Name: ______________________________ Date: ______________

Section: ___________ Score: ___________

ACTIVITY 1: INTRODUCTION TO MEDICAL CHART

OBJECTIVES:At the end of this activity, the students should be able to:
1. _______________________________________________________
2. _______________________________________________________
3. _______________________________________________________

ACTIVITY 1.1 THE PATIENT’S MEDICAL CHART

DIRECTION: Study the medical chart components and determine the use of each in
developing Drug Therapy Problems (DTP).

COMPO EXAMPLES SIGNIFICANCE

NENTS

1
Admissi  An admission note
on is written for any
Notes patient to be
admitted to a
hospital.
Admission notes
are used by
healthcare payors
to determine
billing; doctors use
them to record a
patient's baseline
status and may
write additional
on-service notes,
progress notes
(SOAP notes),
discharge notes,
preoperative notes,
operative notes,
postoperative
notes, procedure
notes, delivery
notes, postpartum
notes, and
discharge notes.
These notes
constitute a large
part of the medical
record.
 Admission notes
document the
reasons why a
patient is being
admitted for
inpatient care to a
hospital or other
facility, the
patient's baseline
status, and the
initial instructions
for that patient's
care.

2
Medical  Providing your
History primary care
physician with an
accurate medical
history helps give
him or her a better
understanding of
your health. It
allows your doctor
to identify patterns
and make more
effective decisions
based on your
specific health
needs.

Laborat Clinical laboratory test

ory results are a very
Results important parameter in
diagnosis, monitoring and
screening. 70-80 % of
decisions in diagnosis are
based on laboratory
results and more and
more laboratory analyses
are requested.
 Laboratory tests
are often part of a
routine checkup to
look for changes in
your health. They
also help doctors
diagnose medical
conditions, plan or
evaluate
treatments, and
monitor diseases.

3
Physicia Physician orders serve a
n Order variety of important
Sheets purposes including
communicating the
physician’s direction for
ancillary services and
required diagnostic tests
and securing the ability to
receive reimbursement
for services that flow from
the physician’s encounter
with the patient. The
systematic use of
physician orders also
serves as proof that the
physician is directing
services to the patient
and that conditions of
participation of the
facility, which require a
physician driven process,
are being complied with
on a systematic basis.

4
Progres The importance of progress
notes is to ensure that client’s
s Notes health is top priority, for our
carers to communicate
between each visit and to be
able to report back to certain
days or a time for any reason.
 The purpose of
progress notes is to
provide a daily
account of your
patients and their
illnesses, and of
developments in
their diagnosis and
treatment, for all
of those who share
in their care.

5
Operati The operative report must
ve be written or dictated
Record immediately after an
operative or other high risk
procedure.  The most
important issue is that there
needs to be enough
information in the record
immediately after surgery in
order to manage the patient
throughout the
postoperative period. 

Medica The medical record is an

tion important tool that serves
Adminis as a basis for planning
tration care, communicating
Record between medical
providers and other
workers, and providing
documentation as to the
course of illness,
treatment, and response
to treatment.

6
Vital  Recording
Signs thorough and
Record accurate vital signs
supports the urgent
care physician in
asking the right
questions of the
patient's history of
present illness,
guides the
physician in the
physical exam, and
thus is essential in
reaching an
accurate diagnosis
and devising an
effective treatment
plan.

QUESTIONS:

1. How does medical chart help the pharmacists in developing Drug Therapy Plans?
A medication chart in a residential aged-care facility serves as a communication
tool between doctors, nurses, pharmacists, other health professionals and
hospitals regarding a resident's medicines. It is used to direct how and when
drugs are to be administered and as a record of their administration.

2. How might incomplete information on a medical chart create an inaccurate drug

treatment?
The consequences of incomplete medical records are:

 Lack of clarity in communication between physicians treating the patient leading to failure to follow
through with evaluation and treatment plans
 Incorrect treatment decisions compromising patient safety
 Loss of practice revenue
 Unnecessary and expensive diagnostic studies
 Inappropriate billing
 Affects patient-related studies

7
CONCLUSION:

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