Fiala

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Metropolitan Community College, Omaha *

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1020

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Health Science

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Jan 9, 2024

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docx

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Uploaded by phillipssamantha21

HDIM 1020: Healthcare Data and EHR Page 1 Unit 1: Medical Records: Uses, Format and Content Module 1: Medical record: definition, uses and formats Exercises - 50 points General Directions : Be sure to utilize the Homework Checklist found on the course home page. The following items are most often missed. Beginning with Unit 2, 1 point for each missing item will be deducted when these directions and those on the homework checklist are not followed. 1. Write your answers on this document in Red font . 2. Save this document with your last name as the first word in the file name before uploading it to the drop box as Hajek.1020Unit1M1exercise.docx. 3. Cite all resources used when the ideas are not general knowledge or your own. Place the citation within each exercise that referenced the resource. Words taken verbatim should be in quotations. A full APA citation is not needed for: a. For your text books, use the editor’s last name and page number. b. For web sites, include the name of the web site, the date accessed and the URL. 4. Include your name on this document in the space provided. 5. To submit your homework, save it to a disk you can access. Attach it to the assignment page in Blackboard. DO NOT use the text edit function on the assignment page. Student’s Name: Samantha Fiala Exercise 1: Key questions answered by the medical record. (10 points) Using the key questions that a medical record should answer provided on the PowerPoint for Module 1, evaluate your assigned medical record. See the Scanned Medical Records Folder for this course to find your assigned record. Be sure to consider the whole record and all the services provided. For the location of the information, select the place that confirms the service was provided not just ordered, e.g. the physician’s order contains the order for a drug and the medication profile shows when and the amount of a drug was given. The location to include on the table would be the medication profile. My patient’s name is: Cleo Place each question in a separate box. Key question to be answered by the medical record Data that answers the question. If the medical record does not include the answer, state so. Location of the data item – Form name and date of entry If the answer is not in the medical record, identify the form name where it would found. Clematis, Cleo F. William B. Ackerman, Dr. Summers Self pay Admission Summary Total Abdominal Hysterectomy, Bilateral salpingo-oophorectomy Discharge summary and Operative report.

HDIM 1020: Healthcare Data and EHR Page 2 Unit 1: Medical Records: Uses, Format and Content Module 1: Medical record: definition, uses and formats Exercises - 50 points Key question to be answered by the medical record Data that answers the question. If the medical record does not include the answer, state so. Location of the data item – Form name and date of entry If the answer is not in the medical record, identify the form name where it would found. Admitted on 1-19. Discharged on 1-24. Discharge summary. Sundance Healthcare Systems Painted Valley, USA OR (operating room), Recovery room Room 218 Consent of admissions to hospital care. Procedure or operative record. Discharge Summary. I rregular menses. Back pain related to ovarian cysts. Uterus Fibroid. History and physical, History of present illness. The effectiveness what that the procedure was that it was completed. Until the post operative follow- up appointment, we will not know for sure if pain has subsided or how effective/outcome is affected. Operative Findings. Exercise 2: Primary purpose of the medical record. (10 points) 1. What is the primary purpose of a medical record? The purpose of a medical record is to provide any data or evidence for current and future care that the patient will receive. It allows for communication between staff that is caring for the patients. It allows for insurances to be billed and claims to be paid. 2. Create an example of a patient encounter with the healthcare system. Using this example, describe how documentation of the encounter facilitates and supports the primary purpose. The best resource is the PowerPoint presentation for Module 1. Do not create a note as would appear in the medical record. A patient is coming to receive a consult from a specialty care provider. Patient is registered at admissions and giving all demographic information and insurance. Patient signs consent to treat then waits for appointment. Nurse comes for patient and takes back to room. Vitals are done, along with questions about reason for visit and history of illnesses. After nurse is finished, the nurse will go and brief the physician. The physician comes in and assesses patient and determines what needs to be done for patient. Patient then is scheduled for surgery. Patient leaves clinic.

HDIM 1020: Healthcare Data and EHR Page 3 Unit 1: Medical Records: Uses, Format and Content Module 1: Medical record: definition, uses and formats Exercises - 50 points Exercise 3: Uses of medical records (4 points) Using the example developed for Exercise 2: (The descriptions should show that the student understands the use.) 1. Describe one non patient care use that benefits the patient. Patients’ insurance card was given to registration, which then the patients claim for visit will be able to be paid. 2. Describe one non patient focused use that does not relate to the patient. The licensure of all the staff that are providing care. Examples would be the physician having his licenses current, along with the nursing staff. Exercise 4: Problem Oriented Medical Record – SOAP notes (10 points) Beside each of the following (unrelated) statements, indicate either S, O, A, P to identify whether the statement would be considered subjective, objective, assessment or plan if it appeared in a problem oriented medical record. 1. __ S ___ Patient complains of 3 months of fatigue and recent diarrhea. 2. __ P ___ Check blood sugar and electrolytes every 4 hours. 3. __ O ___ Uncontrolled insulin-dependent diabetes mellitus 4. ___ P __ R/O ulcerative colitis with colonoscopy and barium enema. 5. __ S ___ Patient complained of headache, fatigue and photosensitivity 6. __ S ___ Patient states “I have a fever”. 7. __ A ___CPK 335, LDH 450, SGOT 165 8. _ O ____A 2 cm red area is noted over the sacrum. 9. __ S ___ Complaining of a sore throat on swallowing 10. __ P ___ Daily dressings with antibiotic ointment Exercise 5: Problem oriented progress note (11 points) Using your assigned medical record, describe how it would be reformatted into a problem-oriented record by following the directions below. 1. List the problems. Specify if they are active or resolved and the date/year the problem was diagnosed/identified. (5 points) 1.Regular menses ended in August, then irregular menses began. 2. January – three days of moderate bleeding. 3. Ovarian Cyst- golf ball size. 4. Backpains – several months. 5. Incontinence with heavy lifting. All are active prior to surgery.

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