’s past history show any-
medical record. thing of consequence?
e. Does this patient have any drug or food
Equipment/Supplies: Patient’s medical record,
allergies?
form to insert abstracted data, and pen or pencil.
f. What is the etiology (cause) of this dis-
Directions: Follow these step-by-step proce- ease, injury, or illness?
dures, which include rationales, to learn this job
g. What is the prognosis for this patient’s
skill. An exercise is presented in the Workbook
case?
to practice this skill.
h. Was any laboratory work performed or
1. Read and review the patient’s entire med- ordered?
ical record thoroughly to become familiar
i. Were any x-rays performed or ordered?
with all aspects of the case.
j. Define all abbreviations listed in the
2. Answer the following questions to see if you patient’s progress notes or history and
understand all aspects of this patient’s med- physical examination.
ical record.
k. What documents helped you find the
a. Did this patient have surgery, and, if so, answers to these questions?
what was performed?

Table 7-3. Internal Medical Record Review

1. Confirm that the patient’s name or identification number is listed on each page of documentation for the date of
service reviewed.
2. Make sure dates are recorded for all entries and that the date of service matches the date on the insurance claim
form.
3. Look to see if all chart entries are signed or initialed by the attending physician.
4. Check to see if allergies and adverse reactions are noted prominently so patients are not prescribed medications
they will have allergic reactions to.
5. Be sure evaluation and management procedures codes conform correctly to either 1995 or 1997 documentation
guidelines.
6. Check for documentation of a request from a third party when a consultation is billed.
7. Determine if handwritten progress notes are legible to an outside reviewer.
8. Check to see if there is an authorization form for release of records that was signed by the patient within the
past year.
9. Verify that selected codes representing procedures and services are correct, and make sure medical necessity is
documented.
10. Verify that the documented diagnosis is consistent with the diagnostic code on the insurance claim form,
matches the treatment plan, and is documented for the correct date of service.

with a physician have the right to do an external audit of ance carrier. Elements in the medical record are catego-
medical records. This usually occurs as the result of rized and awarded points according to the extent of the
unusual billing patterns by a medical practice and after documentation. For example, the history would be one
insurance claims have been submitted and paid. During category. Other categories might include the extent of
the external audit, charts may be selected by the insur- the physical examination, complexity of medical deci-
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CHAPTER 7 Patients’ Medical Records 187

sion making, time, and so forth. No points are given ical documentation and financial records, and inter-
when elements are missing. This system shows where view the staff and all physicians who participated in the
deficiencies occur in documentation and whether billed care of the patients’ cases being audited. If improper
diagnostic and procedures codes are substantiated. coding patterns are discovered, the physician may have
Investigators may question the patient, review the med- to refund monies or may be penalized.

W O R K B O O K A S S I G N M E N T

To develop competency-based job skills, refer to the Workbook and complete the exercises to
give you practice in typing or keying patient records, making file folders, typing file cards
for cross-reference, shingling laboratory reports, typing a medical history and physical
examination, correcting entries on a record, abstracting information from a patient record,
and learning medical terms.

C O M P U T E R A S S I G N M E N T
To review the concepts you have learned in this chapter, insert the Student Practice CD-ROM
into a computer and answer the multiple-choice, fill-in-the-blank, and true/false questions.
Start the Medical Assisting program, then click on “To Library” in the floor plan. In the
library, click on the Administrative Medical Assisting Book. Then choose Chapter 7 and start
playing hangman, concentration, Tic Tac Toe, or the championship game.

R E S O U R C E S

Magazine Internet
ADVANCE for Health Information Professionals Office of the Inspector General (OIG) and Federal
Information on medical recordkeeping, medical Bureau of Investigation
transcription, diagnostic, and procedure coding (pub- OIG national hotline: (800) HHS-TIPS
lished biweekly—free subscription). Web Site: http://www.cms.gov
(800) 355-1088 American Health Information Management Associa-
tion (AHIMA)
Books Web Site: http://www.ahima.org
Dorland’s Illustrated Medical Dictionary
Updated periodically—available on CD-ROM
W. B. Saunders/Elsevier Science
Philadelphia, PA
(800) 545-2522
Medical Abbreviations and Eponyms
Sheila B. Sloane
W. B. Saunders/Elsevier Science
Philadelphia, PA
(800) 545-2522