Chapter 2 Health Records PDF

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Chapter 2 notes for Bruce Hanik...

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2.1 The SOAP Method Providers employ a logical approach to solving medical problems. The pattern is presented as a picu. SOAP is an acronym that stands for the four general parts of a medical note: Subjective, Objective, Assessment, and Plan Diagnostic work in medicine is similar to the investigative work of a detective. S: the first part of the note is the subjective part. It is subject to how a patient experiences and personally describes his or her problem as well as personal and family medical histories. It is the problem in the patient’s own words. It includes the duration of the problem, the quality of the problem, and any exacerbating or relieving factors for that problem. PATIENT DESCRIPTION O: the next step is collecting objective data. This comprises the patient’s physical exam, any lab findings, and imaging studies performed at the visit. TEST A: Upon gathering info, the doctor formulates a local analysis. This is known as the assessment. This could be a diagnosis, an identification of a problem, or a list of possibilities for a diagnosis (differential diagnosis). DIAGNOSIS OR IDENTIFICATION P: the provider then forms a plan, or a course of action consistent with his or her assessment. This could be a treatment with medicine or a procedure. It could also consist of collecting further data for a more accurate diagnosis. A SOLUTION SOAP process is repeated in every health care visit across all disciplines of medicine. Healthcare records reflect this thought process. 2.2 Common terms in medicine

Subjective section of a health record tells the patient’s personal story of the health issue. It includes things such as: ● The main reason for a health visit ● The description of his or her problem ● The timing of the problem ● Previous medical problems or surgeries ● Family health problems that might relate ● Current medications and allergies You may include when the problem began, the severity, any associated problems, and whether anything seems to make the problem better or worse. General subjective terms term

definition

Acute ah-KYOOT

It just started recently or is a sharp, severe symptom

Chronic KRAH-nik

It has been going on for a while now

Exacerbation ek-SAS-er-BAY-shun

It is getting worse

Abrupt ah-BRUPT

All of a sudden

Febrile FEH-brail

To have a fever

Afebrile AY-FEH-brail

To not have a fever

Malaise mah-LAYZ

Not feeling well

Progressive proh-GREH-siv

More and more each day

Symptom SIM-tom

Something a patient feels

Noncontributory NON-kon-TRIB-yoo-TOH-ree

Not related to this specific problem

Lethargic lah-THAR-jik

A decrease level of consciousness; in a medical record, this is generally an indication that a patient is really sick

genetic/ hereditary jih-NEH-tik, hah-REH-dih-TEH-ree

It runs in the family

Objective part of a health record tells about the data collected during a health care provider’s interaction with the patient. General objective terms term

definition

alert

Able to answer questions; responsive; interactive

oriented

Being aware of who he or she is, where they are, and the current time; a patient who is aware of all three is “oriented x3”

marked

It really stands out

unremarkable

Basically normal

Auscultation

To listen

percussion

To hit something and listen to the resulting sound of feel for the vibration; drums are a percussion instrument

palpation

To feel

Assessment: put everything together and reach a conclusion on the nature of the problem. This is known as diagnosis. Also known as “differential diagnosis” term

definition

impression

Another way of saying impression

diagnosis

What the health care professional thinks the patient has

Differential diagnosis

A list of conditions the patient may have based on the symptoms exhibited and the results of the exam

benign

safe

malignant

Dangerous; a problem

degeneration

To be getting worse

etiology

The cause

remission

To get better or improve; most often used when discussing cancer; remission does not mean cure

idiopathic

No known specific cause; it just happens

localized

Stays in a certain part of the body

systemic/ generalized

All over the body (or most of it)

morbidity

The risk for being sick

mortality

The risk for dying

prognosis

The chances for things getting better or worse

occult

hidden

pathogen

The organism that causes the problem

lesion

Diseased tissue

recurrent

To have again

sequelae

A problem resulting from a disease or injury

Pending

Waiting for

Plan: lays out what the provider recommends to do about the patient’s current health status. term

definition

disposition

What happened to the patient at the end of the visit; often used at the end of ED notes to reference where the patient went after the visit (home, ICU, hospital bed)

discharge

Literally, to unload. 2 meanings: 1. To send home, 2. Fluid coming out of a part of the body

prophylaxis

Preventive treatment

palliative

Treating the symptoms but not actually getting rid of the cause

observation

Watch, keep an eye on

reassurance

To tell the patient that the problem is not serious or dangerous

Supportive care

To treat the symptoms and make the patient feel better

sterile

Clean, germ free conditions; esp important during medical procedures and surgery

Body planes and orientation Often, the words used to describe directions in the body are opposites. It is important to note when describing the directions on the human body, we use the anatomic position. This position is a person standing facing forward, arms at the side with palms forward. Opposites term

definition

proximal

Closer in to the center… close

distal

Farther away from the center… far

lateral

Out to the side

medial

Toward the middle

anterior/ ventral/ antral

The front (ventral means stomach)

dorsal/ posterior

The back

cranial

Toward the top

Caudal

Toward the bottom

superior

above

inferior

below

prone

Lying down on belly

supine

Lying down on back

contralateral

Opposite side

ipsilateral

Same side

unilateral

One side

bilateral

Both sides

dorsum

The top of the hand or foot

plantar

The sole of the foot

palmar

The palm of the hand

Another way of looking at the body is through the three dimensions: right to left (sagittal), front to back (coronal) and top to bottom (transverse). A CT scan is a series of layered images along one of these dimensions. Sagittal - right to left Coronal - front to back Transverse - top to bottom Body planes term

definition

sagittal

Divides the body in slices right to left

coronal

Divides the body into slices from front to back

transverse

The body from top to bottom

Health professionals term

definition

physician

A skilled health care provider who attended and graduated medical school (MD and DO)

pediatrician

A physician with special training in caring for children

surgeon

A physician qualified to treat patients surgically, that is, by operation or invasive procedure

anesthesiologist

A physician with special training in pain sedation and pain control

Physician assistant (PA)

A midlevel health care provider who works under a license of a supervising physician; requires less postgraduate training

Nurse practitioner (NP)

A nurse with a post graduate training that serves as midlevel health care provider who works under a license of a supervising physician

Emergency medical technician (EMT)

Specially trained in the emergency care of a patient before and/or during transport to a medical facility

Speech therapist

Specially trained in evaluating and treating problems with speech and/or swallowing

Occupational therapist

Specially trained in evaluating and treating problems with performing daily activities at home, school, or work

Physical therapist

Specially trained in evaluating and treating physical impairments including disabilities or

recovery from an injury Respiratory therapist

Specially trained in treating patients respiratory issues under the guidance of a health care provider

dietician

Specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan

Licensed practical nurse (LPN)/ licensed vocational nurse (LVN)

Trained and certified to provide basic care to a patient

Registered nurse (RN)

An advanced level nurse who has completed an associate's or bachelor’s degree; often assists with patient care planning and patient education.

Medical assistant

Trained to carry out basic administrative and clinical tasks under the guidance of a health care provider

pathologist

A physician with special training in both evaluating the causes and effects of disease in lab medicine

Medical laboratory technician

Trained in performing lab testing on bodily fluids

phlebotomist

Trained in the removal of blood from the body for diagnostic or therapeutic purposes

radiologist

A physician specially trained in evaluating images of the body to diagnose illness or injury

Radiology technician

Trained to perform radiologic testing or administer radiation therapy under the direction of a health care provider

ultrasonographer

Trained in performing ultrasound imaging on a patient

pharmacist

Trained and licensed in preparing and dispensing medicine

Pharmacy technician

Trained to assist a pharmacist with pharmacyrelated tasks

Patient service coordinator

Handles administrative tasks and coordinates patient care

Medical transcriptionist

Trained in converting the voice-recorded dictations of health care providers into text format.

2.3 Types of health records Medical records are routinely scoured to find specific information. Subheadings can serve as helpful guideposts. Subjective: blue Objective: red Assessment: yellow Plan: green (Note: Sometimes assessment and plan run together; these instances appear in light green.) Dictated, written electronically or handwritten

Sections of a health record

description

Chief complaint

The main reason for the patient’s visit

History of present illness

The story of the patient’s problem

Review of systems

Description of individual body systems in order to discover any symptoms not directly related to the main problem

Past medical history

Other significant past illnesses

Family history

Any significant illnesses that run in the patient’s family

Social history

A record of habits like smoking, drinking, drug abuse, and sexual practices that can impact health

Anytime a patient is seen in an office setting, a professional must document the visit. These notes always follow the SOAP method. Summary of health record notes

Clinic note

author

location

purpose

Format and order

Unique features

Medical professional

clinic

Documents a visit

SOAP

New patient: includes more history,

separate form Repeat patient: streamlined note Consult note

Physician; usually a specialist

Clinic or hospital

Provides an expert opinion on a more challenging problem

SOAP

Can be in the form of a letter to the PCP

Emergency department note

ED medical staff

Emergency department

Documents an emergency department visit

SOAP

The A includes the emergency department course

Admission summary

Hospital medical professional

hospital

Documents SOA/P the admission of a patient to the hospital

S, O= Very thorough A= differential diagnosis P= further testing and care A+P= problembased approach

Discharge summary

Medical profession

hospital

Describes when and why the patient was admitted; the note will lead with the diagnosis; documents a longer stay

ASOP

Starts with A

Operative report

surgeon

Documents a surgery in deta

ASOP

Daily Report hospital note/ progress

Medical professional

Documents daily hospital visit

SOA/P

Inpatient health care facility

S: focuses on how patient’s condition has changed

since the previous note A: sometimes includes a differential diagnosis Radiology report

Radiologist

Explains reason for image, how image was performed, what was seen on image, radiologist’s assessment; sometimes a recommendat ion

SOA

Pathology report

pathologist

Provides reasons for what was seen on the test, and an assessment

SOA

Prescription

Medical professional

Provides directions for medication

P

Consult Note - Sometimes written in a letter to primary care giver Emergency Department Note - New patient

Usually includes only SOA, but may include P if it recommends that further studies should be performed

1 Medicine’s name 2 Instructions for patient 3 How much medicine should be given 4 Refills, if any 5 Health care professional’s signature and whether generic substitution is allowed

-

One unique part of these notes is the emergency department (ED) course, which explains what happened to the patient during his or her stay in the ED. The ED course is a mixture of any completed diagnostic tests, the patient assessment, and a plan for the patient that unfolds over time. Admission Summary - Detailed admission summaries are usually thorough notes that are very heavy on the subjective and objective parts - Sent to Primary care giver sometimes, less detailed though Discharge Summary - Often, the note will lead with the diagnoses—both the initial and also the final—because medical professionals want the most important information to come first. Radiology Report - A radiology report note explains the reason for ordering a radiologic image, how the image was performed, what was seen on the image, and the reviewing radiologist’s assessment. Pathology Report - A pathology report note mirrors the same style as the radiology note. This note mentions the reason for the study, what was seen in detail, and the assessment. The first line is for the name and strength of the medicine. The Second line of the presecription, the part that provides the patients instructions is the sig. The third line of the prescription, the part that tells the pharmacist how much medication to give the patient is the dispense. The fourth line mentions how many refills are available for the prescription. The last line is the health care providers signature.

2.4 Abbreviations Abbreviations associated with health care facilities abbreviation

definition

CCU

Coronary care unit

ECU

Emergency care unit

ER

Emergency room

ICU

Intensive care unit

PICU

Pediatric intensive care unit

NICU

Neonatal intensive care unit

SICU

Surgical intensive care unit

PACU

Post-anesthesia care unit

L&D

Labor and delivery

OR

Operating room

post-op

After surgery

pre-op

Before surgery

Abbreviations associated with patient care Found on patient charts and other health records Symbols abbreviation

definition

♂

male

♀

female

(R)

right

(L)

left

(B)

Bilateral or both sides

↑

increased

↓

decreased

Abbreviations on health records abbreviation

definition

VS

Vital signs

T

temperature

BP

Blood pressure

HR

Heart rate

RR

Respiratory rate

Ht

height

Wt

weight

BMI

Body mass index (measurement of body fat based on height and weight)

I/O

intake/ output: the amount of fluids a patient has taken in (by IV or mouth) and produced (usually just urine output)

Dx

diagnosis

DDx

Differential diagnosis

Tx

treatment

Rx

prescription

H&P

History and physical

Hx

history

CC

Chief complaint (main reason for visit)

HPI

History of present illness (the story of the symptoms)

ROS

Review of systems (anything else not directly related to the CC)

PMHx

Past medical history

FHx

Family history

NKDA

No known drug allergies

PE

Physical exam

Pt

patient

y/o

Years old

h/o

History of

PCP

Primary care provider

f/u

Follow up

Abbreviations used for symptoms or exam findings

Abbreviation

definition

SOB

Shortness of breath (or shortness of air SOA)

HEENT

Head, eyes, ears, nose, and throat

PERRLA

Pupils are equal, round, and reactive to light and accommodation

NAD

No acu...