1. Chapter 19
Documentation and Medical Records
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2. Definitions
• Medical documentation
• Medical record
• Charting
© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

3. Purposes
• Contributes to good patient care
• Provides legal protection
• Helps ensure regulatory compliance
• Improves cost control
• Decreases denials from insurance
companies
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duplicated, or posted to a publicly accessible website, in whole or in part.

4. Characteristics
• Complete with all requested information
• Concise and factual
• Properly identified
• Legible
• Correct spelling, terminology, punctuation,
and grammar
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duplicated, or posted to a publicly accessible website, in whole or in part.

5. Characteristics
• Clearly and objectively expressed
• Findings not duplicated
• Approved abbreviations listed in facility’s
policy used
• Time and date given for all entries
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duplicated, or posted to a publicly accessible website, in whole or in part.

6. Characteristics
• Signed by proper person
• Completed without leaving empty lines
• Always charted after giving medication or
performing procedure
• Written with black or blue ink
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duplicated, or posted to a publicly accessible website, in whole or in part.

7. Making Corrections
• Draw single line through error
• Write in correct information
• Note error per facility policy
• Date and initial correction
• Correct immediately on computer
• If discovered later, correct as above
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8. Question
• Which of the following is the recording of
observations and information about
patients?
A. Charting
B. Medical documentation
C. Medical record
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duplicated, or posted to a publicly accessible website, in whole or in part.

9. Answer
• A. Charting
• Charting
– Recording of observations and information
about patients
• Medical documentation
– Notes and documents that health care
professionals add to medical record
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duplicated, or posted to a publicly accessible website, in whole or in part.

10. Answer
• A. Charting
• Medical record
– Collection of all documents filed together
– Form complete chronological health history
© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

11. Medical Records
• Organized per facility policy
• All health care workers responsible to
maintain records per facility policy
• Chronological or source-oriented
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duplicated, or posted to a publicly accessible website, in whole or in part.

12. Medical Records Content
• History and physical (H&P)
• Physician’s orders
• Diagnostic tests
• Admissions
• Surgical procedures
© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

13. Medical Records Content
• Graphics
• Flow sheets
• Medications record
• Progress notes
© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

14. Medical Records Content
• Reminder:
– Verify correct form in chart by ensuring
patient’s name on each document
• Each section chronological
• Thinning a chart
• Security of files
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duplicated, or posted to a publicly accessible website, in whole or in part.

15. Question
• Which of the following is a form used for
specialty needs?
A. Progress notes
B. Graphics
C. Flow sheets
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duplicated, or posted to a publicly accessible website, in whole or in part.

16. Answer
• C. Flow sheets
• Flow sheets
– Forms for specialty needs
• Progress notes
– Written chronological statements about
patient’s care
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duplicated, or posted to a publicly accessible website, in whole or in part.

17. Answer
• C. Flow sheets
• Graphics
– Graphed forms for vital signs
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duplicated, or posted to a publicly accessible website, in whole or in part.

18. Progress Notes
• Primary tool
– Recording, communicating, and coordinating
care of patient
• May include the following:
– Observations
– Treatments
– Patient response
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duplicated, or posted to a publicly accessible website, in whole or in part.

19. Progress Notes: Formats
• Problem-oriented charting
• Narrative charting
• Charting by exception
• Computerized
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duplicated, or posted to a publicly accessible website, in whole or in part.

20. Question
• True or False:
– The chief complaint is the reason the patient is
seeking medical care.
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duplicated, or posted to a publicly accessible website, in whole or in part.

21. Answer
• True
• Chief complaint
– Reason patient seeks medical care
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duplicated, or posted to a publicly accessible website, in whole or in part.

22. EMRs
• EMR systems can go far beyond core
charting
– Coordination tools
– Information
– Safety tools
– Scanned documents
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duplicated, or posted to a publicly accessible website, in whole or in part.

23. EMRs
• Can only communicate within same health
care system
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duplicated, or posted to a publicly accessible website, in whole or in part.

24. Personal Health Record (PHR)
• Recommended for patients
– Due to mobility of individuals
– Frequent changes in providers
– Frequent changes in insurance coverage
• Assists patient to recall events and dates
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duplicated, or posted to a publicly accessible website, in whole or in part.

25. Personal Health Record (PHR)
• Prevents long delays in requesting
information
• Types of information to include
– Demographics, such as name, address,
contact information, etc
– Emergency contacts
– Name, specialty and contact information of
previous providers
– Insurance provider(s)
© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

26. Personal Health Record (PHR)
• Types of information to include
– Medical directives, living will, organ donation,
etc.
– General medical information: height, weight,
blood type, vital signs, etc.
– Allergies and drug sensitivities
– Current conditions and date of diagnosis
– Previous surgeries, including date and results
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duplicated, or posted to a publicly accessible website, in whole or in part.

27. Personal Health Record (PHR)
• Types of information to include
– Medications (prescription and nonprescription)
– Immunizations and when last received
– Any relevant health care visits, such as
hospitalizations, other specialists or therapists
– Pregnancies
– Medical devices
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duplicated, or posted to a publicly accessible website, in whole or in part.

28. Personal Health Record (PHR)
• Types of information to include
– Foreign travel
– Family history information
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duplicated, or posted to a publicly accessible website, in whole or in part.

29. Question
• True or False:
– EMRs have about the same capabilities and
limitations as written charting.
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duplicated, or posted to a publicly accessible website, in whole or in part.

30. Answer
• False
• EMR systems can go far beyond core
charting
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duplicated, or posted to a publicly accessible website, in whole or in part.

31. HIPAA
• The Privacy Rule
• The Security Rule
• Possible consequences of not following
HIPAA regulations
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duplicated, or posted to a publicly accessible website, in whole or in part.

32. Question
• Which of the following is true about HIPAA?
A. It protects the health care facilities
B. It protects patients
C. It protects the safety of health care
professionals
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duplicated, or posted to a publicly accessible website, in whole or in part.

33. Answer
• B. It protects patients
• HIPAA Privacy Rule gives patient specific
rights related to medical records
• HIPAA Security Rule requires
administrative, physical, and technical
safeguards be developed by facilities to
protect patient information
© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.