Guided Notes

The Electronic Health Record

1. List the components of a medical record. (20 items).

a. Patient ID and demographics
b. Medical history
c. Conclusion and impression on admission
d. Diagnostic and therapeutic orders
e. Clinical observations
f. Report of relevant physical examination
g. Consultation reports
h. Diagnostic and therapeutic reports
i. Final diagnosis and prognosis
j. Discharge summary
k. Postmortem results
l. Psychologic needs summary
m. Physical examination report
n. Treatment plan
o. Evidence of informed consents
p. Progress notes
q. Reports of surgical and invasive procedures
r. Records of donations and implants
s. Conclusions at termination of stay
t. Discharge info given to patient and family

2. Who owns the medical record? Caregiver or facility. Electronic health record (EHR):
electronic health record system generally considered as the portal through which
clinicians access a patient’s health record, order treatments or therapy, and document
care delivered to patients; allows providers to gather multiple types of data about a
patient.

3. List the 3 do’s and don’ts for recording information in the medical record.

Do: keep info concise, record the information as it occurs, keep info confidential
Don’t: include critical comments about the patient or other health care professionals,
record information for someone else, divulge information concerning the patient

4. Informed Consent states that the patient has been informed of the procedures or
operation to be performed, of the risks involved, and of the possible consequences. By
signing the consent form, the patient or the patient’s representative indicates that he or
she has been informed of and consents to the procedure or treatment.
5. What are the 5 elements of informed consent according to The Joint Commission?
a. The nature of the procedure
 b. The risk and benefits of the procedure
c. Reasonable alternatives to the procedure
d. The risks and benefits of the alternatives
e. Assessment of the patient’s understanding of the above elements
6. What part of the radiographic procedure is part of the patient medical record? The image
is not part of the record, but the order and the results of the exam are part of the medical
record. Pregnancy questionnaires/forms and exam specific forms may also be used.

Legal responsibilities: Radiographers may be required to give depositions or testimony regarding

information in the health record or in the case of a radiograph, testimony regarding the
procedures involved.

Radiology health records/RT’s may add

 Patient demographic information

 Specific procedure requested
 Order physician
 Documentation of medical necessity
 Procedure results
 Dosage of contrast or radionuclides for procedures
 Special reports documenting evaluation or treatment of a patient