Patient Health Records Overview

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Questions and Answers

What is the first step in the ACSM 5-step approach?

Medical history

Care plan

Fitness assessment

Screening (correct)

Which aspect is NOT a requirement for the documentation of care according to the SJHC standard?

Must be accurate and legible

Must include the patient's unique identifier

Must contain personal opinions (correct)

Must be timely and signed by the provider

What is the most common exercise-related complication identified?

Dehydration

Cardiovascular events

Fatigue syndromes

Musculoskeletal injuries (correct)

Which phrase best describes cardiovascular events in relation to exercise?

Often leads to acute myocardial infarction and sudden cardiac death Signup and view all the answers

What method should be used to correct an entry in clinical documentation?

Cross out the incorrect statement, note 'mistaken entry' and explain Signup and view all the answers

What is the risk level of exercise-related cardiovascular events in general?

The risk is extremely low but not 0. Signup and view all the answers

How does vigorous exercise affect the risk of cardiovascular events?

It lowers the risk. Signup and view all the answers

What does the old ACSM pre-participation screening algorithm primarily focus on?

Medical examination by a physician. Signup and view all the answers

What criteria define someone as 'regularly active' according to step 1 of the ACSM algorithm?

Performing planned, structured activity of moderate intensity for at least 30 minutes on 3 or more days per week. Signup and view all the answers

What is the primary purpose of the ACSM pre-participation screening algorithm?

To identify an individual's risk of exercise-related cardiovascular events. Signup and view all the answers

Which factor was removed from the new ACSM pre-participation screening algorithm?

Pulmonary disease considerations. Signup and view all the answers

Which of the following represents a common risk for sedentary individuals engaging in exercise?

Higher likelihood of experiencing a myocardial infarction. Signup and view all the answers

What should individuals consider before participating in exercise after a long period of inactivity?

The likelihood of a heart attack. Signup and view all the answers

What is the primary purpose of a patient's health record?

To document the health history and care journey of the patient Signup and view all the answers

Which of the following is NOT a reason for maintaining a patient's health record?

To memorize each patient's preferences Signup and view all the answers

What principle is essential for recording keeping in health records?

Records should be accurate and timely Signup and view all the answers

How long must RKin retain records for patients who are 18 years or older?

At least 10 years after last contact Signup and view all the answers

Which aspect is crucial for ensuring that records are usable and maintain integrity?

Every entry must be dated and signed Signup and view all the answers

What should NOT be recorded in a patient's health record?

The patient's favorite activities Signup and view all the answers

What is a critical component of demonstrating effective record keeping as a kinesiologist?

Each record being written in chronological order Signup and view all the answers

When should an RKin decide to document an encounter with a patient?

After consent is obtained and relevant discussions occur Signup and view all the answers

What ensures accountability in patient record keeping?

Following guidelines mandated by organizations and laws Signup and view all the answers

What is one of the key objectives of proper record keeping?

To facilitate safe and quality care Signup and view all the answers

Study Notes

Patient's Health Record

A patient's health record is a detailed written account of their health history and care journey
It includes health history, health goals, details of each encounter, outcomes, and prognosis.

Importance of Patient's Health Record

Acts as a communication tool for other healthcare providers.
Allows tracking of patient progress and adjustment of care.
Helps determine future care needs.
Serves as a memory aid for healthcare professionals managing many patients.

Objectives of Record-Keeping

Facilitates quality patient care by documenting events and knowledge history.
Ensures access to accurate information about a patient's health.
Ensures continuity of care from different healthcare professionals.
Maintains accountability to patients, clients, payors, healthcare providers and professional organizations
Demonstrates professional judgment, reasoning and adherence to practice standards.
Meets organizational and legal requirements.

Principles of Recording Keeping

Identifiable
Legible and understandable (grammatically correct)
Comprehensive (easy to understand)
Accurate (timely recording, generally within 2 hours)
Accessible and retrievable
Secure and confidential

Kinesiologist's Role in Record Keeping

Every part of the record has a unique identifier (e.g., hospital number, date of birth).
Records should be sequential (e.g., chronologically).
Every entry should be dated and signed.
Changes to records should be clearly indicated, and the original record retained.
Information recorded should be legible.
Information should be entered within a reasonable timeframe (ASAP or within 24 hours).
Appropriate language should be used.
An audit trial should be maintained.

Information to Record

Demographics (date of birth, address).
Primary physicians and referring professionals.
Reason for referral.
Date, purpose, and mode of contact.
Chief complaints or concerns and supporting data.
Past health, family, and social history.
Records of imaging and reports from other healthcare professionals.
Appointment cancellations and reasons.
Examinations, assessments, tests, impressions, treatments, and who performed them.
Informed consent details and recommendations.
Referrals to other health professionals.
Any controlled acts performed.
Any procedures that were commenced but not completed or refused and the reasons why.
Perceived or potential conflicts of interest.
Abbreviations used, and the discharge of the patient.
Consent and discussion details.
Health history, assessment results, and interpretations.
Treatment provided and patient response.
Referral to other professionals.

Patient Record Retention

Records are to be kept for at least 10 years if the patient is 18 or older.
If the patient is below 18 years of age, the record is to be retained for a period of at least 10 years after the patient reaches 18 years of age or the last contact.

Record Destruction

Records must be destroyed securely using a method that prevents retrieval.

SJHC 'Clinical Documentation' Standard

Documentation must be complete, accurate, legible, and timely.
Completed by healthcare professional, including signature and date.
Uniquely identify the patient and avoid value judgments.
Indicate corrections by crossing out, re-writing the correct information, and stating “mistaken entry” and the reason.

ACSM 5-Step Approach

Screening
Medical history
Fitness assessment
Special considerations
Care plan

Musculoskeletal injuries are the most common.
Risks of musculoskeletal injuries and cardiovascular complications tend to be lower with higher physical fitness

Cardiovascular Events

Less common than musculoskeletal injuries but can lead to long-term morbidity and higher risk of mortality.
Heart attack risk increases significantly during periods of re-entry into vigorous exercise after a period of inactivity.
Risk inversely related to physical fitness

ACSM Pre-Participation Screening Algorithm

Based on current physical activity levels.
Accounts for signs of cardiovascular, metabolic, or renal disease.
Includes planned physical activity intensity.
Emphasises medical clearance when necessary.

Step 1 of ACSM Pre-Participation Screening Algorithm

The individual should be checked for having regularly engaged in physical activities (30 minutes or more physical activity every 3 days for the past 3 months).

Step 2 of ACSM Pre-Participation Screening Algorithm

Assess if the individual has any diseases present, or signs of disease. Risk factors include: hypertension; metabolic/ type 1 or 2 diabetes; renal issues (renal disease, poor appetite, swelling (in lower body); angina (chest pain); shortness of breath; feeling lightheaded; breaking out in cold sweats; sickness to the stomach.

Step 3 of ACSM Pre-Participation Screening Algorithm

Establish the individual's exercise intensity planned for their workouts. This intensity may result in a slight increase in breathing and heart rate, allowing for conversations.

Rate of Perceived Exertion (RPE) Scale

Used for ascertaining workout intensity.
RPE 6 (resting), RPE 20 (maximal exertion). Moderate to vigorous intensity lies between RPE 12-15.

Submaximum CRF tests

Use heart rate and breathing to determine activity intensity in submaximum testing.
Typically 70% of heart rate reserve (HRR) or 85% of predicted maximum heart rate (HR max) .

Other considerations for Exercise Testing

Ensure adequate cool-down and recovery time.
Monitor symptoms throughout testing
Stop testing if signs of discomfort or distress are present.

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Description

This quiz covers the essential components and significance of a patient's health record in the healthcare system. It highlights the importance of accurate documentation and continuity of care, addressing the objectives of record-keeping in patient management. Test your knowledge on how health records influence communication among healthcare providers and support patient care.