Chapter 9 - Maintaining patient records. After studying this chapter you will be able to understand: Explain the purpose of compiling patient medical records, describe the contents of patient record forms, describe how to create and maintain a patient record, identify and describe common approaches to documenting information in medical records,. | PowerPoint® to accompany Chapter 9 Second Edition Ramutkowski Booth Pugh Thompson Whicker Chapter 9 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Medical Assisting Chapter 9 Objectives 9-1 Explain the purpose of compiling patient medical records. 9-2 Describe the contents of patient record forms. 9-3 Describe how to create and maintain a patient record. 9-4 Identify and describe common approaches to documenting information in medical records. Maintaining Patient Records Maintaining Patient Records 9-5 Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records. 9-6 Discuss tips for performing accurate transcription. 9-7 Explain how to correct a medical record. 9-8 Explain how to update a medical record. 9-9 Identify when and how a medical record may be released. Objectives (cont.) Maintaining Patient Records Importance of Patient Records Patient Records Also known as charts . | PowerPoint® to accompany Chapter 9 Second Edition Ramutkowski Booth Pugh Thompson Whicker Chapter 9 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Medical Assisting Chapter 9 Objectives 9-1 Explain the purpose of compiling patient medical records. 9-2 Describe the contents of patient record forms. 9-3 Describe how to create and maintain a patient record. 9-4 Identify and describe common approaches to documenting information in medical records. Maintaining Patient Records Maintaining Patient Records 9-5 Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records. 9-6 Discuss tips for performing accurate transcription. 9-7 Explain how to correct a medical record. 9-8 Explain how to update a medical record. 9-9 Identify when and how a medical record may be released. Objectives (cont.) Maintaining Patient Records Importance of Patient Records Patient Records Also known as charts containing: Past and present medical conditions Communications between health team members Name and address Insurance coverage Occupation Medical treatment plan Health-care needs Response to care Lab and radiology reports The chart is a legal document and can play a role in patient and staff education. It may also be used for quality control and research. Importance of Patient Records Legal Guidelines for Patient Records As a general rule, if information is not documented, there is no proof it was ever done. Charts are used in court. Standards for Records Complete, accurate, and well-documented records can serve as convincing evidence that the doctor provided appropriate care. Incomplete, inaccurate, altered, or illegible records may imply poor standards. Importance of Patient Records Additional Uses of Patient Records Patient Education Quality of Treatment Research Contents of Patient Charts Standard Chart Information Patient Registration Form Date of current visit Demographic data
