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7. HRSC 1 > Module 3 Health Records and Forms > Flashcards

Module 3 Health Records and Forms Flashcards

1
Q

What are the three types of health records?

A
  1. paper
  2. electronic (EHR)
  3. hybrid
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2
Q

Information in a health record can be grouped into what two main categories?

A
  1. Administrative

2. Clinical

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3
Q

What is a common clinical documentation method?

A

SOAP

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4
Q

What does SOAP stand for?

A

Subjective
Objective
Assessment
Plan

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5
Q
  • Traditional paper-based health records organize information by ____ or use of an ____
A

source or problem, integrated format

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6
Q

EHR’s organize patient information by _____ and _____ type, in _____ order

A

EHR’s organize patient information by encounter and document type, in chronological order

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7
Q

What are the three traditional sections of source-oriented health records (SOMR)?

A

Identification Section
Medical Section
Nursing Section

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8
Q

Source oriented health records are organized into _____ categories.

A

Organized into practitioner categories.

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9
Q

Source-oriented health records are arranged in _____ order while the patient is on the floor, and are then ____ following separation in the facility determined chart order.

A

chronological order; reassembled following separation

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10
Q

What are the two advantages of source-oriented health records?

A
  1. Quickly find individual sheets
  2. Easy to see the work of each department in providing patient care

quick find, each department’s work
QFED
Q Federline

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11
Q

What are the disadvantages of source-oriented health records?

A
  1. difficult to get an overall picture of the patient’s problem(s)
  2. can’t quickly see all of the patient’s problems
  3. treatment may overlap therapeutic areas, and may be hard to categorize

overall picture; overlap therapeutic areas; hard to categorize
OP OT HC
original poster occupational therapy hot chocolate

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12
Q

What are three traditional sections in problem-oriented health records?

A

bowel obstruction
diabetes
high blood pressure

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13
Q

What are the advantages of problem-oriented health records?

A
  1. creates a HOLISTIC picture of the patient and their care
  2. a physician can consider each of the problems in CONTEXT with other problems
  3. GOALS and METHODS of treatment are clearly documented
  4. QUALITY assurance can be easier

holistic picture; context; goals and methods; quality
HP CG QA
harry potter context goals quality assurance

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14
Q

What are the disadvantages of problem-oriented health records?

A
  1. TIME consuming to implement
  2. may require additional TRAINING for staff
  3. only successful if most/all physicians seeing a patient are DOCUMENTING this way

TTAP

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15
Q

Health record format where information is organized in strict chronological order without any divisions by source

A

integrated health records

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16
Q

Health record format where the physician defines and follows each clinical problem individually and organizes them for a solution.

A

problem-oriented health records

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17
Q

Health record format broadly organized into practitioner categories

A

source-oriented health records

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18
Q

Health record format where forms from different sources are mixed together

A

integrated health records

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19
Q

Health record format sorted by origin of report

A

source-oriented health records

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20
Q

Health record format sorted by each problem

A

problem-oriented health records

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21
Q

Health record format sorted by date chronologically

A

integrated health records

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22
Q

What does the S in SOAP stand for?

A

subjective symptoms; intangible symptoms personal to each patient

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23
Q

What does the O in SOAP stand for?

A

objective symptoms; measurable symptoms by health professionals

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24
Q

What does the A in SOAP stand for?

A

assessment or examination

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25
Q

What does the P in SOAP stand for?

A

plan or course of action

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26
Q

What is an alternate name for a discharge summary?

A

narrative summary

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27
Q

The history and physical must be completed within how many hours of admission?

A

within 24 hours after admission and always prior to surgery

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28
Q

What are alternate names for Physician’s Orders?

A

requisitions, doctors notes

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29
Q

What is the difference between Physician Progress Notes and Multidisciplinary Notes?

A

progress notes can only be written by physicians involved in the patient’s care; multidisciplinary notes can be completed by any healthcare professional involved in patient care

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30
Q

In the case of a stillborn patient, is a new chart created or is the information filed on the mother’s chart?

A

Filed on mother’s chart

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31
Q

What are the advantages of using standardized forms?

A
  1. reduces cost
  2. helpful to physicians who move between facilities
  3. decreased duplication of information results in reduced clerical work, decreased number of errors, increased efficiency

CMPDD

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32
Q

What 3 types of information that should be held in the forms inventory?

A
  1. drafts
  2. approval requests
  3. authorization (who and when)
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33
Q

All forms used in a facility should be reviewed regularly for what purpose?

A
  1. addition of new data elements
  2. removal of obsolete or repeated data elements
  3. reformatting for easier use as EHR becomes more advanced
  4. correction of errors

NDE ORDE REF COE

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34
Q

What are the roles and responsibilities of healthcare professionals in the completion of forms?

A

Providing input on data collection requirements, physical layout, user completion, identification, ongoing review, revisions

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35
Q

What is the purpose of forms?

A

Communication tool between providers, standardization of data collection, ensures documentation consistency, collection of data to support clinical decision making

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36
Q

List some basic principles in forms design.

A
  1. consider the purpose, use, and user of the form
  2. keep it simple
  3. use headings to identify the purpose
  4. include the facility ID and patient chart number on each page
  5. use standard formatting and terminology
  6. Include guidelines for data collection
  7. sequence the data in a logical order
  8. use standardized font type and size
  9. use shading and lines to separate sections
  10. use checkboxes/dropdown menus for easy data collection elements
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37
Q

What are the advantages of having forms in an EHR?

A
  1. Can add built-in edits and present entry requirements to ensure accurate and consistent data collection
  2. Allow for various methods of inputting and retrieving information (voice recognition, scanning, direct entry, etc)
  3. Has the potential to decrease workload and minimize errors
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38
Q

list the basic principles in EHR forms design.

A
  1. Ensure users aren’t arbitrarily designing their own forms (have policies and guidelines to follow)
  2. Ensure all legal requirements are met so that necessary data elements are included and confidentiality maintained
  3. Have an audit trail that can be monitored
  4. Ensure efficiency and integration into your EHR
  5. Maintain the same specifications as paper forms
  6. Control the printing of forms
  7. Provide standardized terminology (data dictionary)
  8. Provide unauthorized changes/duplications
  9. Ensure that forms can be indexed/scanned
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39
Q

History of all editions of forms in use in a facility that includes drafts, approval requests, and authorization

A

forms inventory

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40
Q

What are the components of forms identification?

A
  1. title identifying form and its use
  2. numerical identification system (ex bar code)
  3. creation and revision dates
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41
Q

The act of regularly reviewing forms

A

forms analysis

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42
Q

Forms analysis focuses on which 4 areas?

A
  1. addition of new data elements
  2. removal of obsolete or repeated data elements
  3. reformatting for easier use as EHR become more advanced
  4. correction of errors
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43
Q

What is the main purpose of administrative data

A

uniquely identify the person

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44
Q

What does administrative data contain?

A

demographic, identification, financial and legal data

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45
Q

What does clinical data contain?

A

information about the patient’s illness, treatment, treatment results, prognosis, and continuing care plan

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46
Q

List examples of common administrative forms.

A
  1. patient registration record
  2. release of responsibility for belongings
  3. consents
  4. personal directives
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47
Q

One of the most commonly computerized forms and its contents are downloaded into other systems in the hospital, such as the transcription/coding/abstracting computer applications

A

patient registration record

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48
Q

Consists of the demographic information about the patient and their next of kin, and key clinical information

A

patient registration record

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49
Q

Who completes and who signs the patient registration record?

A

admitting clerk completes, attending physician signs

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50
Q

T or F. It is common for pre-booked (elective and urgent) patients to be pre-registered days prior to the actual admission

A

T

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51
Q

When are emergency patients registered?

A

At the time they are seen

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52
Q

Alternate names for patient registration record

A

identification form, face sheet, admission-discharge record

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53
Q

What are the contents of patient registration records?

A
  1. socioeconomic data
  2. admission data
  3. separation data
  4. clinical data
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54
Q

Patient registration record data: contains patient name, address, phone #, DOB, age, sex, marital status, occupation and employers name, medical insurance coverage and policy numbers, next-of-kin information

A

socio-economic data

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55
Q

Patient registration record data: contains name of admitting physician, admitting diagnosis, type of admission

A

admission data

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56
Q

List different types of admission.

A
  1. elective
  2. urgent
  3. emergent
  4. outpatient
  5. day surgery
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57
Q

A unique ____ is assigned when collecting admission data and will be contained on each and every report within the patient’s health record

A

patient chart number

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58
Q

Patient registration record data: contains the date and time of separation from the nursing unit or other area of the hospital; recorded when the patient is discharged from the facility or expires

A

separation data

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59
Q

Patient registration record data: contains admitting diagnoses, preliminary statement of planned procedures, signed by admitting physician

A

clinical data

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60
Q

Common form that contains a statement in which the patient releases the hospital from liability if personal belongings such as jewelry or money are lost, stolen or damaged; may contain an itemized Property/Valuables list

A

release of responsibility for belongings

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61
Q

____ envelopes can be provided and belongings may be kept in a safe place until patient discharge

A

safekeeping

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62
Q

Who signs the release of responsibility for belongings form?

A

the patient or the guardian

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63
Q

Common form that is signed by a patient/guardian; may also be signed by a relative in an emergency situation

A

consent forms

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64
Q

What are the 2 types of consents?

A
  1. consent for admission and treatment

2. special consents

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65
Q

Consent form that covers the consent only to basic, routine care and services; doesn’t include surgical procedures/medications or non-surgical procedures involving risk

A

consent for admission and treatment

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66
Q

Who signs the consent for admission and treatment?

A

the admitting department at time of admission, or elective patients during the pre-admission process

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67
Q

Consent form required for any non-routine diagnostic or therapeutic procedure

A

special consents

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68
Q

What is an example of a special consent form?

A

consent to surgery

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69
Q

Consents must be ___, that is, the physician discusses the procedure, risks, alternatives, probable outcomes, and the patient must demonstrate that they understand the explanations

A

informed

70
Q

T or F. Discussions for informed consent must be explained in a language and terminology the patient can understand; an interpreter must be provided if needed

A

T

71
Q

Common administrative form that allows the patient to prepare written instruction on personal matters in case you become incapable of making those decisions later

A

personal directives form

72
Q

Who signs the personal directives form?

A

patient

73
Q

T or F. The law in Alberta allows another person to automatically make decisions for a patient.

A

F

74
Q

Anyone over the age of __ can complete a personal directive

A

18.

75
Q

Personal directives become legal documents when it is ___, ___, and ___

A

dated, signed and witnessed

76
Q

Power of Attorney covers ____ only, not health related matters

A

financial

77
Q

List examples of common clinical forms.

A
  1. discharge summary
  2. emergency chart
  3. history & physical (H&P)
  4. physician’s orders
  5. consultation report
  6. progress notes
78
Q

Who signs the discharge summary?

A

attending physician

79
Q

What are alternate names for the discharge summary?

A

narrative summary

80
Q

Common clinical form that is a concise summary of the patient’s course in hospital including the reason for hospitalization, significant findings, events, condition upon discharge/release from the hospital, recommendations and arrangements for future care

A

discharge summary

81
Q

Dictated by the attending physician at the time of or immediately following discharged; usually filed at the front of the chart

A

discharge summary

82
Q

Copies of the discharge summary are usually sent to the ___ or ___

A

attending physician or any medical practitioner responsible for the future care of the patient (family physician)

83
Q

Who signs the emergency chart?

A

physician who saw and treated the patient in the emergency department

84
Q

Common clinical form that provides a concise report regarding the events surrounding the patient’s visit to the ER.

A

emergency chart

85
Q

If the patient is admitted to a hospital as an inpatient from the ER, the ER record accompanies them and becomes part of the ___ for that admission

A

IP record

86
Q

If the patient is not admitted as an inpatient, the ER record is sent to the ___ for coding and filing once the patient is released

A

health information department

87
Q

Who signs the history and physical?

A

examining physician, usually the same as the attending physician, unless a consultant takes over the care of the patient

88
Q

Common clinical form that provides the foundation needed to establish a provisional or tentative diagnosis and to develop a treatment plan

A

history and physical (H&P)

89
Q

When should the H&P be completed by?

A

within 24 hours after admission and always prior to surgery

90
Q

H&P findings are both ____ and ____

A

subjective and objective

91
Q

What does the H&P contain?

A
  1. chief complaint (CC)
  2. present illness/history of present illness (HPI)
  3. psychosocial history/personal history/social history
  4. past medical history/past health
  5. family history
  6. review of systems (ROS)
  7. physical examination (PE)
  8. impression
92
Q

In the H&P, contains a subjective description of why the patient is seeking medical attention

A

chief complaint

93
Q

In the H&P, contains a detailed chronological account of development of the patient’s illness

A

present illness/history of present illness (HPI)

94
Q

In the H&P, contains daily routine, use of drug/alcohol, education, occupation, home environment, marital status, important experiences. religious beliefs, recent travel, habits etc

A

psychosocial history/personal history/social history

95
Q

In the H&P, contains a summary of childhood and adult illness and condition, allergies, treatment history, past surgeries

A

past medical history, past health

96
Q

In the H&P, contains age and health or cause of death of immediate family members, hereditary diseases

A

family history

97
Q

In the H&P, contains a review by body system of the patient’s symptoms and subjective sensations; begins with an overview of the patient’s general health and concerns, and then describes complaints by body system

A

review of systems (ROS)

98
Q

ROS documentation often uses __ terms the patient uses rather than medical terms

A

lay

99
Q

In the H&P, this is the actual examination that adds objective data to the subjective data provided by the patient in the ROS

A

physical examination (PE)

100
Q

In the H&P, documented by the physician using medical terminology; provides the foundation from which a diagnosis can be made and a treatment plan developed

A

physical examination (PE)

101
Q

What are the four basic procedures used during a general physical exam?

A

IPPA

102
Q

What does IPPA stand for?

A

inspection, palpation, percussion, and auscultation

103
Q

In the H&P, can be either a provisional/tentative diagnosis or a differential diagnosis

A

impression

104
Q

Diagnosis based on incomplete information and subject to change

A

provisional/tentative diagnosis

105
Q

Statement of more than one possible diagnosis due to similar signs and/or symptoms

A

differential diagnosis

106
Q

Who signs the physicians’ orders?

A

the physician responsible for each order or group of orders must date and sign these

107
Q

Physicians use this common clinical form to communicate their plans for the therapeutic care and diagnostic procedures of their patients by giving written or verbal directions to the nursing staff and other practitioners

A

physician’s orders

108
Q

T or F. Only members of the hospital medical staff are permitted to give orders, which are now usually entered into the hospital EMR and printed to add to the patient’s chart

A

T

109
Q

Who signs the consultation report?

A

the consulting physician

110
Q

Common clinical form that contains the opinion of another physician, usually a specialist, about the patient’s condition

A

consultation report

111
Q

Where can consultations be written?

A

on a form designed for this purpose, dictated, transcribed, or may be documented in progress notes

112
Q

T or F. Routine investigations such as x-rays, medical imaging, tissue analysis and ECGs constitute as a consultation

A

F.

113
Q

Who signs progress notes?

A

author of the note

114
Q

What are the two formats for documenting progress notes?

A

physician progress notes and multidisciplinary progress notes

115
Q

Only the physician can document in this common clinical form; provide observations including changes in symptoms or diagnosis, changes in treatment, response to treatment, significant diagnostic test results, operation and procedures performed, unusual occurences, complications, consultation findings

A

physician progress notes

116
Q

In physician progress notes, there should be documentation including the exact ___ the death was pronounced, the ___ who pronounced the death, ___ surrounding the death, any significant findings, suspected cause of death, and whether consent was obtained for autopsy and/or organ donation

A

time, name of the physician, circumstances

117
Q

Common clinical form that contains all of the above documentation, but used by all healthcare providers caring for the patient on one location

A

multidisciplinary progress notes

118
Q

T or F. Nurses document on forms exclusively used by them to record their observations and care of the patient.

A

T

119
Q

List examples of nursing forms.

A
  1. nurses’ notes
  2. clinical/graphic record
  3. medication records
  4. other nursing record/forms
120
Q

Who signs nurses notes?

A

Nurse who made the entry along with credentials

121
Q

This nursing form fills in the gaps of information not found on other nursing forms like medication sheets

A

nurses notes

122
Q

Nursing form where nurses document the care provided and the patient’s signs and symptoms in response to care; does not diagnose the patient

A

nurses notes

123
Q

Physicians must first ___ all treatments carried out.

A

authorize

124
Q

What do nurses notes include?

A
  1. date and time of entry
  2. signature or initial of the nurse who made it
  3. nursing care and treatment including significant events
  4. documentation of visits by physicians, other healthcare providers, family and friends
  5. discharge date, time, manner of disposition, destination of the patient, accompaniment of the patient
  6. if patient signs out AMA
125
Q

What do nurses have to include in their nurses notes if patient dies?

A
  1. time heart and respirations stopped
  2. name of physician notified
  3. time/date/name/ of physician who pronounced the death
  4. whether relatives were present or otherwise notified and by whom
  5. disposition of the clothes and valuables
  6. destination of the body (morgue/funeral home/medical examiner)
126
Q

This nursing form records a continuous graphic picture or plot of the patient’s vital signs and other information on a daily basis

A

clinical/graphic record

127
Q

Nursing form containing vital signs (TPR + BP), intake an output of fluid, height and weight, diet, elimination, physician visits, number of days since admission and or surgery

A

clinical/graphic record

128
Q

Who signs medication records?

A

the person who administered the drug

129
Q

This nursing form provides documentation of medication given, or if a drug isn’t given as ordered, this is also documented

A

medication record

130
Q

What must be recorded on a medication record?

A
  1. date and time of administration
  2. name of the drug
  3. dosage
  4. route of administration
131
Q

What are other nursing records/forms?

A

sensitivity record, nursing assessment/nursing care plan, BP record, fluid balance record, diabetic record, anticoagulant record, IV therapy record, patient education/discharge instructions

132
Q

Nursing form that lists patient sensitivities and allergies

A

sensitivity record

133
Q

Nursing form that lists nursing measures to be taken to facilitate medical care and comfort needs of the patient

A

nursing assessment/nursing care plan

134
Q

Nursing form used if vital signs need to be recorded more frequently than allowed on the graphic sheet

A

BP record

135
Q

Nursing form that shows I&O by route and by shift, with 8 and 24 hour totals

A

fluid balance record

136
Q

Nursing form that shows urine/blood testing for glucose, diet restrictions and insulin administration

A

diabetic record

137
Q

Nursing form that shows daily prothrombin times in relation to the dosage of anticoagulants

A

anticoagulant record

138
Q

__ and __ notes replace the graphic sheet/nurses notes when the patient is on a special care unit

A

ICU and CCU notes

139
Q

Nursing form that provides info regarding the types of IV or blood components administered and the condition of the IV site(s)

A

intravenous therapy record

140
Q

Nursing form that provides a record of patient teaching and discharge instructions, including medications to be taken at home

A

patient education/discharge instructions

141
Q

Additional investigations and treatments carried out by the appropriate department and only when ordered by a physician

A

ancillary reports

142
Q

Ancillary report that contains patient identification information, place of death, and the medical cause(s) and contributing factors of the death

A

Medical Certificate of Death (VS)

143
Q

A copy of the Medical Certificate of Death is left on the patient chart and the original goes to the ____

A

government

144
Q

Ancillary report that contains the date/time of of the ECG, interpretation of the tracings, portions or copies of the actual tracings, and diagnosis or impression

A

ECG/EKG report

145
Q

Who signs ECG/EKG report?

A

cardiologist

146
Q

Graphic tracing representing the electrical changes in the heart muscle as the heart beats

A

ECG

147
Q

ECG is normally performed by a ___ while a ___ interprets the results

A

qualified ECG technician, cardiologist

148
Q

Amplifies the electrical fluctuations of the brain and provides a graphic tracing of the activity of the brain

A

EEG

149
Q

May be on its own form or may be documented in the progress notes, or both

A

EEG/ECG/EKG

150
Q

T or F. EEGs are usually very in-depth and therefore dictated by the physician for transcription

A

T

151
Q

EEGs are performed by a qualified ____ while a ___ interprets the results are these are significantly more difficult to read than an ECG

A

EEG technician, neurologist/neurosurgeon

152
Q

T or F. A general practitioner or other type of specialist wouldn’t attempt to interpret an EEG

A

True

153
Q

Ancillary report that contains the date and time of EEG tracings, portions or copies of the actual tracings, interpretation of the tracings by a neurologist or neurosurgeon, and diagnosis or impression

A

EEG report

154
Q

Ancillary report that include diagnostic imaging procedure reports such as x-ray, nuclear medicine, CT, MRI and ultrasound

A

radiology/medical imaging reports

155
Q

DI tests are performed by the appropriate ___ and are interpreted by ___

A

medical imaging technician; radiologist/qualified physician

156
Q

Ancillary report that contains information about the preparation/positioning of the patient, identity, date, amount of radiopharmaceutical used, dose, time and route of administration of contrast or drugs, and radiological findings

A

radiology/medical imaging reports

157
Q

Ancillary report that details the assessment and treatments used to restore the patient to useful activity and patient education

A

physical therapy/physiotherapy record

158
Q

May be continued on an outpatient basis after discharge from the hospital

A

physiotherapy

159
Q

Physiotherapy is ordered by the ___ and is performed by a ___ either at bedside or in the Physio Department

A

attending physician; physiotherapist

160
Q

Ancillary report that contains info about the initial assessment, methods used, patient response, additional exercises for patient to do on their own, discharge note/summary when service is discontinued

A

physical therapy/physiotherapy record

161
Q

Ancillary report that involves not only treatment but also diagnostic testing when required (PFT, spirometry, lung volume measurements, arterial blood gas analysis, etc)

A

respiratory therapy record

162
Q

Examples of respiratory treatments.

A

administration of oxygen and other therapeutic gases, aerosols and humidity, mechanical ventilation, emergency resuscitation

163
Q

Respiratory services are provided usually at the __ by a ___

A

bedside, respiratory therapist

164
Q

Ancillary report that contains a description of the therapy; date and time of administration; patient response to breathing therapy

A

respiratory therapy record

165
Q

Social services is becoming more necessary especially as ___ continue to shorten based on arranging homecare and other community report

A

length of stays

166
Q

Ancillary report that contains background/social info about the patient and family, problems identified by the patient, family and social worker, plan of action, referrals for various types of social assistance if required

A

social services record

167
Q

Ancillary report that is a standard form in AB with mandatory use in cases of patient transfer

A

patient transfer information form

168
Q

How are two copies of patient transfer information forms distributed?

A

One for the health record of the sending hospital, other copy for the health record at the receiving hospital

169
Q

Ancillary report that contains patient information, diagnoses, medications, when the most recent medications were administered, activity and mental status of the patient, other helpful information

A

patient transfer information form

170
Q

Surgical form that provides a concise report of the patient’s immediate postoperative or postanesthetic care

A

postanesthetic recovery room (PARR) record

171
Q

Each entry on the PARR record is signed by ___, usually the PARR nurse or anesthetist

A

person who makes the entry

172
Q

Surgical form that contains the condition of the patient on arrival to PARR, VS, colour, breathing, condition of surgical wound, level of consciousness, response to stimuli, procedures or medications given in the PARR, discharge note to the nursing unit including the condition of the patient on transfer to the unit

A

PARR record

7. HRSC 1 (7 decks)

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