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AMA Chapter 11
Medical Record Management
Terms in this set (10)
What does EDP stand for?
Electronic Data Processing
What four types of patient information must be included in medical records?
Personal information, financial information, medical information, and social information.
What kind of social information is included in medical records?
Any personal information on the patient, such as race and ethnic city, hobbies, and regular support participation. This may also include lifestyle choices such as smoking, alcohol consumption, drug use, and sexual habits.
What is the purpose of the medical record?
A medical record documents a patient's treatment plan and goals, whether the record is in paper or electronica. It must contain a full amount of patient treatment including what treatment was given and why it was given, or if treatment was withheld and why. These records must be complete, accurate, organized, concise, timely, and factual. They should never contain opinions or judgments about patients.
What is the five C's rule when medical charting?
Concise-to the point in continuing no entries that feels to relate to the patient's health care in someway, Complete-complete and objective to all pertinent information must be included well opinions and judgments are excluded, Clear-handwriting should be printed, not written in cursive, and delivered in clear, easy to read manner, Correct-Medical records must be air free both improper additions and omissions (when errors are made they must be corrected as soon as possible), Chronologic-medical records should be in chronological order with the latest entries on top.
Define SOAP charting?
A method that tracks the subjective, objective, assessment, and plan for a patient's visit.
What is the acronym CHEDDAR for personal to follow in charting patient information?
Chief complaint-this is the main reason for the patient currently seeking care, history of the patient's illness-pertains to any of the history the patient has with the chief complaint, examination findings by the physician, details of any further problems or complaints the patient might be experiencing, drugs and dosages the patient might be on to include both prescription medications and those purchased over the counter, assessment of the patient to include diagnosis made by the physician, and return visit information regarding the physicians advice for follow up care.
What is a flow chart and give an example.
A flow chart is visual tools that help track certain information and patient's medical records. For an example the growth of a child.
Why is it important to be very careful when using abbreviations in patient's charts?
Different facilities may use different abbreviations for medical terms therefore they must ensure that the abbreviations are excepted by their facilities. Confusion among abbreviations can be avoided with a standard list of abbreviations between facilities.
How must errors in medical charts be covered?
Errors in medical charts should never be scribbled out or covered with correction fluid because records such as effects are viewed as an attempt to hide the truth or cover wrongdoing. Therefore one line should be drawn through an incorrect entry.
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