chapter 2 introduction to health records. health records can be found in a paper chart or an...
TRANSCRIPT
CHAPTER 2
INTRODUCTION TO HEALTH RECORDS
INTRODUCTION TO HEALTH RECORDS
• Health records can be found in a paper chart or an electronic
health record (EHR)
• Health records contain information about the patient
• Previous illnesses and treatments
• Current medical problems
• History of family illnesses
• Current medications
• The health record contains the data that will determine the
patient’s care plan
INTRODUCTION TO HEALTH RECORDS
• Medical notes share a consistent, logical organization
• Chapter 2 focuses on the organization of medical documents
• Health information Career Map from the American Health Information Management Association
THE SOAP METHOD• SOAP is an acronym for the different types of
information documented by health care providers
S = subjective: what the patient says
O = objective: what the tests reveal
A = assessment: the analysis of the subjective and objective
information; performed by the health care provider
P = plan: course of action for the patient
TYPES OF HEALTH RECORDS
• Medical records vary in length and content
TYPES OF HEALTH RECORDS• Example Note #1: Clinic Note
TYPES OF HEALTH RECORDS• Example Note #2: Consult Note
TYPES OF HEALTH RECORDS• Example Note #3: Emergency Department
Note
TYPES OF HEALTH RECORDS• Example Note #4: Admission Summary
TYPES OF HEALTH RECORDS• Example Note #5: Discharge Summary
TYPES OF HEALTH RECORDS
• Example Note #6: Operative Report
• Example Note #7: Daily Hospital Note/ Progress Note
• Radiology Report
• Pathology Report
TYPES OF HEALTH RECORDS
• Example Note #10: Prescription
COMMON TERMS ON HEALTH RECORDS• Subjective
• These are the problems that the patient states he/she has
• Those problems are then translated into medical terms
• This is so that you can correctly communicate the problems to all health care providers
COMMON TERMS ON HEALTH RECORDS
General subjective terms:
• symptom
• noncontributory
• acute vs. chronic
• abrupt
• progressive vs. exacerbation
• febrile vs. afebrile
COMMON TERMS ON HEALTH RECORDS• General objective
terms:
• Things that are seen:• alert
• oriented
• Things that are heard:
• auscultation
• percussion
• Things that are felt:• Palpation
• Descriptions of what is observed:
• unremarkable
• marked
COMMON TERMS ON HEALTH RECORDS
General assessment terms:
• impression
• diagnosis
• differential diagnosis
• etiology vs. idiopathic
• benign vs. malignant
• remission
COMMON TERMS ON HEALTH RECORDS
General assessment terms (cont.):
• morbidity
• mortality
• prognosis
• localized vs. systemic/generalized
• pathogen
• lesion
• sequelae
COMMON TERMS ON HEALTH RECORDS
General plan terms:
• disposition
• observation
• reassurance
• supportive care
• Palliative
COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation
COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation
COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation
COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation
COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation
COMMON TERMS ON HEALTH RECORDSBody Planes and Orientation
A FEW COMMON ABBREVIATIONS
Areas of the Health Care Facility
pre-op, OR, PACU, post-op
ICU – intensive care unit: CCU, SICU, PICU, NICU
ER, ED, and ECU
L&D
A FEW MORE ABBREVIATIONSCommon on Health Records
• H&P – the history and physical
• CC – the patient’s chief complaint
• HPI – history of present illness
• ROS – review of systems
• PE – physical exam
• PCP – primary care provider
And there are many more you will need to
know!
HEALTH RECORDS AND HEALTH INFORMATION MANAGEMENT
• There is substantially more to a Career in Health Information Management than Health Records
• HIM careermap
• HIM professional video
• HIM professional 2 video
• HIM professional 3 video