Elements of Medical Record

Questions and Answers

Which of the following elements typically includes information about habits such as smoking and alcohol consumption?

Social History

What part of the record format is primarily used to document the patient’s narrative of their current symptoms?

History of Present Illness

In a medical record, where would you typically find the list of the patient's known drug reactions?

Allergy

Which section of a patient’s record includes their blood pressure, heart rate, and temperature?

Vital Signs Signup and view all the answers

Where in the medical record would one typically document the patient’s surgical interventions?

Surgical History Signup and view all the answers

Which of the following is typically included in a medical record?

Current active diagnosis Signup and view all the answers

What type of history specifically outlines a patient's previous illnesses in a medical record?

Past medical histories Signup and view all the answers

Which of these is not a component typically recorded in a patient's medical record?

Diet preferences Signup and view all the answers

What information in the medical record provides insight into the patient’s living habits and potential exposures?

Social histories Signup and view all the answers

Which component of the medical record helps in identifying inherited health patterns?

Family histories Signup and view all the answers

What is a key characteristic of Electronic Medical Records (EMRs)?

They are digital versions of paper charts. Signup and view all the answers

How are handwritten medical records typically created?

By writing the information manually. Signup and view all the answers

Which description best fits EMRs?

Electronic Health Records (EHRs). Signup and view all the answers

What distinguishes handwritten records from EMRs?

Handwritten records involve physical writing. Signup and view all the answers

In what aspect are EMRs and handwritten records similar?

Both may contain detailed health information of a patient. Signup and view all the answers

What is the primary function of medical coding?

To transform healthcare diagnosis, procedures, and services into universal alphanumeric codes. Signup and view all the answers

Which manuals might a medical coder use to assign codes?

ICD10PCS, CPT, HCPCS Signup and view all the answers

What is the initial step in the medical coding process?

A patient meets with a physician for a medical consult. Signup and view all the answers

In which stage does the creation of the medical record occur?

Physician creates medical record for his patient Signup and view all the answers

In the medical coding process, what does the medical coder do after analyzing the patient's medical record?

Assigns codes using ICD10CM/ICD10PCS/CPT/HCPCS manuals. Signup and view all the answers

What additional medication was prescribed along with the short course of prednisone?

Pulmicort flex haler Signup and view all the answers

Which of the following symptoms did the patient deny experiencing?

Fever Signup and view all the answers

Which physical exam finding was noted in the patient's lung examination?

Rhonchi Signup and view all the answers

How long has the patient experienced difficulty expectorating?

2-3 weeks Signup and view all the answers

Which of the following is NOT part of the patient's medical history?

Diabetes Signup and view all the answers

What was the patient's oxygen saturation level during the physical exam?

97% Signup and view all the answers

What is the primary purpose of the E-Tool?

To enter medical codes after reviewing medical records. Signup and view all the answers

How does a 'Record' differ from an 'Encounter'?

A Record contains medical documentation of patient visits. Signup and view all the answers

Which statement accurately describes an 'Encounter'?

It is each visit of a patient to a healthcare facility. Signup and view all the answers

In which scenario could a patient record possibly have empty pages?

When the record contains only one visit. Signup and view all the answers

What does the review process of medical records typically entail in the context of E-Tool usage?

Abstracting and entering codes into the E-Tool. Signup and view all the answers

Which of the following elements is critical in identifying a patient in a medical record?

Patient's demographics details Signup and view all the answers

Which of these is a key difference between electronic tools (E-tools) and traditional medical records?

E-tools offer more sophisticated data analysis and management capabilities. Signup and view all the answers

What is a significant advantage of face-to-face encounters in medical assessments?

They allow for direct physical examinations. Signup and view all the answers

Which of the following is not typically considered an element of a medical record?

Insurance policy information Signup and view all the answers

Why is the provider's signature an essential concept in medical records?

It confirms the authenticity and accountability of the healthcare provider's notes. Signup and view all the answers

What observation about the left ear is documented?

Ear pop at this Signup and view all the answers

What does 'Px patent' signify in the document?

Patent airway Signup and view all the answers

Which term indicates a specific ear condition in the text?

EP 1/2 Block Thin wall of un Signup and view all the answers

Which acronym or term in the document is not clearly defined and might need further clarification?

Phonynt Signup and view all the answers

What phrase indicates a normal physical examination of the cardiovascular system?

PE: Reg (NB) card + The Signup and view all the answers

Which medication was added to the patient's treatment plan during the fourth encounter?

Pulmicort flex haler Signup and view all the answers

What symptom did the patient NOT report during the subjective examination?

Chest pain Signup and view all the answers

During the objective examination, which abnormal respiratory finding was observed?

Rhonchi Signup and view all the answers

What was the patient's oxygen saturation on room air during the physical examination?

97% Signup and view all the answers

Which historical condition is listed in the patient's assessment?

Hypertension Signup and view all the answers

What type of follow-up was planned for the patient?

Chest X-ray Signup and view all the answers

What is the patient's current smoking status?

He is a non-smoker. Signup and view all the answers

Which diagnostic imaging was performed to check for disease recurrence?

CT of the chest Signup and view all the answers

What type of follow-up is recommended for the patient?

Semi-annual chest x-rays Signup and view all the answers

How is the patient's physical condition described regarding lung examination?

Lungs are somewhat diminished in the resected area. Signup and view all the answers

What treatment did the patient undergo after resection of the lung cancer?

Adjuvant carboplatin and Alimta Signup and view all the answers

Which of the following symptoms is NOT mentioned as absent in the patient's health report?

Nausea Signup and view all the answers

Study Notes

Medical Record

A medical record is a document that explicitly describes a patient's current clinical picture.
It includes current active diagnosis, past medical histories, social histories, surgical histories, family histories, physical exam, lab orders & values, medications, and radiology.

Elements of Record

Patient demographic details
CC - Chief Complaint
HPI - History of Present Illness
PMH - Past Medical History
Surgical History
Social History
Family History
ROS - Review of System

Other Elements

Problem list/Active problem list/chronic problem list
Medication list
Allergy
Risk Factors
Vital Signs
Physical Examination
Assessment/Impression
Plan/Refer

Types of Medical Record

EMR (Electronic Medical Record)
Handwritten records

EMR

Electronic medical records (EMRs) are digital versions of the paper charts which include all the health information of the patient.
EMR is a software where the coders enter the codes after reviewing the medical records.

Handwritten Records

Handwritten records are written documents of patient information, health history, physical examination, and treatment plans instead of typing.

Medical Coding

Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
Stages of medical coding:
- Patient meets physician
- Physician creates a medical record
- Medical coder analyzes the medical record
- Medical coder assigns codes using specified manuals

E-Tool

E-Tool is a software where the coders enter the codes after reviewing the medical records.

Record vs Encounter

Encounter: Patients each visit to the hospital or clinic regarding health issues.
Record: A record may have either one visit or more than one number of visits. Some records may even have empty pages.

Examples of Handwritten Records

Written document of patient details, including patient DOB, vital signs, physical examination, and treatment plans.

Examples of EMR Records

Electronic version of patient's medical information, including history, physical examination, impression, and plan.

Provider Information

Provider type: IP, OP, P
Codes: 110 - Essential Hypertension

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Description

This quiz covers the essential components of a medical record, including patient demographics, chief complaint, medical history, and more. Test your knowledge of medical documentation and patient assessment.