Essay about patient assessment

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Patient assessment quiz one

Function of the medical record
1. Written record of important patient information
2. Basis for health care decisions
3. Serves as a legal document

Components of the medical record
1. Medical office administrative documents – 3 parts to it. o Patient Registration Record - Demographic info -Billing info o Notice of Privacy Practices (NPP) o Correspondence

2. Medical office clinical documents - 6 parts to it. o Health Hx Report o Physical Exam Report o Progrss Notes o Medication Record
- Prescriptions/OTC
- Medication Administration Record (MAR) o Consaltation Report o Home Health Report

HIPAA o Provides patients with better control over the use and disclosure of their personal health information. o Health care providers, health plans, health care clearinghouses (billing services) must all comply o Federal law

Different types of Documents

Lab documents - Reports of analysis of exam of body specimens to assist physician in diagnosing and treating disease. o Ex) Hematology, urinalysis, Microbiology, cytology, histology

Diagnostic procedure documents- procedures performed to assist in the diagnosis, management or treatment of patient. o Ex) ECG/EKG, Holter monitor report, colonoscopy report, Spirometry Report, Radiology Report

Therapeutic services Documents- Documents the assessments and treatments designed to help restore a patient’s function. o EX) Physical therapy, Occupational therapy, Speech therapy

Hospital Documents- Dictated by a physician and transcribed at the hospital and a copy is sent to the patient’s regular attending (primary) physician. o EX) H&P report, Operative report, Discharge summary report, Pathology report, emergency department report.

Consent Documents- legal documents required to perform certain procedures or to release info contained in the patient’s medical record.
 PHYSCIANS responsibility to INFORM patient of risks, benefits, and prognosis of procedures being performed.
 Signature must be WITNESSED when the patient signs, to verify that the correct patient has signed. – the MA does this
 Is it your responsibility to explain prognosis/risks/benefits?
No, only to witness the signature.

Types of medical records – Know the difference’s
Paper based patient record (PPRs)- almost all paper

Electronical Medical Record (EMR)- all stored on computer
Advantages Disadvantages
- Speed/productivity - Initial cost
- Efficiency - Time investment
- Accessibility - Occupational tasks

Medical record formats – 2 types
Source oriented record-
 Usually reverse chronological order (oldest
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