Review Questions

Review Questions

1. What are five major purposes of medical documentation?

Medical documentation:

* Helps ensure good patient care
* Provides legal protection
* Helps ensure compliance with regulatory agencies
* Improves cost control
* Decreases payment denials from insurance companies

2. What are five characteristics of good medical documentation?

Good medical documentation is characterized by the following:

* Completeness; all requested information is included
* Records are concise and factual
* Properly identified with patient name and identifying number
* Legibility
* Correct spelling, terminology, punctuation, and grammar
* Details are clearly, objectively expressed
* Avoids duplicate findings
* Uses only approved, facility-sanctioned abbreviations
* Contains a time and date for all entries
* Is signed by proper person(s)
* Completed without leaving empty lines
* Charted only after completing procedure/treatment
* Written in black or blue ink

3. How should errors be corrected on medical records?

Medical records cannot be corrected in a way that covers up what was originally written. Doing so gives the appearance they have been illegally altered and negates their value as legal records. Draw a line through the error, provide the correct information, and date and sign the correction. Note the fact that the original entry was an error per facility policy.

4. What information is typically found in a medical record?

A medical record usually contains:

* Patient medical history
* Physician’s orders, for example, medications prescribed
* Diagnostic test results/findings
* Admissions forms/consents
* Surgical procedures consents/reports
* Any graphics, such as blood pressure, etc.
* Flow sheets from monitoring
* Medication records, to show all medications given

5. What are three different formats used for progress notes?

The following formats may be used for progress notes:

* Problem-oriented charting: organized around a patient’s health problem(s)

* Narrative charting: provides written notes on all aspects of a patient’s health problem(s) and care

* Charting by exception: this abbreviated format notes only a patient’s abnormal findings

6. What are the advantages and disadvantages of each progress note format?

Problem-oriented charting advantage: all health care workers focus charting on the same problems; the disadvantages: keeping the problem list up to date and maintaining a humanistic, not problem resolution listed, approach to care

Narrative charting advantage: each health care worker can use his or her own approach to describing the patient and care given; the disadvantage: this is time consuming and can result in long, non-specific, and difficult-to-read records

Charting by exception advantages: the time savings and plain problem identification; the disadvantage: this approach is problem oriented and prevents the inclusion of preventive/wellness information