Thinking it Through ch 5

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Mountain Empire Community College *

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271 A81.

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Medicine

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Feb 20, 2024

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docx

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2

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1. You are going through a patient's medical record to find information on a specific lab report, and you notice that several chart notes are not dated. What should you do? If the chart notes are not dated then, one should gather the information that the chart was made by whom, their shift timings, etc. and based on this one can resolve the problem. 2. How does the use of the SOAP format for organizing medical record data minimize a provider's exposure to legal risk? The SOAP format minimizes a provider's exposure to legal risk by improving communication for everyone involved in the care of the patient. 3. You retrieve a patient's medical record and notice that the abbreviation WDWNYM issued several times in the chart notes. You know that this is not an approved abbreviation, though you eventually figure out that it stands for "well-developed, well-nourished young male. "What do you do with this information? In this case, the abbreviation WDWNWF is not an approved abbreviation. However, if this information is pertinent to the care of the patient, you should include it in the chart notes. But I would make a note of what the original author meant by the abbreviation. 4. You are asked to retrieve information regarding a patient's family history of intestinal cancer. The physician generally uses the POMR format. Where in the file should you look? It depends on what type of information you are retrieving. If you are looking for the complete history, you should look in the Database. If you are looking for the patient’s problems, you should look in the Master Problem List. If you were looking for the plan of action for the problems, you would look in the Initial Plan section. If you were looking for the providers’ notes on the patient, you would look in either the Notes section or in the Initial plan section as some providers include notes with their plan of action. 5. A former patient calls, hoping to locate x-rays taken more than 5 years ago. What should you say? I would explain the process for locating old x-rays, then I would ask for information such as the patient’s full name, date of birth, and the date the x-rays were taken. I would then tell the patient that it may take some time for me to find the x-rays, and to assure them that I will do my best to find them. If the x-rays are found I would inform the patient about the next steps to get their x-rays, such as deciding whether they want me to mail them or if they wanted to pick them up from the healthcare facility. If the x-rays cannot be found, I will apologize and explain the situation. Then I would offer alternative solutions such as recommending that the patient discuss with their current provider and have them advise the patient on the best course of action. 6. A patient calls and is moving out of town. She is concerned about her medical record. What would you suggest? When the patient finds a new healthcare provider, they can always request for the patient’s medical record to be transferred to the new provider. If they are not able to do that, the patient can always request a physical copy of the medical record be given to her to take with her.
7. You are transcribing the physician's dictation and cannot understand several words in a chart note. What do you do? I would ask the doctor to talk loudly into the microphone, stay away from disturbances, and communicate effectively. If I continued to have trouble understanding the dictations, I could ask the doctor to explain it to me again.
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