Charting

1. Charting Medical Careers Ms. Bystrom

2. The Medical Record (chart) • Most important document kept in medical office • Must be accurate & clearly written • Legal document

3. Methods of Charting • Some MDs have assistant chart while they perform the exam • Some MDs chart themselves • Some dictate (record) information to be transcribed • Computer charting

4. Purpose of a Chart • Serves as a basis for planning patient care • documents evidence of the course of the evaluation, Tx and change in condition • documents communication between the MD and other healthcare professionals

5. Purpose of a Chart • Protects in legal issues involving the pt and MD • Establishes a database for use in continued education • Protects from loss of contract with insurance companies

6. Subjective & Objective notes • Subjective: Information supplied by the patient that the MD cannot see • Objective: Information provided by the physician that can be seen, heard, measured or felt.

7. Parts of a Chart • Administrative data • Insurance information • Correspondence • Referrals • Past medical records • Progress notes • Diagnostic information • Lab information • Medications

8. SOMR & POMR Two types of medical records are: • SOMR: Source-Oriented Medical Record • Chronological set of notes for each visit; most recent on top • POMR: Problem-Oriented Medical Record • List of problems on top, sections within the chart for each problem

9. SOAP Notes • A method of charting each visit the patient comes in for. • Subjective info • Objective info • Assessment (Dx) • Plan

10. Abbreviations • Shortened form of a word used to save time and space • Never make up abbreviations or use them if unsure • Some abbreviations have a completely different meaning if they are CAPITALIZED or lower case-use caution!

11. Correcting a Mistake while charting • Draw a single line through it • Write “error” above it • Write your initials & date • Never use white out or scribble out completely

12. First office contact • Telephone contact • Personal visit • Emergency visit

13. Forms in a Chart • Medical Hx Form • Pt information sheet • Chart note • Miscellaneous forms

14. Medical History Form

15. Parts of a Medical Hx Form • Chief Complaint • Present illness • Past Hx • Family Hx • Social Hx • Review of systems

16. Completing a Medical Hx Form • Put pt at ease • Keep conversations on track • Be professional • Don’t pry for information from a difficult pt • Address sensitive topics last • Ensure pt privacy • Update forms as needed for established pts

17. Patient information sheet

18. Patient information sheet • Contains: • Personal information (non-medical) • Patient demographics (age, sex, race) • Insurance/billing information

19. Chart note

20. Chart note • Completed at each visit for current chief complaint • Includes SOAP

21. Chief Complaint • A chief complaint (CC) is the specific reason why the patient came to see the doctor that day. • The CC should be short but detailed. Use abbreviations and medical terms when possible.

22. Characteristics of a Chief Complaint • Location • Radiation • Quality • Severity • Associated symptoms • Aggravating factors • Alleviating factors • Setting and timing

23. Rules of Charting • Use black ink • After charting draw a line to the end and initial and abbreviate your title. • Do not leave spaces between chart note and initials. • Do not use ditto marks • Do not erase, scribble out or white out any mistakes

24. Rules of Charting cont… • Do not leave spaces between each chart note • Use standard abbreviations only • Use correct grammar and spelling • Write patients name and DOB on each page • NEVER chart for another person

25. Rules of Charting cont… • Do NOT diagnose! • Date every visit • Be specific