The Medical Record

1. Chapter 4 The Medical Record

2. History and Physical H & P Figure 4.1 page 58 • Document of medical history and findings from physical examination Includes: • Subjective information — Historyobtained from patient including his/her personal perceptions • Objective Information — Physicalfacts and observations made by an examiner

3. History (Hx) • Record of the patient’s personal medical history including past injuries, illnesses, operations, defects, and habits • Includes: chief complaint, history of present illness, past history, family history, occupational history and review of systems

4. History (Hx) Abbreviations CC Chief Complaint orc/o complains ofBrief description of why patient is seeking care PI or HPI Present Illness/History of Present IllnessNotation of duration and severity of complaintHow bad is it? How long have they had it? Sx symptomEvidence of illness that the patient reports

5. History (Hx) Abbreviations (continued) PH, PMH Past History, Past Medical HistoryNotation of surgeries, injuries, physical defects, medications, allergies UCHD usual childhood diseases NKA no known allergies NKDA no known drug allergies

6. History (Hx) Abbreviations (continued) FH Family HistoryNotes about the state of health of immediate family members Example: FH: father, age 58, mother, age 54, brother, age 32, all L&W A&W alive and well L&W living and well

7. History (Hx) Abbreviations (continued) SH Social Historyrecreational interests, hobbies, use of tobacco/drugs OH Occupational Historywork habits that may involve work related risks ROS or SR Review of Systems, Systems Reviewquestions related to function of the body systems HEENT head, eyes, ears, nose, throat

8. Physical Exam (Px or PE) • Document of physical examination of a patient including notations of positive and negative findings Includes: results of diagnostic testing Sign — objective evidence of disease

9. Physical Exam Abbreviations HEENT head, eyes, ears, nose, throat PERRLA pupils equal, round and reactive to light and accommodation NAD no acute distress, no appreciable disease WNL within normal limits

10. History and Physical Impression (IMP) Diagnosis (Dx) Assessment (A) identification of a disease or condition after evaluation of all subjective and objective information Rule out (R/O) a differential diagnosis noted when one or more diagnoses are suspect — requires further testing to verify or eliminate each possibility

11. History and Physical (continued) PLAN,RECOMMENDATION, orDISPOSITION outline of the treatment plan designed to remedy the patient’s condition, which includes instructions to the patient, orders for medications, diagnostic tests, or therapies

12. Problem Oriented Medical Record (POMR) • Health record with focus on patient’s problem • Information organized for access at a glance • Documents thought processes of provider • Consists of four sections: • Database • Problem list • Initial plan • Progress notes

13. Problem Oriented Medical Record (POMR) (continued)

14. SOAP Notes Progress notes made after the initial history and physical is recorded. The letters represent the order in which progress is noted: S subjective — that which the patient describes O objective — observable information, such as test results, blood pressure readings, etc. A assessment — progress and evaluation of the effectiveness of the plan P plan — decision to proceed or alter strategy

15. Common Hospital Records • History and Physical • Physician’s orders • Diagnostic tests/laboratory reports • Nurse’s notes • Physician’s progress notes • Consultation Report • Operative Report • Pathology report • Anesthesiologist’s report

16. Common Patient Care Abbreviations Use only those acceptable to workplace emergency facility ER, ECU place to recover after surgery PAR, PACU registered bed patient IP care before surgery preop patient pt well developed, well nourished WDWN bathroom privileges BRP

17. Common Patient Care Abbreviations (continued) difficulty breathing SOB treatment Tx, Tr temperature, pulse, T, P, R, BP =respiration, blood pressure VS or vital signs increase  decrease  degree or hour ° pound or number sign #

18. Error Prone Abbreviations and Symbols Medical errors caused by illegible entries and misinterpretations have led health care agencies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), to require that medical facilities publish lists of authorized abbreviations for use by all personnel, including a list of those unacceptable.

19. Error Prone Abbreviations and Symbols (continued) q. d every daymistaken for q.i.d when the period after the “q” is sloppily written to look like an “i” spell out “daily” q.o.d. every other daymistaken for q.d when the “o” is mistaken for a period spell out “every other day”

20. Error Prone Abbreviations and Symbols (continued) DC, D/C discharge, discontinuemistaken for “discontinue” when followed by medications prescribed at the time of discharge spell out “discontinue” or “discharge” >, < greater than, less thanmistaken for each other spell out

21. Error Prone Abbreviations and Symbols (continued) AS, AD, AU left ear, right ear, both earsOS, OD, OU left eye, right eye, both eyesmistaken for each other spell out SC or SQ subcutaneousmistaken for SL (sublingual), or “5 every”. spell out "subcutaneously“ or use Sub-Q

22. Diagnostic Imaging Modalities IONIZING IMAGING a process that changes the electrical charge of atoms with a possible effect on body cells. Overexposure can have harmful side effects, e.g. cancer • RADIOGRAPHY (X-RAY) • COMPUTED TOMOGRAPHY OR COMPUTED AXIAL TOMOGRAPHY • NUCLEAR MEDICINE IMAGING OR RADIONUCLIDE ORGAN IMAGING

23. Diagnostic Imaging Modalities (continued) NON-IONIZING IMAGING a process that presents no apparent risk • MAGNETIC RESONANCE IMAGING • SONOGRAPHY

24. Common Terms Related to Disease acute vs chronic benign vs malignant localized vs systemic exacerbation vs remission progressive recurrent degenerative

25. Common Terms Related to Disease (continued) symptom (subjective) sign (objective) diagnosis (through knowing) syndrome (running together) prognosis (before knowing) etiology (study of cause) idiopathic (disease of individual) sequela

26. Common Terms Related to Disease (continued) good vs malaise febrile vs afebrile gross marked equivocal noncontributory unremarkable morbidity mortality

27. Pharmaceutical Abbreviations and Symbols • Metric • cc (cubic centimeter) • cm (centimeter) • g or gm (gram) • kg (kilogram) • L (liter) • mg (milligram) • ml, ML (milliliter) Note: 1 cc = 1 mL • mm (millimeter) • cu, mm (cubic millimeter)

28. Pharmaceutical Abbreviations and Symbols (continued) • Apothecary • fl oz (fluid ounce) • gr (grain) • gt (drop) • gtt (drops) • dr (dram) • oz (ounce) • lb or # (pound) • qt (quart)

29. Medication Administration — Drug Forms • Solid and Semisolid Forms • Tablet (tab) • Capsule (cap) • Suppository (suppos) • Liquid Forms • Fluid • Parenteral (ID, Sub-Q, IM, IV) • Cream, lotion, ointment • Other delivery systems • Transdermal • Implant

30. Parenteral Drug Administration

31. The Prescription • Physician’s written direction for dispensing or administering a medication for a patient • Must be written in a specific format • Rx — • Symbol at beginning of prescription • Stands for recipe

32. Drug Names Chemical name — assigned to drug at the time it is formulated Generic name — the official, nonproprietary name given a drug Trade or brand — the manufacturer's name for a drug

33. Drug Names (continued) For example: Chemical name: 1-[[3-(6,7-dihydro-1-methyl-7-oxo-3-propyl-1H-pyrazolo[4,3-pyrimidin-5-yl)-4-ethoxyphenyl]sulfonyl]-4-methylpiperazine citrate Generic name: sildenafil Trade or Brand name: Viagra

34. Sample Prescription

35. Military Time

36. Corrections • Careful clarification of an error when making an entry in a medical record is essential. • Include: • Date • The abbreviation “corr” • Initials of person making corrections • Do not use correction fluid!

37. Proper Correction of a Medical Record