Documentation and Medical Records

What is documentation? notes and documents that hcp add to medical record

So what is the purpose of medical documentation?

What are characteristics of GOOD medical documentation?

How do you make corrections in medical records?

What is some information that you find in a medical record?

progress notes- there are different formats all with advantages and disadvantages

purpose- legal protection

compliance

cost control

decrease denial from  ins co. omg my dad!!

Characteristics-complete

facts and concise-what does concise mean?

properly labeled and ID on q page

legible

correct grammar

objective/clear

no double charting

only approved abbreviations

signed by person doing charting

completed with  no empty spaces

no charting in advance-ever

black ink/ maybe blue-THATS IT! no red no pencil

CORRECTIONS ON MED RECORDS

single line

put correct info next or close to

error if facility policy

date and initial

almost a non issue w computers

contents of records

H & P

hx- familial, social, and personal-what do these mean?*

Phys/np orders

dx tests

consents/admissions

surgical reports and consents

graphics

flow sheets

med record

progress note-chronological, every time pt is seen, to update findings and plan for care,

this is written by..any one who provides care to patient*

Charting-you record observations and info about your pt-EVERY SINGLE ENTRY YOU MAKE NEEDS TIME/DATE/SIGNATURE 2/23/15 0700 MHudecek RN

if you chart by exception what does this sound like?

Assessment-our view or opinion about pts problem "I Assessed..."

Chief complaint-what do you think this is?

SOAP
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