GUIDELINES AND PROTOCOL IN DOCUMENTATION AND HEALTH CARE RECORDS Flashcards
(16 cards)
- Compilation of pertinent facts of the patient’s life history, their illness and treatment
- Contains past and present medical history, daily condition and treatment given, impression or diagnosis,
observation of the attending physician, nurses’ notes, report of radiology department, pathology, operating
room, and all other pertinent document which have anything to do with the management.
medical records
Medical records can only be disposed or destroyed after:
▪ ___ – For outpatient or emergency room patients
▪ ___ – In-patient/admitted patient
10 years
15 years
true or false - There is no law as to how long such records must be preserved
true
The ___ is the guardian and owner of the record; likewise, physicians are considered owners of the
medical records generated and maintain by them in their private office
hospital
types of medical records
hospital medical records and
physician’s private office records
purpose of maintaining record
- To provide the best medical care
- To supply statistical information
- To provide legal protection
how to correct a handwritten entry on a patient’s medical record
draw a line through the error,
insert the correction above or immediately following, write correction or corr, the initials of the entrant and date
The patient’s right of access to his or her medical record does not include possessing the original medical
record but only a ___
certified photocopy of the original
In cases of ___, the court, through a subpoena duces tecum can order the hospital to bring the
original during the hearing for purposes of comparison
lawsuits
The ___ is the owner of the original copy of the medical record.
hospital
true or false - The physician could not take the physical possession of the original medical record, but he or she can only have a photocopy.
true
The ___ also has entries in the patient’s chart and he or she carries out the orders of the attending
physician
nurse
___ have right of access to the medical records because when patients
apply for coverage, they pre-sign an authority designating the insurance of HMO representative
authorizing them to have access in the patient’s medical records.
insurance and HMO
Hospital uses ___ and ____ and ensures the standardized use of
approved symbols and abbreviations across the hospital
standardized diagnosis and procedure codes
Abbreviations are NOT used on:
▪ Informed consent documents
▪ Discharge summaries
▪ Other documents that a patient and his or her family may read or receive about the
patient’s care.
When a nurse of a clinical instructor ___ the charting of a nursing student, he or she attests that
he or she has personal knowledge of the information and that such is accurate and authentic
countersigns
