Copyright 2007 by Thomson Delmar Learning ALL RIGHTS

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Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 1

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 1

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 2

Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 2

Definitions • Medical documentation • Medical record • Charting Copyright © 2007 by Thomson

Definitions • Medical documentation • Medical record • Charting Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 3

Purposes • • • Contributes to good patient care Provides legal protection Helps ensure

Purposes • • • Contributes to good patient care Provides legal protection Helps ensure regulatory compliance Improves cost control Decreases denials from insurance companies Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 4

Characteristics • • • Complete Concise and factual Properly identified Legible Correct spelling, terminology,

Characteristics • • • Complete Concise and factual Properly identified Legible Correct spelling, terminology, punctuation, and grammar Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 5

Characteristics • Clearly and objectively expressed • Do not duplicate findings • Use approved

Characteristics • Clearly and objectively expressed • Do not duplicate findings • Use approved abbreviations listed in facility’s policy • Time and date all entries Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 6

Characteristics • Signed by the proper person • Complete without leaving empty lines •

Characteristics • Signed by the proper person • Complete without leaving empty lines • Never chart in advance of giving medication or performing procedure • Written with black or blue ink Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 7

Making Corrections • • • Draw a single line through error Write in correct

Making Corrections • • • Draw a 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 Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 8

Medical Records • Organized per facility policy • All health care workers are responsible

Medical Records • Organized per facility policy • All health care workers are responsible to maintain the records per facility policy • Chronological or source oriented Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 9

Medical Records Contents • • • History and Physical (H&P) Physician’s orders Diagnostic tests

Medical Records Contents • • • History and Physical (H&P) Physician’s orders Diagnostic tests Admissions Surgical procedures Graphics Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 10

Medical Records Content • • Flow sheets Medications record Progress notes Reminder – Verify

Medical Records Content • • Flow sheets Medications record Progress notes Reminder – Verify correct form in chart by ensuring patient’s name is on each document Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 11

Medical Records Content • Each section will be chronological • Thinning a chart •

Medical Records Content • Each section will be chronological • Thinning a chart • Security of files Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 12

Progress Notes • Primary tool – Recording, communicating, and coordinating care of patient •

Progress Notes • Primary tool – Recording, communicating, and coordinating care of patient • May include: – Observations – Treatments – Patient response Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 13

Progress Notes—Formats • • Problem-oriented charting Narrative charting Charting by exception Computerized Copyright ©

Progress Notes—Formats • • Problem-oriented charting Narrative charting Charting by exception Computerized Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 14