CHAPTER 1 THE MEDICAL RECORD. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 2 PRETEST 1.The medical record serves as

CHAPTER 1CHAPTER 1THE MEDICAL RECORD

Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 2

PRETESTPRETEST

1. The medical record serves as a legal document.

2. The purpose of progress notes is to update the medical record with new information.

3. The patient registration record consists of a list of the problems associated with the patient's illness.

4. All over-the-counter medications taken by the patient should be charted on the medication record form.

5. A consultation report is a narrative report of a clinical opinion about a patient's condition by a practitioner other than the primary physician.

True or False


PRETEST, cont. PRETEST, cont.

6. A report of the analysis of body specimens is known as a diagnostic report.

7. Medical impressions are conclusions drawn from an interpretation of data.

8. A consent to treatment form is required for tuberculin skin testing.

9. Diabetes mellitus is an example of a familial disease.

10. Pain is an example of an objective symptom.

True or False


Content OutlineContent Outline

1. Medical record: Written record of important information regarding a patienta. Patient: An individual receiving medical care

2. Functiona. To make decisions regarding patient's care

and treatmentb. To document results of treatment and

patient's progressc. Communicate information to authorized

personnel in medical officed. Serves as a legal document

• Law requires that patient's care and treatment be documented

Introduction to the Medical Record


Introduction to the Medical Record, cont.

Introduction to the Medical Record, cont.

3. Good documentation a. Works to legally protect the physician and

medical staff

4. Incomplete recordsa. Can be used as evidence to show that

patient did not receive quality care

5. Information is strictly confidentiala. Must not be read or discussed by anyone

not involved in care of the patient


Highlight on the HIPAA Privacy Rule

Highlight on the HIPAA Privacy Rule

1. HIPAA: Health Insurance Portability and Accountability Act

2. HIPAA Privacy Rule: Federal law that protects patient's privacya. Went into effect April 14, 2003b. Purpose

• Provide patients with more control over use and disclosure of their health information (Known as PHI: Protected health information)


Highlight on the HIPAA Privacy Rule, cont.

Highlight on the HIPAA Privacy Rule, cont.

c. Who must comply: Anyone that uses, stores, maintains or transmits health information• Health care providers• Health plans• Health care clearinghouses (e.g., billing

services)

d. What is included in the HIPAA Privacy Rule• See Highlight on the HIPAA Privacy Rule


Components of the Medical Record

Components of the Medical Record

1. Consists of numerous documentsa. Each document has a specific function

2. Preprinted forms are often used3. Documents can be classified into

categories


Medical Office Administrative Documents

Medical Office Administrative Documents

1. Consists of demographic and billing information

2. Must be completed by all new patients

Contain information for efficient record keeping of office

Patient Registration Record


Patient Registration Record, cont.


3. Most offices enter this information into the computera. Original placed in front of patient's chart

4. Information is used for a number of computerized functions (e.g., scheduling appointments, posting patient transactions, processing patient statements and insurance claims)

5. Original registration recorda. Placed in front of patient’s medical record




6. Includes:a. Demographic information• Full name• Address• Phone (home

and work)• Date of birth

•Gender•Marital status•Employer




b. Billing information• Name of responsible party• Social Security number• Address of responsible party• Name of insured• Insurance company• Policy and group number


CorrespondenceCorrespondence

1. May be received from:a. Insurance companies

• Example: Precertification authorization

b. Patient’s attorneyc. Patient


Correspondence, cont. Correspondence, cont.

2. May be sent from office:a. Patient referral letterb. Collection letter


Medical Office Clinical Documents

Medical Office Clinical Documents

1. Subjective data about the patient Health History Report

Records and reports that assist physician in care and treatment of patient


Health History Report, cont. Health History Report, cont.

2. Health history obtained by:a. Having patient complete a preprinted

formb. Physician or MA during an interview



3. Health history, physical examination, and laboratory and diagnostic tests are used to:a. Determine patient's state of healthb. Arrive at a diagnosis

• Diagnosis: The scientific method of determining and identifying a patient's condition

c. Prescribe treatmentd. Document change in patient's illness after

treatment



4. Thorough history obtained on each new patient

5. Subsequent visitsa. Provides additional information regarding

changes in:• Patient's condition• Treatment


Physical Examination ReportPhysical Examination Report

1. Physical examination: Assessment of each part of patient's bodya. Purpose: Provides objective data about

the patient• Assists physician in determining patient's

state of health


Physical Examination Report, cont.


2. Physical Examination Report: a. A summary of the physician's findings

from each part of the bodyb. Includes:

• General appearance

• Head and neck

• Eyes

•Ears•Nose




• Mouth and pharynx• Arms and hands• Chest and lungs• Heart

• Breasts• Abdomen• Genitalia and rectum• Legs and feet


Progress NotesProgress Notes

1. Purposea. Update medical record with new

information when patient visits the office or telephones

2. Must include:a. Date and timeb. Signature and credentials of individual

making entry


Medication RecordMedication Record

1. Detailed information on patient's medications

2. Includes:a. Prescription medsb. Over-the-counter medicationsc. Meds administered at medical office


Medication Record, cont. Medication Record, cont.

3. Types of formsa. Prescription and Over-the-Counter

Medication Record Formb. Medications Administration Record Form


Medication Record, cont. Medication Record, cont.


Consultation ReportConsultation Report

1. Narrative report of clinical opinion about a patient's condition by a practitioner other than primary physician (consultant)

2. Usually is usually a specialist (e.g., cardiologist)

3. Consultant's opinion is based on:a. Review of patient's recordb. Examination of patient


Consultation Report,cont.Consultation Report,cont.

Modified from Diehl MO, Fordney MT: Medical transcription: techniques and procedures, ed 5, Philadelphia, 2003, Saunders.


Home Health Care ReportHome Health Care Report

1. Home health care: The provision of medical and nonmedical care in a patient's home

2. Purposea. Minimize effect of disease or disability on

the patient by:• Promoting health• Maintaining health• Restoring health

3. Home health care must be ordered by physician


Home Health Care Report, cont.


4. Home health care professionalsa. Nursesb. Home health aidesc. Dietitiansd. Physical therapistse. Occupational therapistsf. Speech therapistsg. Social workers




5. Home health servicesa. Cardiacb. Infusion (IV) therapyc. Respiratory therapyd. Pain managemente. Diabetes managementf. Rehabilitationg. Maternal-child care

6. Summary report sent to patient's physician




Courtesy of and Modified from Briggs, Des Moines, Iowa.


Laboratory DocumentsLaboratory Documents

1. Laboratory Report: A report of the analysis or examination of body specimens

2. Purposea. Relay results of laboratory tests to

physician to assist in diagnosis and treatment of disease


Laboratory Documents, cont. Laboratory Documents, cont.

3. Categories of Laboratory testsa. Hematologyb. Clinical chemistryc. Serologyd. Urinalysise. Microbiologyf. Parasitologyg. Cytologyh. Histology


Diagnostic Procedure Documents

Diagnostic Procedure Documents

1. Diagnostic Procedure Report: Narrative description and interpretation of a diagnostic procedure

2. Diagnostic procedure: A type of procedure performed to assist in diagnosis, management, or treatment of a patient's condition.a. Performed by physician, MA, or specially

trained technicianb. Interpretation of results made by physicianc. Physician completes a written report


Diagnostic Procedure Documents, cont.

Diagnostic Procedure Documents, cont.

3. Examples of diagnostic procedure reportsa. Electrocardiogram reportb. Holter monitor reportc. Sigmoidoscopy reportd. Colonoscopy reporte. Spirometry reportf. Radiology report g. Diagnostic imaging report


Radiology Report Radiology Report

Modified from Diehl MO, Fordney MT: Medical keyboarding, typing, and transcribing, ed 4, Philadelphia, 1997, Saunders.


Diagnostic Imaging Report (CT Scan)

Diagnostic Imaging Report (CT Scan)


Therapeutic Service Documents

Therapeutic Service Documents

1. Therapeutic Service Report: Documents the assessments and treatment designed to restore a patient’s ability to function


Therapeutic Service Documents, cont.


2. Example of therapeutic services:a. Physical therapy: Use os physical

agents to restore function and promote healing following an illness or injury

• Therapeutic exercise

• Thermal modalities

• Cold

•Hydrotherapy•Electrical stimulation•Massage




b. Occupational therapy: Helps the patient learn new skills to adapt to a disabling condition• Enables patient to perform activities of daily

living• Achieve as much independence as possible

c. Speech therapy: Treatment for the correction of a speech impairment resulting from:• Birth• Disease• Injury


Hospital DocumentsHospital Documents

1. Prepared by the physician responsible for care of the patient in the hospitala. Known as the attending physician

• May be:– Patient’s regular physician– A different physician (e.g., emergency

room physician)


Hospital Documents, cont. Hospital Documents, cont.

2. Dictated by attending physician and transcribed at the hospitala. Original kept on file at hospitalb. Copy sent to patient’s physician

3. Assists patient’s physician in:a. Reviewing patient’s hospital visitb. Providing follow-up care


History and Physical ReportHistory and Physical Report

1. Inpatient: Patient who has been admitted to hospital for at least one overnight stay

2. Health history and physical examination must be performed on all inpatientsa. Exception:

• If history and physical examination are performed at medical office 1 week before admission– Can be used instead


History and Physical Report, cont.


3. If reliable health history cannot be obtained from patient a. Obtained from a person able to relay the

facts

4. Consists of a narrative report of: a. Health historyb. Physical examinationc. Physician’s medical impressions




5. Purpose of health history: document patient’s current complaints and symptoms

6. Purpose of physical examination: assess patient’s current health status




7. Medical impressions: Conclusions drawn from interpretation of dataa. Other terms used:

• Provisional diagnosis• Tentative diagnosis

b. Physician interprets data from health history and physical examination• Draws conclusions (medical impressions) as to

patient’s state of health


Hospital History and Physical Examination Report

Hospital History and Physical Examination Report


Operative ReportOperative Report

1. Must be completed on all patients who have had a surgical procedure

2. Purpose: describes the surgical procedure

3. Completed and signed by surgeon performing operation


Operative Report, cont. Operative Report, cont.

4. Includes:a. Patient identification informationb. Date of surgeryc. Preoperative diagnosisd. Name of surgical proceduree. Full description of findings



f. Description of technique and procedures used

g. Ligatures and sutures usedh. Number of packs, drains, and sponges

usedi. Description of specimens removedj. Condition of patient after completion of

surgeryk. Postoperative diagnosisl. Name of surgeon




Discharge Summary ReportDischarge Summary Report

1. Summary of the significant events of a patient’s hospitalization

2. Includes:a. Concise account of patient’s illnessb. Course of treatmentc. Response to treatmentd. Patient’s condition at time of discharge


Discharge Summary Report, cont.


3. Purpose is to document information needed by:a. Patient’s family physician for continuity of

future careb. Respond to authorized requests for

information regarding patient’s hospitalization

4. Completed and signed by attending physician






Pathology ReportPathology Report

1. Macroscopic and microscopic description of tissue removed during:a. Surgeryb. Diagnostic procedure

2. Includes a diagnosis of the patient’s condition

3. Pathologist examines tissue; completes and signs report


Pathology Report, cont.Pathology Report, cont.



Emergency Department ReportEmergency Department Report

1. Record of significant information obtained during an emergency department visit

2. Prepared and signed by emergency department physician

3. Copy sent to patient’s physician so follow-up care can be provided


Emergency Department Report, cont.


4. Includes:a. Date of serviceb. Patient’s identification informationc. Nature of illness or injuryd. Laboratory or diagnostic test results


e. Procedures performedf. Treatment renderedg. Diagnosish. Condition of patient at dischargei. Instructions regarding follow-up care







Consent DocumentsConsent Documents

1. Required to:a. Perform certain proceduresb. Release information contained in patient’s

medical record

2. Typesa. Consent to treatment formb. Release of medical information form


Consent to Treatment FormConsent to Treatment Form

1. Required for:a. All surgical operationsb. Nonroutine therapeutic and diagnostic

procedures

2. Example of diagnostic procedure: Sigmoidoscopy


Consent to Treatment Form, cont.


2. Signed by patient or legally authorized representative

3. Purpose: provides written evidence that patient agrees to procedure(s) listed on form




4. Informed consent: patient has received the following information before giving consent:a. Nature of patient’s conditionb. Nature and purpose of recommended

procedurec. Risks involvedd. Alternative treatment or procedures

availablee. Prognosis: likely outcome of the proceduref. Risks of declining or delaying procedure




5. Must be in terms patient can understand

6. Patient must be given opportunity to ask questions

7. Form should not be signed until patient has been provided with all necessary information




8. Patient’s signature must be witnesseda. Witnessing a signature

• Means: MA verified the patient’s identity and watched patient sign form

• Does not mean: MA is attesting to accuracy of information on form


Witnessing the patient’s signature

Witnessing the patient’s signature


Consent to Treatment FormConsent to Treatment Form


Release of MedicalInformation Form

Release of MedicalInformation Form

1. Not required for medical treatment, payment, and health care operations (TPO)

a. Stipulated by HIPAA2. Required for purposes that are not part

of TPO a. Example: Patient moving to another

state and transferring medical records 3. Must be signed by patient (or

parent/guardian)


Release of MedicalInformation Form, cont.


4. Includes:a. Patient full name and addressb. Medical practice releasing infoc. Individual or facility to receive infod. Info to be releasede. Purpose or need for infof. Method of release




g. Signature of patient (or legal representative)

h. Date signedi. Expiration date of form

5. May be faxed or mailed if patient is unable to come to office





Medical Record FormatsMedical Record Formats

1. PPR: paper-based patient recorda. Most of record is paper-basedb. Some patient data stored on computer Example: Patient registration informationc. Formats

• Source-oriented record• Problem-oriented record

2. EMR: electronic medical recorda. Entire medical record is stored in computer


Source-Oriented RecordSource-Oriented Record

1. Used most often in the medical office2. Organized into sections based on

department, facility, or other source that generated information (e.g., laboratory)


Source-Oriented Record, cont.Source-Oriented Record, cont.

3.Separated by chart dividers: color-coded tabs labeled with title of section


Source-Oriented Record, cont. Source-Oriented Record, cont.

1. Within each section: Documents arranged according to datea. Most recent document placed on top or in

front of the others• Known as: reverse chronological order


Source-Oriented Record, cont.Source-Oriented Record, cont.

5. Titles of sections:a. History and Physicalb. Progress Notesc. Medicationsd. Laboratory Reportse. Electrocardiogramf. X-Ray Reportsg. Consultations


Source-Oriented Record, cont. Source-Oriented Record, cont.

h. Rehabilitation Therapyi. Home Health Carej. Hospital Reportsk. Insurancel. Consentsm. Correspondencen. Miscellaneous


Problem-Oriented Record (POR, POMR)

Problem-Oriented Record (POR, POMR)

1. Organized according to patient’s health problems

2. Advantage: Patient’s problems can be defined and followed individually


Problem-Oriented Record (POR, POMR), cont.


3. POR developed in four stagesa. Database: Consists of a collection of

subjective and objective data • Includes:

– Health history report– Physical examination report– Results of baseline laboratory and

diagnostic tests




b. Problem list: Consists of a list of patient’s problems • Problem: Any patient condition that requires

observation, diagnosis, management or patient education

• Includes:– Medical problems– Psychologic problems– Social problems

• Each problem in the list is numbered and titled– Serves as a table of contents for the record




c. Plan: Plan of action for each problem • May include plans for:

– Laboratory tests– Diagnostic tests– Medical treatment– Surgical treatment– Therapy– Patient education

• Each plan begins with the problem number followed by the plan of action


Problem-Oriented Record(POR, POMR), cont.

Problem-Oriented Record(POR, POMR), cont.

d. Progress notes: Follow-up for each problem• Begins with the number of the problem• Includes:

– Subjective data: Data obtained from the patient

– Objective data: Data obtained by observation, physical examination, laboratory and diagnostic tests, etc.




– Assessment: Physician’s interpretation of the current condition based on the subjective and objective data

– Plan: Proposed treatment for the patient» Acronym: SOAP»

a) Advantages of using SOAP format:

• Can deal with each problem clearly

• Can analyze data in an orderly manner

Soaping : Writing progress notes using the SOAP format


POR SOAP Progress NotesPOR SOAP Progress Notes

Courtesy of and modified from Briggs, Des Moines, Iowa.


Preparing a Medical Record for a New Patient

Preparing a Medical Record for a New Patient

1. Method of preparation depends on:a. Format used to organize recordb. Filing systemc. Type of storage equipment


Preparing a Medical Record for a New Patient, cont.

Preparing a Medical Record for a New Patient, cont.

2. Most medical offices use:a. Source-oriented formatb. Alphabetic filing systemc. Shelf filing units


Medical Record SuppliesMedical Record Supplies

1. File Folder: protective cover that holds medical documentsa. Metal fasteners: often used to hold

documents in folder


Medical Record Supplies, cont.Medical Record Supplies, cont.

b. Tab: projection extending from a folder• Identifies contents• Located on side or top• Full cut tab: tab extending across entire side

or top– Full cut side tab: often used in medical

office• Indentions on full cut tabs: indicate placement

of labels– Ensures that labels on every record is

affixed at same place


Medical Record Supplies, cont. Medical Record Supplies, cont.

2. Folder labels: identifies the medical recorda. Most common types used:

• Name labels• Alphabetic color-coded labels• Color-coded year labels


Affixing labels to the chartAffixing labels to the chart


Medical Record Supplies, cont. Medical Record Supplies, cont.

3. Chart Dividers: identifies each section of medical record by subjecta. Color-coded tab

with subject title attached


Taking a Health HistoryTaking a Health History

1. A collection of data obtained by interviewing a patient and/or having patient complete a preprinted form

a. Reviewed for completeness by MA2. Thorough history taken on a new

patient3. Subsequent visits: information is

obtained regarding changes in the patient’s illness or treatment (progress notes)


Taking a Health History, cont.Taking a Health History, cont.

4. Quiet, comfortable room encourages patient to communicate

5. Showing interest and concern reduces patient apprehensiona. Facilitates collection of data


Components of the Health History

Components of the Health History

1. Health history is taken before the physical examinationa. Provides physician opportunity to

compare findings

2. Identification data: basic patient dataa. Completed by patient


Components of the Health History, cont.


3. Chief Complaint (CC):a. Patient’s reason for seeking care

• Symptom causing the patient the most trouble

b. Foundation for present illness and review of systems

c. MA usually responsible for obtaining and recording CC

d. Recorded on a preprinted lined form




e. Guidelines for obtaining and recording CC:• Use open-ended questions

– Example: What seems to be the problem? • Limit CC to one or two symptoms

– Should refer to a specific rather than a vague symptom

• Record CC concisely and briefly in patient’s own words as much as possible

• Include duration of symptom• Do not use names of diseases or diagnostic

terms




f. Examples:• Correct: Burning during urination that has

lasted for 2 days.• Incorrect: Ear pain and fever. (Duration of

symptom is not listed)




4. Present Illness (PI)a. Expansion of CCb. Full description of patient’s current illnessc. MA often completes; asks patient

questionsd. Recorded on same form as CCe. MA asks patient questions

• To obtain a detailed description of the CC

f. Requires skill and practice in asking proper questions




5. Past Historya. Past medical status of patientb. Assists physician in providing optimal

carec. Patient completes this section; checklist

form• MA should assist if needed




d. Includes:

• Major illness• Childhood diseases• Unusual infections

• Accidents and injuries

• Hospitalizations and operations

• Previous medical tests• Immunizations• Allergies• Current medications


Past HistoryPast History




6. Family Historya. Review of health status of patient’s blood

relativesb. Focuses on familial diseases

• Familial disease: a disease that occurs in blood relatives more frequently than would be expected by chance




-Examples:(1) Hypertension(2) Heart disease(3) Allergies(4) Diabetes mellitus




• Patient completes this section• Includes following info on each blood relative

– State of health– Presence of any significant disease– If deceased: cause of death


Family HistoryFamily History




7. Social Historya. Information on patient’s lifestyle: Health

habits and living environmentb. Purpose: Lifestyle may have impact on

patient’s condition c. If a major lifestyle adjustment is

necessary (e.g., smoking cessation)• Support services may be recommended

d. Completed by patient




e. Includes:• Education• Occupation (past and present)• Living environment• Diet




e. Includes, cont.:• Personal history• Exercise• Sleep patterns• Use of tobacco, alcohol, drugs• Travel to foreign countries


Social HistorySocial History




8. Review of Systems (ROS)a. Systematic review of each body systemb. Purpose: detect any symptoms that have

not yet been revealedc. Physician completes this section

• Asks a series of detailed and direct questions related to each body system

d. Assists physician in determining type and extent of physical examination required


Review of SystemsReview of Systems


Charting in the Medical RecordCharting in the Medical Record

1. Charting: The process of making written entries about a patient in the medical recorda. Performed by personnel directly involved

with health care of patient

2. Legal document: Important to chart information completely and accurately


Charting in the Medical Record, cont.


1. Check name on chart before making an entrya. If document in wrong chart

• Procedure may be excluded from correct patient’s record

• From a legal standpoint: A procedure not documented was not performed

Charting Guidelines




2. Use black inka. Provides permanent recordb. Easier to reproduce (e.g., information

needed by insurance company, patient referral)

3. Write legibly




4. Chart information accurately using clear and concise phrases as follows:a. Be brief but completeb. Avoid vagueness and duplication of

informationc. Do not need to include patient’s name in

entry• Entire record centers on one patient• Assumed that info refers to that patient




d. Begin each phrase with a capital letter and end with period

e. Begin each new entry on a separate linef. Include date and time on all entriesg. Use standard abbreviations, medical

terms, and symbols:• Save time and space• First check office policy for terms used in

office

h. Spell correctly• Use dictionary if necessary




5. Chart immediately after performing a procedurea. If delay: may not remember certain aspects of

procedureb. Never chart in advancec. Individual performing procedure should be the one

to chart it• Do not chart for someone else

6. Each entry should be signed by person making ita. Include first initial, full last name, and credentials




7. Never erase or obliterate an entrya. Reduces credibility if involved in litigationb. To correct an error:

• Draw a single line through incorrect information

• Write the word error above incorrect data• Include date, first initial, last name, and

credentials• Insert correct information next to error


Correcting a charting errorCorrecting a charting error


Charting Progress NotesCharting Progress Notes

1. Updates medical record with new information each time patient visits office

2. Documents patient’s health status, care, and treatment

3. Provides communication among office personnel

4. Serves as legal document5. Preprinted lined sheets used: known as

progress note sheets


Charting Patient SymptomsCharting Patient Symptoms

1. Symptom: Any change in the body or its functioning that indicates the presence of diseasea. Subjective symptom: A symptom that is

felt by the patient and cannot be observed by another person (pain, pruritus, vertigo, nausea)

b. Objective symptom: A symptom that can be observed by another person (rash, coughing, cyanosis)


Charting Patient Symptoms, cont.

Charting Patient Symptoms, cont.

2. Taking patient symptoms consists of:a. Obtaining chief complaintb. Obtaining additional information about CC


Other Activities That MustBe Charted

Other Activities That MustBe Charted

1. Proceduresa. MA frequently charts procedures

performed on the patient (e.g., vital signs)

b. Include: Date, time, type of procedure, outcome, patient reaction


Other Activities That MustBe Charted, cont.


2. Administration of Medicationa. Important responsibilityb. Include: Date, time, name of medication,

dosage given, route of administration, injection site, any significant observations or patient reactions


Administration of MedicationAdministration of Medication




3. Specimen Collectiona. Include: Date, time of collection, type of

specimen, area of body where specimen was obtained

b. If specimen sent to outside laboratory: chart test(s) requested, date specimen sent, where sent• Provides data if test results are not back yet


Specimen CollectionSpecimen Collection




4. Diagnostic Procedures and Laboratory Testsa. Include: Date, time, type of

procedure/test(s) ordered, scheduling date, where procedure/test(s) being performed

b. Purpose of charting:• If patient does not undergo test ordered:

documented proof exists that test was ordered• Refreshes physician’s memory that tests were

ordered (if results not yet back from laboratory)


Diagnostic Procedure and Laboratory Test

Diagnostic Procedure and Laboratory Test




5. Results of Laboratory Testsa. STAT tests or critical findings may be

telephoned• Must record results on a report form

b. Laboratory tests performed in office must be charted• Include: date, time, name of test, and test

results


Test Results Test Results




6. Patient Instructionsa. May need to relay instructions to patient

regarding medical care (e.g., wound care)b. Important to chart this information: date,

time, and type of instructions relayed to patient




c. Preprinted instruction sheet may be used:• Patient signs form to indicate has

read/understands instructions• MA witnesses the signature • Filed in chart; copy given to patient• Legally protects physician: If patient does not

follow instructions and causes harm to a body part


Patient Instruction SheetPatient Instruction Sheet


Patient InstructionsPatient Instructions




7. Other areas of chartinga. Missed or canceled appointmentsb. Telephone calls from patientsc. Medication refillsd. Changes in medication dosage by

physician


Telephone Call and Missed Appointment

Telephone Call and Missed Appointment


POSTTESTPOSTTEST

1. The purpose of HIPAA is to provide patients with more control over the use and disclosure of their health information.

2. The health history provides subjective data about a patient to assist the physician in arriving at a diagnosis.

3. Physical therapy helps a patient with a disability learn new skills to perform the activities of daily living.

4. A copy of the patient’s emergency room report is sent to the patient’s family physician.

5. When a medical assistant witnesses a patient’s signature on a form, it means that the medical assistant is verifying that the patient understands the information on the form.

True or False


POSTTEST, CONT.POSTTEST, CONT.

6. SOAP is the acronym for the format used to organize POR progress notes.

7. The chief complaint is the symptom causing the patient the most trouble.

8. The purpose of progress notes is to update the medical record with new information.

9. The patient’s name must be included at the beginning of each entry charted in the patient’s medical record.

10. A decrease in the amount of water in the body is known as edema.

True or False