Chapter 11

• The assessment portion of the medical records helps to document the evaluation of the patient to support diagnosis and treatment decisions.
• The primary purpose of medical documentation is to help health professionals communicate effectively, make informed decisions, and provide continuity of care.
• Physician’s orders consist of directives for tests, treatments, medications, and follow-up care.
• A patient’s medical record is considered a legal record of their medical history and health care.
• A flow sheet contains a graphic record of a patient’s vital signs, medications, or other specific information over a period of time.
• Progress notes that record information in a paragraph style using a narrative format.
• An intake sheet includes demographic data and insurance information provided by the patient prior to receiving care.
• Military time is based on a 24-hour cycle.
• Most health care facilities have converted from paper records to an electronic format.
• Benefits of using electronic physician’s orders include improved accuracy, accessibility, and efficiency in managing patient care.
• The purpose of progress notes is to document the patient’s current status, changes in condition, and the effectiveness of treatments.
• Family history is included in the patient’s history to identify potential hereditary health risks or conditions.
• Health care facility quality assurance efforts include the review of patient medical records.
• A problem-oriented medical record is organized around a patient’s specific health problems or diagnoses.
• The assessment portion of the medical records helps to document the evaluation of the patient to support diagnosis and treatment decisions.
• Objective data in a medical record refers to measurable and observable information (e.g., vital signs), while subjective data is based on the patient’s feelings or experiences.
• The primary purpose of medical documentation is to help health professionals communicate effectively, make informed decisions, and provide continuity of care.
• A source-oriented medical record is organized by the source of the documentation, such as a separate sections for laboratory reports, progress notes, etc.
• Physician’s orders consist of directives for tests, treatments, medications, and follow-up care.
• Advantages of computerized medical records include improved efficiency, accessibility, legibility, and reduced risk of errors.
• A patient’s medical record is considered a legal record of their medical history and health care.
• A key benefit of electronic charting is the ability to easily access and update patient information, improving overall efficiency and accuracy.
• A flow sheet contains a graphic record of a patient’s vital signs, medications, or other specific information over a period of time.
• SOAP stands for Subjective, Objective, Assessment, Plan.
• Progress notes that record information in a paragraph style using a narrative format.
• Medical records include codes that document diagnoses and procedures.
• An intake sheet includes demographic data and insurance information provided by the patient prior to receiving care.
• Military time is based on a 24- hour cycle.
• A social history is a record of a patient’s lifestyle, including occupation, education, marital status, diet, and alcohol and tobacco use.
• Most health care facilities have converted from paper records to an electronic format.
• Military time is used in health care to avoid confusion between a.m. and p.m.
• Benefits of using electronic physician’s orders include improved accuracy, accessibility, and efficiency in managing patient care.
• “Charting by exception” is a documentation talking about only the stuff that is wrong with the patient.
• The purpose of progress notes is to document the patient’s current status, changes in condition, and the effectiveness of treatments.
• Family history is included in the patient’s history to identify potential hereditary health risks or conditions.
• Health care facility quality assurance efforts include the review of patient medical records.
• A record is organized around a patient’s specific health problems or diagnoses.
• Objective data in a medical record refers to measurable and observable information (e.g., vital signs), while subjective data is based on the patient’s feelings or experiences.
• A source-oriented medical record is organized by the source of the documentation, such as a separate sections for laboratory reports, progress notes, etc.
• Advantages of computerized medical records include improved efficiency, accessibility, legibility, and reduced risk of errors.