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RTH 120 Review of the Medical Record - Ch. 3

Terms in this set (24)

what are medical records?
they provide a standardized method of recording and collating information pertinent to the care and treatment of the hospitalized patient
medical chart organization function will always include:
-serving as a database clinicians can access for data collection and review
-*providing a legal record of all care and services provided
-*providing clear documentation of diagnosis and care provided for reimbursement
-*establishing a central location for interdisciplinary communication and documentation to monitor and improve patient outcomes
if something is not recorded in the medical record, then ___________.
it did not happen
what are the four basic criteria that must be met for the medical record to be deemed admissible as evidence?
-documented in the normal course of providing care
-kept in the regular course of business
-made at or near the time of the matter recorded
-made by a person was in the hospital or health Care agency with knowledge of the acts, events, conditions, opinions, or diagnoses record
what are some components of the medical record?
-patient information / admissions sheet
-physician's orders
-reports of history and physical examinations
-laboratory study results
-imaging reports
-respiratory therapy notes
-reports of procedures and operations
what types of medical records are there?
-EMR (electronical medical record)
-EHR (electronical health-record)
*what is the difference between an EMR and EHR?
-EMR is within one healthcare organization
-EHR is with more than one healthcare organization
what is a benefit of the EMR?
provides a centralized electronic chart that is accessible at multiple workstations, and enhance has accessing clinical efficiency
what is the benefit of the EHR?
they have the potential to improve patient care and safety
what are some advantages and disadvantages of the EMR?
Advantages: facilitates effective quality assurance, produced a legible record, accessible by multiple people at the same time, reduce the number of lost records
Disadvantages: it has an initial high cost, power failures, large training investment, software glitches
in the acronym of SOAP IER was added,what do they stand for?
*I - Intervention: the specific interventions that have actually been performed by the caregiver
*E - Evaluation: patient responses to interventions and medical treatments
*R - Revision: care plan modifications suggested by the evaluation. changes may target revised outcomes, interventions, or target dates.
Review of the medical record, better known as "chart review," is:
*the first step in development of a comprehensive respiratory care plan
*Orders for the following types of medications should be noted:
-antimicrobials (antibiotics or antiviral or antifungal agents)
-Respiratory Care medications (bronchodilators inhaled corticosteroids and other end to asthma medications, etc.)
-cardiac/cardiovascular agents (vasopressors, and inotropic agents, anti-arrhythmic agents, diuretics, etc.)
-sedative, hypnotic, narcotics, and pain medications (opioids actors set it is and made depressed ventilation)
-systemic steroids (cortisone, hydrocortisone, prednisone, etc.)
-neuromuscular blocking agents (these are sometimes used during surgical procedures to paralyze a patient while providing ventilation via and anesthesia ventilator)
-airway medication instillations (medications that may be instilled directly into the airway include epinephrine, lidocaine, and cold saline)
-reversal agents (number of agents are used to reverse the effects of another drug- narcan)
*when noting intravenous (IV) fluid administration what should be included?
the solution to be used, rate of infusion, and any medications or electrolytes that may be included
*Respiratory Care orders that should be reviewed include orders for:
-oxygen therapy
-respiratory therapy
-diagnostic studies
-Respiratory Care and procedures
-mechanical ventilatory support
what are some examples of typical physician's orders for Respiratory Care?
-oxygen therapy: should specify the device and liter flow and/or desired fio2
-treatments: bronchodilator via metered dose inhaler to treat asthma exacerbation in the emergency department
-Respiratory Care procedures: tracheostomy care
*what can give the respiratory care clinician an idea of what diagnoses have been considered by the admitting physician?
orders for certain laboratory and imaging tests and procedures
what is a DNR order (do not resuscitate)?
a form of advance directive in which the patient or family indicates in advance that her or she does not wish to receive CPR and advanced life support in the event of a cardiac or respiratory arrest
*what type of progress notes should you review in the medical record?
-pulmonary, cardiology, or other consultation reports
-progress reports by nurses, physicians, physician assistants, respiratory therapists
-reports of operations or special procedures, such as broncoscopies, thoracentesis, or lung biopsy
under the patient education section of a medical record what should be recorded?
*education provided to the patient
*With charting the clinician makes a flammatory judgment, based on the information that is in the medical record or chart. The clinician should ask:
-is the ordered therapy indicated and appropriate?
-could another form of therapy be more effective?
-how should the therapy be assessed?
Failure to chart information related to the care of the patient may result in:
duplicate procedures, interventions, and/or therapy
what are some rules for charting that should be followed by the clinician?
-note the time, effects, and results of all treatments and procedures
-note any patient complaints or adverse reactions
-chart accurately
-avoid criticism
what are some rules for electronic charting?
-document in real time
-document only services performed
-avoid charting by exception
-do not delete unwanted entries without documentation
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