TAILIEUCHUNG - Medical assisting: Administrative and clinical procedures (5e) - Chapter 11: Medical records and documentation

After studying this chapter you will be able to: Explain the importance of patient medical records; identify the documents that comprise a patient medical record; compare SOMR, POMR, SOAP, and CHEDDAR medical record formats; identify the six Cs of charting, giving an example of each; | 11 Medical Records and Documentation Learning Outcomes (cont.) Explain the importance of patient medical records. Identify the documents that comprise a patient medical record. Compare SOMR, POMR, SOAP, and CHEDDAR medical record formats. Identify the six Cs of charting, giving an example of each. Learning Outcomes (cont.) Describe the need for neatness, timeliness, accuracy, and professional tone in patient records. Illustrate the correct procedure for correcting and updating a medical record. Describe the steps in responding to a written request for release of medical records. Introduction Medical assistants role regarding patient health records Documentation Maintenance Medical records – critical to patient care Evaluation Management Treatment Learning Outcome: Explain the importance of patient medical records. A medical assistant plays a major role in documenting in and maintaining patient health (or medical) records. These records detail the evaluation, management, and treatment given to the patient. Patient records are critical to the patient’s care. Parts of a medical record Personal information or data Physical and mental condition Medical history Medical care Medical future if patient is referred to other physicians The Importance of Medical Records Past medical history and present condition Communication tool for healthcare team Legal documentation Patient and staff education Quality control and research Documentation for billing and coding Learning Outcomes: Identify the documents that comprise a patient medical record. Medical record Information about a patient’s medical history and present condition. Used as a communication tool and legal document Used for patient and staff education and quality control and research Provides a “map” or plan to follow for the continuity of patient care Is a supporting documentation for billing and coding purposes Importance of Patient Records (cont.) .

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• Medical assisting
• Administrative practices
• Clinical practices
• Medical assisting practice
• Medical records
• Medical documentation
• Clinical procedures
• Administrative medical assisting
• Clinical medical assisting
• Medical assisting profession
• Medical assistant credentials
• Responsibilities of the medical assistant
• Medical assisting organizations
• Medical assisting externships
• Externship scenarios
• Assisting in geriatrics
• Geriatric patients
• Medical office
• Accounting for the medical office
• Assisting in pediatrics
• Pediatric patient care
• Medical coding
• Diagnosis codes
• Minor surgery
• Medical asepsis
• Medical specialties
• Nursing careers
• Medical law
• Physician rights
• Externship process
• Expectations of externship candidates
• Insurance terminology
• Managed care plans
• Standard payment procedures
• Accepting payment
• Body organization
• Anatomical terminology
• Integumentary system
• Structure of skin
• Skeletal system
• Bone structure
• Skeletal muscles
• Muscular system
• Cardiovascular system
• Structures of the heart
• respiratory system
• Paranasal sinuses
• Nervous system
• Neuron structure
• Urinary system
• Renal sinus
• Reproductive system
• Male reproductive system
• Female reproductive system