Medical Records What are medical records Legal documents

What are medical records? § Legal documents § Management of patient care § Alert

Types/format § Inpatient: § § § § Hospital, rehabilitation facility, nursing home Admission demographics

Types/format § § § § Outpatient Physician’s practice Clinic History and physical Lab/radiological reports

Admission § § § § § Physician must authorize; RN has primary responsibility Assistive

Transfer § To another unit or hospital (discharge); usually dependent upon patient condition §

Discharge § Home, another hospital, extended care facility, funeral home § discharge assessment and

Summary § Medical records provide vital information about the patient over a period of

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Medical Records

What are medical records? § Legal documents § Management of patient care § Alert healthcare providers to changes in patient conditions § Provide clinical data for research § Documents belong to healthcare provider § Medical information belongs to patient § Governed by HIPAA guidelines § May be paper, electronic, or combination of both

Types/format § Inpatient: § § § § Hospital, rehabilitation facility, nursing home Admission demographics Admission assessment Physician’s orders History and physical Intake/output; vital signs Medication administration records Progress notes Multidisciplinary team notes Nurses notes/flow sheets Transfer forms Lab, radiological reports Billing information

Types/format § § § § Outpatient Physician’s practice Clinic History and physical Lab/radiological reports Physician’s orders Vitals signs flow sheet Physician’s progress notes

Admission § § § § § Physician must authorize; RN has primary responsibility Assistive personnel help as directed Identify patient Customer service important to patient and family; provide comfort and reassurance Admission assessment; specimen collection, document medications from home, equipment or prosthesis from home, valuables History and physical Physician’s orders Lab/radiological reports Physician and multidisciplinary team notes

Transfer § To another unit or hospital (discharge); usually dependent upon patient condition § transfer form including assessment § If patient to be transferred to another facility; pack all belongings. Document if belongings sent with patient or family member. § If patient transferred to another unit, pack belongings, may have to gather medications, take medical record; document that belongings and records sent with patient

Discharge § Home, another hospital, extended care facility, funeral home § discharge assessment and documentation § Disposition of belongings

Summary § Medical records provide vital information about the patient over a period of time § Follow facility policy and HIPAA guidelines re: access, storage, retrieval