Question

1.Explain the importance of patient medical records.

2.Identify the documents that constitute a patient medical record.

3.Recall the 6 Cs of charting.

4.Describe the need for neatness, timeliness, accurate, and professional tone in patient records.

5.Describe the steps in responding to a written request for release of medical records.

Answer 1

Ans1. IMPORTANCE OF PATIENTS MEDICAL RECORDS -.

.1. help  in improving quality health care facilities and help the doctors to diagnose and treat patient.

2. Provide support and communication to other team member.

3. Helps the hospitals to comply with legal , ethical and legislative requirements of maintaining patients medical records.

4. Provide a window for clinical judgement being exercised at the time.

ANS 2. DOCUMENTS-

1. The personal data includes the patient's address , contact number and other relevant information.

2. PATIENT's medical history and diagnose.. It must contain the author 's identification , it may be handwritten signature or electronic signature.

3. Treatment plans with diagnosis , encounter forms having follow -up care , calls or visits when required.

ANS 3. 6' C's OF CHANTING -.

1. Client word - don't interpret PATIENT's word

2. Clarity - precise description.

3. Completeness - fill out forms completely.

3. Conciseness - to the point observation.

5. Chronological order - legal issues.

6. Confidentiality - follow HIPAA guidelines.

Ans 4. NEEDS -

1. Neatness - It helps the physician and other health care professional to evaluate and plan the treatment.

2. Timeliness - there is specific time requirement for completion of medical records for timely Treatment of patients.

3. Accurate -. Medical records must be correctly if Information is incorrect it may lead to medication errors.

4. Professional tone - It must have recent Information and avoid sarcasm  , too casual tone. It should use direct, clear language and conversational tone.

ANS 5. STEPS -

1. Check that patient record is written

2. To release a copy , not original

3. Physician may prepare a summary of medical records

4. Cost based fee may be charged.

5. Another provider records contain your records may  be released

6.vto check whether it Comply with specific laws to protect the medical records.