Lecture 2: Documentation

Question 1

What is the purpose and definition of medical record?

Answer 1

• Purpose: Communication & Information
• Definition: A repository of information compiled by many individuals regarding a single patient.

Question 2

Who does the medical record serve?

Answer 2

• The Patient
• Health professionals involved in the patient’s care
• Supervisors & Administrators
• Clinical investigators/researchers
• May be used in legal proceedings

Question 3

• Performing a procedure without documenting it in the clinical note can result in what?
• Undocumented procedures cannot be what?
• What is Medicolegal

Answer 3

• Performing a procedure without documenting it in the clinical note can result in loss of critical information affecting patient care
• Undocumented procedures cannot be reimbursed
• Medicolegal – if it is not documented it never happened

Question 4

What is the HIPAA privacy rule?

Answer 4

The Privacy Rule standards address the use and disclosure of individuals’ health information (known asprotected health informationorPHI) by entities subject to the Privacy Rule.

These individuals and organizations are called “covered entities.”

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Question 5

What are the procedure note guidelines?

Answer 5

Question 6

What are the procedure Documentation Purposes

Answer 6

• Communication Device
• Memory Aid
• Quality Assurance Instrument
• Risk Reduction Aid
• Reimbursement Aid
• Evaluation Tool
• Research Tool

Question 7

How is documentation a communication device?

Answer 7

Communication about the procedure performed and its findings to other members on the patient’s healthcare team.

Question 8

How is documentation a memory aid?

Answer 8

Serves as a method of recording patient medical condition information that may be forgotten

Question 9

How is documentation a quality assurance instrument?

Answer 9

Monitoring of the quality of care
* Involves medical record review by peers.

Question 10

How is documentation a risk reduction aid?

Answer 10

Medical record serves as a legal document that may be used in court as evidence.

Question 11

How is documentation a reimbursement aid?

Answer 11

The medical record is used to verify that the procedure performed was indicated and performed appropriately

Question 12

How is documentation a evaluation tool?

Answer 12

• Student documentation evaluation reviewed by supervising faculty
• Employee documentation reviewed by supervisors or orientation staff

Question 13

How is documentation a research tool?

Answer 13

The Medical Record
* A data source for clinical research

Question 14

In patient’s chart, what do you need to record, be what and consider using what?

Answer 14

Record all the Pertinent Data
* pertinent positives & pertinent negatives

Be Objective

Consider the use of Diagrams

Question 15

For a patient’s note what do you need to avoid using? What do you need to make sure? Consider using what?

Answer 15

• Avoid the use of nonstandard Abbreviations-> The Joint Commission Official “Do Not Use” List
• Make sure if the record is handwritten that it is legible
• Consider using digital Photographs

Question 16

What are the Electronic Versions of the Paper Healthcare Chart?

Answer 16

• EHR = Electronic Health Records
• EMR = Electronic Medical Records

Question 17

What are all the advantages of EHR?

Answer 17

• Providing accurate, up-to-date, and complete information about patients at the point of care.
• Enabling quick access to patient records for more coordinated, efficient care.
• Securely sharing electronic information with patients and other clinicians.
• Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care.
• Improving patient and provider interaction and communication, as well as health care convenience.
• Enabling safer, more reliable prescribing.
• Helping promote legible, complete documentation and accurate, streamlined coding and billing.
• Enhancing privacy and security of patient data.

Question 18

With EHRs, every provider can have the same accurate and up-to-date information about a patient. This is especially important with patients who are:

Answer 18

• Seeing multiple specialists
• Receiving treatment in emergency settings
• Making transitions between care settings
• Better availability of patient information can reduce medical errors and unnecessary tests.
• Better availability of information can also reduce the chance that one specialist will not know about an unrelated (but relevant) condition being managed by another specialist.
• Better care coordination can lead to better quality of care and improved patient outcomes.

Question 19

What are the challeges of EMR?

Answer 19

• HIPPA violations
• Some formats allow patients to see test results prior to meeting with a provider.
• Cybersecurity
• High Quality Documentation