________ serves the dual purpose of providing a brief, short summary of the patient’s illnesses and acts as a tool for organizing the routine of documentation
problem list
The Problem oriented medical record (POMR) has four parts:
- Database
- problem list
initial plan - progress notes
The first step in establishment of a problem oriented record is what
Database
the oriented health record database should include _____ as expressed by the patient
chief complaint
What should be all included in the database
Patient profile includes a history of the present illness past medical history family medical history a systems review and results of a physical examination
Once the database has been collected, an assessment of the information is made and a _________ is developed
problem list
T/F
the problem list is kept in the back of the record within the SPOAP note
False —– front
The function of a problem list is to
register all problems
maintain efficiency, thoroughness, and reliability in treating the “whole” patient
communicate with peers, patients, other health professionals and with oneself
indicate the status of problems, whether active, inactive or resolved
serve as a guide for patient care
The development of the initial plan for the management of a patient’s problems, as defined in the problem list, is the ___step in planning patient care using a problem oriented health record
third
What is the fourth step in the POMR formation
Progress notes
what does SOAP note stand for
subjective
objective
Assessment
plan
the process note must be problem – oriented and _____
functional
what does SNOCAMP stand for
subjective nature of the presenting problem counseling and coordination of care medical decision making plan
the final step in completing any medical record is the preparation of a ________
discharge summary
Forms are used
Forms are used to collect, record, transmit, store and retrieve data
That is, they request action, record the outcome of the action, instruct and assist with the evaluation of data
Forms may also be designed to accompany legislation
The medicolwegal aspect states that as a legal document, the health record should sufficient information to:
- identify the patient
- support DX
- justify tx
- accurately document results
confidentiality must be maintained unless:
- release is authorized by patient
- compelled by law ( subpoena, worker’s comp)
What is the average length of retention for medical health records
most states5- 15 years
GA is 10
If a request is made for the release of information, the HIPAA compliant authorization should contain the following:
Patient identification information (name, address, DOB, social security number)
Name of person/persons or institution to receive information
Name of person/persons or institution to make the disclosure
A clear description of the information to be used/disclosed & related dates.
Statement informing the patient of his right to revoke the authorization, how to revoke it, and any exceptions.
If a request is made for the release of information, the HIPAA compliant authorization should contain the following
Statement that the information disclosed may be subject to re-disclosure by the recipient & no longer covered by the HIPAA Privacy Act.
Statement that the authorization will expire 1) on a certain date, 2) after a specific amount of time, or 3) upon the occurrence of some event related to the patient.
Date and signature of the individual authorizing the release
or
Date and signature of the individual’s authorized representative
what does NCQA stand for
national committee for Quality Assurance
what are important things to keep in mind when writing a documentation
make sure it has
brevity
clarity
accuracy
Past Medical History or PMH should include the following for the initial note :
- presented in outline form
- include all medical problems (active or inactive) that weren’t responsible for the hospitalization or clinic visit
- outline the problems from the most recent to the most remote
- dx (historical) belong here in PMH ( symptoms belong in the review of systems (ROS)
-ask for past/ of same or similar problems - under current care of any other healthcare provider
-medications
-past surgeries - ## trauma
Family History should be presented as:
- outline form
- causes of death os family members
- list major illness of family members ( if initial or annual exam have 3 generations of family member documented)
Social history should be documented as:
- narrative form
- upbringing/education
- cultural/ ethnic background
- current life situation
- living situation
- relationships
diet and sleep pattens
For Occupational history try to identify what
if there is a relationship between the current complaint and occupation
Review of Systems should be presented as:
presented in outline form
ROS appropriate to CC and for ruling out differentials
remember that diagnoses belong in the PMH and symptoms belong here in the ROS
if the patient relates any positive responses in the ROS you must explore the details
discuss all systems not already discussed in the HPI
pertinent positive and negative symptoms dealing with the present illness belong in the HPI, not the ROS
When correcting errors it is recommended to use the ___ method
SLIDE SL-single line I- initials D- date E- entry
the five components of HIPPA
- Electronic Transaction and Code Sets
- Privacy
- Security
- Enforcement
- National Provider Identi er (NPI)
who is HIPPA affected by?
- providers
- health plans
- health clearing houses
- business parters
what are the conditions that you must follow in order not to be HIPPA covered
-Keep records in your o ce on paper. Information in computers must only be out- put to paper and then mailed. No “Protected Health Information” (PHI) may be transmitted electronically to or from your o ce.
■ Do not use a billing service, clearinghouse or other third party to conduct electronic transactions such as submitting electronic claims for you.
■ Do not become a HIPAA Entity by function, contract, agreement, or certi cation.
■ Have no contracts or business agreements that require HIPAA compliance. Many health plans are now including a requirement for electronic claim submission in their agreements. Read your contract renewals carefully.
■ Do not use any internet applications, direct data entry, or point of service application containing PHI from your computer.
■ Do not fax PHI transactions from your computer (conventional, free-standing fax machines may be used).
■ Your practice is not located in a state that requires all claims to be be electronically submitted.
what the 5 components for to HIPPA covered
- electronic transaction
- privacy
- security
- enforcement
- national identifier