Terms Flashcards
(150 cards)
1
Q
health record
A
written or graphic info. documenting facts and events during the rendering of patient care: either paper or electronic format
2
Q
American Recovery and Reinvestment Act of 2009 (ARRA)
A
encourages implementation by offering five annual financial incentives for qualifying offices that convert to an electronic format beginning in 2011 and ending in 2015 or 2016.
3
Q
Common Health record content
A
- Patient registration (demographic information)
- Medication record
- history and physical exam, notes or report
- Progress or chart notes
- Consultation reports
- imaging and x-ray reports
- Laboratory reports
- Immunization record
- Consent and authorization forms
- Operative report
- Pathology report.
In hospital setting would also include
- attending physician’s orders
- date of admission
- hospital stay dates
- discharge date
- discharge summary
4
Q
- problem-oriented record (POR system)
- source-oriented record (SOR system or integrated system)
A
What types of systems are used in electronic health record system (EHR)
5
Q
What types of systems are used in electronic health record system (EHR)
A
Consists of: flow sheets, charts, or graphs, that allow a physician to quickly locate information and compare evaluation
6
Q
Soruce-Oriented Record System (SOR)
A
documents are arranged according to sections (e.g., H&P section, progress notes, lab tests, radiology reports, or surgical operations) SOR system filed in reverse chronological order. More difficult to locate data due to scattering throughout
7
Q
Electronic Health Record System
A
collection of medical information about the past, present and future of a patient that resides in a centralized electronic system.
8
Q
Difference between an EHR and an EMR
A
: An EMR is individual physician’s EMR for the patient, including medical history, allergies, and appointment information.
An EHR is all patient medical information from many information systems, including all components of the EMR.
9
Q
Advantages of EMR
A
- no physical space required
- abstracting data is eliminated except when free-form documentation such as narrative notes, dictations, and natural language processing is used.
- free-text approach, encourages use of abbreviations or fewer spelled out words may result in scant or undecipherable documents.
- Electronic systems have built in security safeguards to protect against improper disclosure, unauthorized access, or unintended alteration of information for both the data and the system.
- ARRA requires covered entities to notify individuals if their protected health information is accessed or disclosed in an unauthorized manner.
10
Q
SNOMED-CT
A
Systemized Nomenclature of Medicine for Clinical Terminology. Medical terminology cassification system that codes text data in an EHR system will assist in standardizing clinical medical terminology
11
Q
Medicare Modernization Act
A
created the Commission on Systemic Interoperability to develop a strategy to make health care information abailable at all times to patients and physicians. Goal by 2014.
12
Q
Electronic medical report
A
part of health record that is used to complete the insurance claim form.
permanent legal document that formally states outcomes of the patients’ examination or treatment in letter or report form.
13
Q
Insurance claim
A
- DOS, date of service
- POS, place of service
- Dx, diagnosis
- Procedures
- codes are used for interpretation by the insurance company when processing a claim
14
Q
documenters
A
all individuals providing health care services that chronlogically record pertinent facts and observations about patient’s health.
15
Q
documentation
A
charting, may be electronically handwritten, dictated and transcribed or downloaded from a (PDA) personal digital assistant or smartphone
16
Q
Speech recognition system
A
computerized voice recognition system which makes it possible for computer to respond to spoken words
17
Q
medical editor
A
correctionist, proofreads and edits the computer-generated documents
18
Q
attending physician
A
refers to the hospital staff member who is legally responsible for the care and treatment given to a patient
19
Q
consulting physician
A
provider whose opinion or advice regarding evaluatio or management of a specific problem is requested by another physician
20
Q
non-physician practitioner (NPP)
A
nurse practitioner, clinical nurse specialist, licensed social worker, nurse midwife, physical therapist, speech therapist, audiologist, or physician assistnat who furnishes a consultation or treats a patient for a specific medical problem, pursuant to state law, and who use the results of a diagnostic test in the management of the patient’s specific medical problem
21
Q
ordering physician
A
individiual in the hospital directing the selection, preparation, or administration of tests, medication, or treatment
22
Q
primary care physician (PCP)
A
oversees the care of the patients in a managed health care plan and refers patients to see specialists for services as needed
23
Q
referring physician
A
provider who sends the patient for tests or treatment
24
Q
resident physician
A
physician who has finished medical school and is performing one or more years of training in a specialty area on the job at a hospital (medical center). Residents perform the elements required for an evaluation and management (E/M service in the presence of or, jointly with, the teaching physican, and residents document the service.
25
teaching physician
doctor who has responsibilities for training and supervising medical students, interns, or residents and who takes them to the bedsides of patients in a teaching hospital to review course and treatment. Teaching physicians must document that they supervised and were physically present at the time during key portions of the service provided to the patient when performed by a resident.
26
Treating or performing physician
provider who renders a service to a patient. In the Medicare program, the definition of a treating physician is a physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiary's specific medical problem.
27
Five reasons for legible documention:
If handwritten, entries in patient record must be legible.
a. avoids denied or delayed payments by insurance carriers
b. enforcement of medical record-keeping rules by insurance carriers requiring accurate document that supports procedure and diagnostic codes.
c. Subpoena of health records by state investigators or the court for review.
d. Defense of a professional liabilty claim.
e. Execution of the physician's written instructions by a patient care-giver.
28
E/M
Evaluation and management, occurs in office visit, inpatient hospital facilities, and nursing homes
29
CPT
Current Procedural Terminology
30
CMS
Centers for Medicare and Medicaid Services.
31
American Medical Association and Centers for Medicare and Medicaid Services.
Developed documentation guidelines for CPT E/M services.
32
Medicare administrator contractors
also called fiscal intermediaries, fiscal agents, and fiscal carriers, conduct reviews for irregular reporting patterns.
HAVE WALK IN RIGHTS, access to a medical practicde w/o apptment or search warrant.
33
Third-party payers and federal programs have responsiblity to ensure that professional services provided to patients were medically mecessary
Documentation must support the level of service and each procedure rendered.
34
medical necessity
criterion used by insurance companies, as well as federal programs, when making decisions to limit or deny payment. Payment may be delayed, downcoded or denied if the medical necessity of a treatment is questioned.
35
Good medical practice standards
Insurers differ on definition and may not cover services depending on the benefits of the plan.
36
ABN
Advance beneficiary Notice of Noncoverage, also know as waiver of liability agreement or responsibility statement
37
Audit
If provider has submitted insurance claims for payments deemed fraudulent or inappropriate by government.
38
External Audit Point System
A point system used while reviewing each patient's health record during the performance of an audit. Points award only if documentation is present for elements required in health record. Point system is used to show where deficiencies occur in health record documentation, evaluation and substantiate proper use of diagnostic and procedural codes.
39
consequences of accidental (or intentional) miscoding.
HMO, PPO, private carriers can claim refunds
Medicare has power to levy fines and penalties and exclude providers from Medicare program
40
Insurance carrier and documentation
If it is not documented, then it was not performed. (have right to deny reinbursement)
41
Medicare carriers frequent audits
prepayment and postpayment audits to monitor accuracy physicians' use of medical services and procedure codes.
42
Billing Patterns causing possible audits
a. billing intentionally for unnecessary services
b. billing incorrectly for services of physican extenders (NPP)
C. billing for diagnostic tests w/o separate report in health record
d. changing DOS on insurance claims to cmply with policy coverage dates
e. waiving copayments or deductibles, or allowing other illegal discounts
f. ordering excessive diagnostic tests
g. using 2 different provider numbers to bill the same services for same patient
h. failing to return overpayments made by the Medicare program
i. misusing prover ID number
j. using improper modifiers for financial gain
43
Common Medical Office Documents/
Documentation guidelines for Medical Services
1. The health record should be accurate, complete (detailed), and legible.
2. Documentation of each patient encounter includes or provide reference to following:
a. chief complaint or reason for encounter
b. relevant history
c. physical examination
d. findings
e. prior diagnostic test results
f. assessment, clinical impression, or diagnosis
g. plan for care
h. date and eligible identity of the health care professional
3. The reason for encounter stated
4. Past and present diagnoses
5. Appropriate health risk factors should be identified
6. The patient's progress, response to and changes to treatment, planned follow-up care and instructions and diagnosis should be documented.
7. Patient refusal to follow medical advise
8. Procedure and diagnostic codes reported on the insurance claim form or billing statement supported by documentation.
9. Confidentiality of health record maintained
10. Each chart entry dated and signed
11. Standardized charting procedures for progress notes. Use either SOAP or CHEDDAR styles or narriative or detailed descriptive style. Must be detailed enough to support current documentation requirements.
12. Treatment plans written and consistent with working dx.
13. medications prescribed and taken, listed
14. request for or need for consultation must be documented. Include: consultant's opinion, services ordered documented, and communicated to requesting physician.- see pg 96 for additional
Four R's: requesting, render, report, reason, (and possibly return"
15. Record patient's fialture to return for needed treatment, in Heath record, appointment book, financial reocrd or ledger, follow telephone call or letter to patient indicated
16. How to correct documentation "errors". see pg 96.
Never delete or or key over incorrect data. or flag it as amended or obsolete and create an addendum typed as a separate document or for a chart note inserted below in the next space availabe. paper charting - initial correction. never erase, white, out or use self adhesive paper over any information record on a patient record.
17. Document all lab tests, physcian intials report as read.
18. Ask physician for approval for differnt code before transmitting claims
19. Retain all records (until positive no longer necessary by conforming to federal and state laws, and physician wishes)
44
Contents of a Medical Report
Degree of documentation depends on the complexity of the service and the specialty of the physican.
history, examination, medical decision making
45
Documentation of History
includes:
chief complaint (CC), History of Present Illness (HPI), review of systems (ROS), past history, family, or social history (PFSID) extent of each depends on present problems
46
Chief complaint (CC)
concise statement usually in patient's own words describing symptom, problem, condition, diagnosis, physician-recommended return, or other factor.
REQUIRED FOR ALL LEVELS OF HISTORY:
47
History of present illness (HPI)
chronological description of development of the patients present illness from first sign or symptom or from previous encounter to present (may include one or more of the following):
1. location,
2, Quality/Character of the symptom/pain,
3. severity or degree (1-10),
4. Duration,
5. Timing, when,
6. Context - situation associated with symptom
7. Modifying factors that make it better or worse,
8. Associated signs and symptoms
48
Review of Symptoms (ROS)
Inventory of body systems obtained through a series of questions that is used to identify signs or symptoms patient might be experiencing or has experienced. In ROS, trhe body systems are counted and totaled. The health record should describe one system of the ROS for a pertinent to problem level. For a complete level, at least 10 organ systems must be reviewed and documented.
49
Past History (PH)
Patients past experiences with illnesses, operations, injuries, and treatments
50
Family History (FH)
A review of medical events in the patient's family including diseases that may be heriditary or place the patient at risk.
51
Social History (SH)
An age-appropriate review of past and current activities (smoking, alcohol, etc.)
52
Documentation review/audit worksheet
there are specific requirements of documentation.
53
Levels of history
1. Problem focused (PF) chief complaint; brief history of present illness or problems
2. Expanded problem focused (EPF) chief complain; brief HPI problem-pertinent system review
3. Detailed (D) - Chief complaint; extended history of present illness; problem-pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, or social history direcdtly related to the patient's problems
4. Comprehensive (C) - chief complaint; extended HPI: ROS that is directly related to the problem identified in the history of the present illness, plus a review of all additional body systems; complete PFSH.
54
Physical Examination (PE or PX)
objective in nature consists of physcian's findings by examination or test results
55
Physical exam Types
1. Problem focused (PF)
2. Expanded problem focused (EPF)
3. Detailed (D)
4. Comprehensive (C)
56
Problem focused (PF) physical exam
Problem focused (PF) physical exam
57
Expanded Problem focused (EPF) physical exam
A limited exam of affected body area or organ system and other symptomatic or related organ systems.
58
Detailed (D) physical exam
An extended examination of the affected body areas and other symptomatic or related organ systems.
59
Comprehensive (C ) physical exam
A general multisystem examination or complete examination of a single organ system.
60
Comorbidity
means underlying disease or other conditions present at the time of the visit.
61
Medical decision making (four types)
1. straighforward (SF)
2. low complexity (LC)
3. moderate complexity (MC
4. high complexity (HC)
62
new patient (NP)
one who has not recieved any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years
63
established patient
patient who has received professional services from the physican or another physician of the same specialty who belongs to the same group practice with the past 3 years
64
consultation
includes services rendered by a physician whose opinion or advise is requested by another physican or agency in the evaluation or treatment of a patient's illness or a suspected problem.
65
referral
transfer of the total or specific care of a patient from physician to another for known problems. Not a consultation, ex. patient with fracture sent to orthopedist
66
concurrent care
providing of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. (ex. cardiologist and endocrinologist)
67
continuity of care
(e.g., a patient who has received treatment for a condition and is then referred by the physician to a second physician for treatment for the same condition),
68
Critical care
intensive care provided in a variety of acute life-threatening conditions requiring constant "full attention" by a physician. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.
69
Emergency care
it may be given by the physician in a hospital ED or in a physician's office setting.
Emergency care is that is provided to acutely ill patients and may or may not involve organ system failure, but does require immediate medical attention.
70
Emergency medical condition as defined by Medicare
medical condition that manifesting itself by acute symptoms of sufficient severity (including severe pain)
such that the absence of immediately medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to body functions, or serious dysfunction of any body organ or part.
71
Lay person definition of an emergency
Any medical condition of a recent onset and severity ,
including but not limited to severe pain, that would lead a produent lay person, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injry is of such a nature that failure to obtain immediate medical care could result in placing the patient's health in serious jeopardy, seirous impairment to bodily functions, or serious dysfunction of bodily organ or part
72
Counseling
discussion with a patient, family, or both concerning one or more of the following:
diagnostic results,
impressions,
or recommended diagnostic studies;
prognosis;
risks and benefits of treatment options;
instructions for treatment or follow-up;
importance of complication with chose treatment options;
risk factor reduction,
and patient and family eduction.
73
imp (abbrevation
impression
74
dx (abbreviation
diagnosis
75
AMA policy on abbreviations
should be eliminated from vital sections of health record, such as final diagnosis, operative notes, discharge summaries, and descriptions of special procedures
76
eponym.
term including the name of a person (e.lg. Graves' disease)) s hould not be used when a comparable anatomic term can be used in its place
ex. "Buerger's disease compared to thromboangitis obliterans
77
acute
a condition that runs a short but relative severe course
78
chronic
a condition that runs a short but relative severe course
79
diagnostic terminology and abbreviations
problems can occur with documentation because of missing or misused essential words (ex. diastolic dysfunction instead of heart failure due to diastolic dysfunction
80
within normal limits (WNL), noncontributroy, negative/normal, other than the above, all systems were normal
may not support billing of services, instead, documentation must indicate exatly which limb was examined and abbreviated wording would not pass an audit.
"CANNED" notes mean no assessment was actually performed, this is fraud.
81
Detailed documentation justifies billed services by providing verification
ex. chest x-ray report reviewed, or read instead of "chest x-ray negative"
82
surgical terminology
a) preoperative vs postoperative,
(b) simple/intermediate/complex
(c) undermining
(d) take down
(e) lysis of adhesion
(f) surgical position
(g) surgical approach (ex. vaginal vs. abdominal
83
preoperative
(preop) period before a surgical procedure, begins with the first preparation to a patient fore surgery and ends with anestheia in operating room
84
postoperative
(PO) period of time after surgery, beginning with patient emerging from anesthesia and continues through time required for acute effects of anestheia and surgical procedures to decrease
85
surgical procedures for integumentary system
(example, repair of lacerations)
listed as simple, intermediate or complex repairs. Documentation should liste the length (in centimeters) of all incisions and layers of involved tissues so that correct procedure codes for excision of lesions and type of repair can be determined.
86
simple laceration (superficial)
one layer closure
87
intermediate laceration
requires layered closure of one or more of the deeper layers of the skin and tissues
88
complex lacerations
require more than layered closure and may require reconstructive surgery
89
If time is factor in coding for reimbursement.
Document length of time spent on procedure, especially if of unusual duration such as prolonged services, counseling, or team conferences. Stated somewhere in the report.
90
State of art equipment
document
91
Surgical procedures one of two categories
therapeutic or cosmetic procedures
92
undermining
cut in a horizontal fashion
93
take down
to take apart
94
lysis of adhesions
destruction of scar tissue
95
bilateral (term)
pertaining to both sides
96
severe bleeding
blood lost of more than 600ml
97
hermorrhage
escape of blood from vessels;bleeding
e.g. brain hermorrhage
98
initial (key term/coding)
first procedure or service
99
mulitple/parital (key term-coding)
affecting many parts of the body at the same time/only a part, not complete
100
simple/subsequent
single and not compound or complex/second or more procedures or services
101
unilateral (term)
pertaining to one side only
102
internal reviews
prospectus review, prebilling audit or review done periodically (daily, weekly, monthly)
103
Prospectus review, stage 1
review to verify that completed encounter forms match patients seen according to appointment book and have been posted on daysheet, then see if all charges are posted
104
Prospectus review, stage 2
review verifies all procedures or services and diagoses listed on encounter form match data on the insuranc eclaim form.
105
retrospective review
review done after billing insurance carrier, usually done by biller/coder to determine if sufficient documentation exists
106
When diagnosis not completed correctly in health record:
an active dx has not been entered i nto the computer system and the computer defaults to the last dx given for established patient. OR dx is not linked to proceudre.
PROBLEMS MUST BE FOUND BEFORE BILLING AND CORRECTED BEFORE CLAIMS ARE PRINTED
107
red flag in billing looking for billing excesses or potential abuse
unusual billing patterns
same dx code every visit
same procedure code repeatedly
lack of documentation
canned templates
illegible documentations
blank documentations
tests documented but not performed
same level of service consistently billed
108
External audit
pg 114 & 115 discusses HIPAA credited to prevent fraud
discusses physician compliance programs
109
compliance programs
composed of policies and procedures to accomplish uniformity, consistency and conformity in medical record keeping that fulfills official requirements.
110
Compliance program elements or Elements of a Successful Compliance program
1. written standards of conduct
2. written policies and procedures
3. compliance officer and/or committee to operate and monitor the program
4. training program for all affected employees.
5. process to give complaints anonymously
6. internal audit performed routinely
7. investigation and remediation plan for problems that develop
8. response plan for improper or illegal activities
111
software edit checks
audit prevent measure. Software program automatically screens transmitted insurance claims and electornically examins them for errors and/or conflict code entries.
112
levels of service
insurance carriers expect to see different levels of service listed. If services are downcoded and physician neglected to document correct level of service, an addendum to medical record must be made to justify level of service reported. Amended chartge notes must be labeled "addendum" or "Late entry" dated on day of amendment and signed by physician.
113
Fax transmissions for insurance claims
unless otherwise prohibited by state law, information that is transmitted by fax is acceptable, and may be filed iwth the patient's health record.
1. fax is derived from facsimile
2. state law may prohibit transmitting claims information by fax
3. sensitive information should have a cover sheet
4. confirm the fax arrived at destination
114
Sensitive information
from legal standpoint, protecting patient's confidentiality in fax process crucial.
PATIENT MUST SIGN AUTHORIZATION TO RELEASE INFORMATION VIA FAX.
fax machines should be in secure, private location. a cover sheet always used containing recipient name, sender, date, total of pages, fax telephone numbers, a statement of personal, priviledged and confidential medical information intended for the named recipient only. with request that authorized receiver sign and return attached receipt form at bottom of cover letter. use coded reference number
115
AHIMA (American Health Information Management Association) vs fax machine
do not use fax machines routinely
1. hand or mail delivery will not meet needs of immediate patient care
2. required by a third party for ongoing certification of payment for hospitalized patient
116
what to not fax
American Health Information Management Association
117
transmittal verification
verify fax was received or ensure fax received at destination or run log from fax machine
118
Medicare fax policy
check with medicare fiscal intermediarey as to acceptability in faxing
119
subpoena (term)
under penalty - writ requiring the appearance of a witness at a trial or other proceeding, see details on pp 118-120
120
subpoena duces tecum (term)
requires witness to appear an dbring or send certain records in his possession
121
PHI
protected health info.
122
ESI
electronically stored info.
123
ESI issues
concern that they may be altered, overwritten without leaving any evidence, or stored in several computer systems. Metadata or supportive data that is information on the computer system about the medical data
124
Metadata
supportive data that is information on the computer system about the medical data such as
- substantive data is application based and may contain modifications, edits, or comments
- system-based data includes author, date and time when the entry was created, and date of modification
- embedded data is text, numbers, content direcdtly imput but not visible on output (eg., spreadsheet formulas or hyperlinks)
125
notary subpoena
subpoena issued by notary public
126
retention of records
preservation of health records governed by federal, state and local laws. see pp 120
127
Federal False Claims Act
proof materials for the establishment of evidence should be kept indefinitely in event of legal inquiry. Calendars, appointment books and telephone logs also should be filed and stored.
128
Federal Rules of Civil Procedure
makes requests for electronic data a standard part of the discovery process during federal lawsuits including health, accounting phone, instant messaging and electronic mail that might be needed for future litigation
129
HIPAA (The Health Insurance Portability and Accountability Act of 1996) NPP (Notice of Privacy Practices) acknowledgements
kept for at least 6 years from date of creation
130
Termination of a case
physican may terminate a contract
- sending a certified letter of withdrawal to patient (if refused by patient, file returned letter in patient's chart)
- sending a certfieid letter of confirmation of discharge when patient states that he or she no longer desires care
- send letter confirming that the patient left the hospital against medical advise or the advise of physician, UNLESS signed statement in patient's hospital records
131
Reasons for proper medical record Documentation (four)
every patient seen by physician must have comprehensive legible documentation about what occurred during the visit for the following reasons; (1) avoidance of denied or delayed paments
2. enforcement of medical record keeping rules by insurance carriers
3. suppoena of health record by state investigators or the court for review
4. defense of a professional liability claim
132
Electronic health record as tool
foremost tool of clinical care and communication
133
Medical records evolving into electronic media
HIPAA directs adoption of national electronic standard
134
CMS introduced documentation guidelines to Medicare carriers
ensures that services paid for have been provided and were medically necessary and that documentation must support the level of service and each procedure rendered
135
External and internal audits
show where deficiencies occur in health record documentations and substantiantes proper use of diagnostic and procedure codes
136
HIPAA medical records
must be signed or electronically verified by provider to show the note was reviewed and the test results were acknowledge
137
Levels of E/M services are based on four types of physical examination:
problem focused, expanded problem focused, detailed, and comprensive
138
retention of Records for living patients
Usual policy of physicans to retain medical records
139
Error corrections for paper chart
Use a permanent ink pen to cross out an incorrect entry on patient's record, mark though it with single line, and write the correct infoeramtion, then date an initial the entry.
140
Error corrections for electronic medical record
note that a section is in error with date and time and enter the correct information with a notation of when and why the physician changed the entry.
Authenticate the correction via electronic signature and date. ALSO, could flag record as amended or obsolete and create an addendum either typed as a separate document or for a chart note inserted belowe in the next space availab.e
141
Documenters
A. physician handwrites or dictates notes for patient visit
B. a transcriptionist or correctionist
c. receptionist/medical assistant
D. insurance billing specialist enters codes and/or claim information
142
in situ (abbv term)
In the original or natural place or site.
143
Physician charting methods
1. SOAP
subjective-objective-assessment-plan
2. CHEDDAR
chief complaint
history of present illness
examination
details
drug & dosage
assessment
return visit information or referral
144
Function of the Medical Chart
Documents health information of patients
Resource for treatment planning
Mechanism of ____communication____ among health care providers
Serves as a __legal document_ _for a patient's healthcare information
Since it is a legal document must careful in what you write in the chart
145
Characteristics of Paper Chart
Storage: 3-ring binder
Hard cover protects paper
Sheets of paper can be easily manipulated
Can be used multiple times
Organization
Separated into logical sections by __tabbed______ dividers
Each tab is labeled with section heading
146
Characteristics of Electronic Chart
Patient information is entered into a computer software program that is available throughout the hospital
Information separated into sections like a paper chart
Advantages over paper charts
Eliminates problems with _illegible___ writing
Easy to access data from previous admissions
Software may interface with labs, diagnostics, etc.
Software may offer physician order entry
147
Using a Medical Chart: Flagging
Each facility has policies for medical chart use
_Flagging_
Process used to identify patient order status
Used to communicate what should be done next to ensure completion of patient orders
Types
Color-coordinated to communicate importance level of orders
Binder _positioning__ or placement
148
Using a Medical Chart: Clipboards or Clip Charts
Extension of the medical chart
Contains _daily_ information that is frequently updated or referenced
Frees up medical chart for use
Information filed in the medical chart at end of day
Used for day to day type of information blood pressure, glucose if diabetic, temperature, so you do not have to carry the entire chart.
149
Typical Locations to Find a Medical Patient Chart
-Nursing Station
-Patient Bedside
-Rolling Chart Rack
-Outside Patient's Room
150
