Contents
- 1 When a patient feels to return for need a treatment documentation should be made?
- 2 How do you correct an entry on a medical record?
- 3 What is the recording of information in a patient’s medical record?
- 4 What types of information should not be included in a patient’s medical record?
- 5 When is a medical record entry considered cloned?
- 6 What makes an entry in a medical record legible?
When a patient feels to return for need a treatment documentation should be made?
A Fordney Ch3
| Question | Answer |
|---|---|
| The SOAP in patient medical record charting may be defined as | S-subjective, O-objective, A-assessment, P-plan |
| When a patient fails to return for needed treatment, documentation should be made | In the patient’s medical record, the appointmant book and on the financial record or ledger card |
How do you correct an entry on a medical record?
When an error is made in a medical record entry, proper error correction procedures must be followed.
- Draw line through entry (thin pen line).
- Initial and date the entry.
- State the reason for the error (i.e. in the margin or above the note if room).
- Document the correct information.
What is the recording of information in a patient’s medical record?
A medical chart is a complete record of a patient’s key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.
Which of the following should occur before an item is filed into the medical record?
Which of the following should occur before an item is filed into the medical record? It should be checked for completeness. It should be checked for readability. It should be checked for appropriate signatures.
Can you get things removed from medical records?
The Privacy Act gives you the option of requesting removal of an item from your medical records, but your physician is only required to add a notation to the record indicating your request. Under HIPAA, there is no legal obligation for your provider to remove information at your request.
What types of information should not be included in a patient’s medical record?
The following is a list of items you should not include in the medical entry:
- Financial or health insurance information,
- Subjective opinions,
- Speculations,
- Blame of others or self-doubt,
- Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
When is a medical record entry considered cloned?
“Documentation is considered cloned when each entry in the medical record for a patient is worded exactly alike or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from patient to patient.
What makes an entry in a medical record legible?
“All entries must be legible to another reader to a degree that a meaningful review may be conducted. All notes should be dated, preferably timed, and signed by the author.” Compliance Tips: Legibility of medical record documentation is not just a billing issue; it’s a patient care issue.
Where does documentation go in a medical record?
When a patient fails to return for needed treatment, documentation should be made in the patient’s medical record, in the appointment book, on the financial record or ledger card.
When is a delayed medical record entry acceptable?
Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.”