The medical record is one of, if not THE, most important documents within the delivery of healthcare services.It is what tracks the course of a patients care. It allows medical providers to review a patients medical history as well as plan a course of care for the future.
It is a communication tool that not only provides clinical data regarding a patient’s current and past medical history, but is also used in the reviewing and reimbursement of insurance claims, and to review utilization and quality of care.
The Contents of a Medical Record
* Face sheets, encounters for each visit
* Vital Signs
* Physician’s orders
* History and Physical forms
* List of Medical Problems
* Medication Lists
* Progress Notes
* Discharge Summary
* Authorization Forms
* Diagnostic Testing
* Laboratory Testing
* Operative Reports
* Pathology Reports
Documentation is the most critical function regarding keeping accurate medical records, as it records all of the important details and facts regarding a patient’s care.
is legal documentation
includes a patient’s medical history
chronologically documents a patient’s care
allows physicians to plan and evaluate a patient’s care
provides continuity in care
allows all physicians involved in a patient’s care to communicate with each other
provides evidence of care provided in legal cases
assists in claims review and reimbursement
assists in meeting accreditation requirements
Centers for Medicare and Medicaid Services (CMS) regulations regarding documentation
Documentation MUST include:
evidence of a physical examination performed no more than seven days prior to admission or within 48
hours of admission
results from patient consultations and the findings from such evaluations
all orders, progress notes, medication records, radiology procedures and results, laboratory results,
and vital signs
the admitting diagnosis
a patient’s medical complications
any relevant risk factors
information that reflects the CPT/ICD-9 codes that were submitted to the patient’s insurance
consent forms signed by the patient
the discharge summary which summarizes the outcome of the admission, disposition of care, and
plans regarding follow up care
The S.O.A.P. Model
Subjective information includes information given directly by the patient, such as how they are feeling, their opinions on their care, and why they made the appointment. It represents the patient’s point of view of their condition.
Objective information represents the physician’s point of view. It includes information that was observed and measured by the physician during an examination or test.
The assessment identifies the main diagnosis that is specific to the visit, and includes the physician’s interpretation of that condition. When a patient has multiple diagnoses, a physician will dictate their assessment based on the patient’s complaint that particular day.
The “Plan” segment is when a physician makes a plan of action for a diagnosis, usually the condition specific to the visit of that day.
Challenges within Documentation
Every organization should ensure that each page within the medical record contains the patient’s name or identification number (the patients first and last name, first initial and last name, social security number, or … Read More »