Nursing department

Second year
} By the end of this lecture , the student will be
able to:
} Explain the purpose of compiling patient medical
records.
} Describe the contents of patient record forms.
} Describe how to create and maintain a patient record.
} Identify and describe common approaches to
documenting information in medical records.
} Discuss the need for neatness, timeliness,
accuracy, and professional tone in patient
records.
} Explain how to correct a medical record.
} Discuss tips for performing accurate
transcription.
} Explain how to update a medical record.
} The patient’s chart ,
◦ Past and present medical conditions.

◦ Communication tool for health-care team

– Plan to provide for continuity of care.

◦ Documentation for billing and coding.

◦ Patient education and research.

◦ Legal document admissible in court.

} Information included in patient record
◦ Name and address
– Current
◦ Insurance coverage and complaint
person responsible
for payment – Health-care
◦ Occupation needs
◦ Medical history – Medical
treatment plan

– Response to
care
} Proof of event or procedure
◦ No documentation
– No proof
– Care is considered not done
} Legal document
◦ Must document complete information about patient
care
◦ Document if patient is noncompliant
} Complete, accurate, and well-documented
records are evidence of appropriate care
} Incomplete, inaccurate, altered, or illegible
records may imply poor standards
} Everyone who documents in the patient
record has a responsibility to the patient and
employing physician
 Additional Uses of
Patient
Patient Records Quality of
Treatment
Education
• Peer review
• Test results Research
• JCAHO review
• Health issues • Source of data
• Health-care
• Treatment analysis and
instructions policy decisions
} Past medical history
◦ Illnesses, surgeries, allergies, and current
medications
◦ Family medical history
◦ Social history (diet, exercise, smoking, use of drugs
and alcohol)
◦ Occupational history
◦ Current patient complaint recorded in patient’s own
words
} Physical examination results

} Results of laboratory and other tests

} Records from other physicians or hospitals

◦ Include a copy of the patient consent authorizing
release of information
} Doctor’s diagnosis and treatment plan
◦ Treatment options and final treatment list
◦ Instructions to patient
◦ Medication prescribed
◦ Comments or impressions

} Operative reports, follow-up visits, and

telephone calls
◦ These are part of the continuous patient record
◦ Document calls made to and from the patient
} Informed consent forms
◦ Verify that the patient understands procedures,
outcomes, and options
◦ Patient may withdraw consent at any time

} Hospital discharge summary forms

◦ Information summarizing the patient’s
hospitalization
◦ Instructions for follow-up care
◦ Physician signature
} Completing medical
history forms Documenting
test results
Initial
Interview
Examination, Documenting
preparation, patient
and vital signs statements
} Follow-up
◦ Transcribe notes the doctor dictates
◦ Post results of laboratory tests and examinations
◦ Record all telephone communication with the client

◦ Record all medical or discharge instructions given

to the client
} Orderly series of steps for dealing with any
medical case

} Lists the following

◦ Patient symptoms
◦ Diagnosis
◦ Suggested treatment
The treatment plan to correct the illness or problem

The impression of the patient’s problem that

leads to diagnosis

What the physician observes lan

during the examination

Information
the patient ssessment
tells you
bjective data

ubjective data
@Neatness and legibility
@Use a good-quality pen.
@Blue ink is preferred (differentiates original from
copy).
@Highlight critical items such as allergies.
@Handwriting must be legible.
@Make corrections properly.
6Timeliness
6Record all findings as soon as they are available.
6For late entries, record both original date and
current date.

6Record date and time of telephone calls and

information discussed.

6Retrieve file quickly in event of an emergency

þAccuracy.
þCheck information carefully.
þNever guess or assume.

þ Double-check accuracy findings and instructions.

þ Make sure most recent information is recorded.
} Professional attitude and tone
◦ Record patient comments in his or her own words
◦ Do not record your personal or subjective
comments, judgments, opinions, or speculations

You may call attention to problems or observations by

attaching a note to the chart, but do not make such
comments part of medical record.
} Computer records
◦ Accuracy is also important with electronic records
◦ Advantages
– Can be accessed by more than one
person at a time
– Can be used in teleconferences
◦ Security concerns
– Protect patient confidentiality
} Transcription means transforming spoken
words into written format.

} Dictated information is part of the medical

record and must be kept confidential.

} Date and initial each transcription page.

} Strive for ultimate accuracy and

completeness of transcribed information.
} Transcribing direct dictation
◦ Use a writing pad and pen that will not smear
◦ Use incomplete sentences and phrases to keep up
with physician’s pace
◦ Use abbreviations
◦ Ask for clarification immediately if something is
unclear
◦ Read the dictation back to verify accuracy
◦ Enter notes into patient record, date, and initial
} When mistakes happen, correct them
immediately.
◦ Draw a line through the original information.
– It must remain legible
◦ Insert correct information above
or below original line or in margin.
◦ Document why correction was made.
◦ Date, time, and initial correction.
◦ Have a witness, if possible.
} Additions to record should not appear
deceptive
◦ Document why late entry is made.
◦ Date and initial added items.
– May have a third party witness addition.
} Records are property of physician
◦ Contain confidential patient health information
◦ Must have patient’s written consent to release
◦ Exceptions: cases of contagious disease or court
order
} Procedures for releasing records
◦ Obtain a signed and newly dated release form
authorizing the transfer of information, and place
it in the patient’s record
◦ Make photocopies of original materials
– Copy and send only documents covered in the
release authorization
◦ Call to confirm receipt of materials
} Special cases
◦ Divorce
– Legal guardian of children (may be one or both
parents)
◦ Death
– Next of kin
– Legally authorized representative
◦ If unsure, ask supervisor
} Medical assistants must properly prepare
and maintain patient records

} There are several methods for

documentation, but regardless of method,
records must be complete, legible, current,
accurate, and professional

} Properly maintain, correct, update, and

release patient medical records