Medical record Flow Chart

Medication

patient's post-examination treatment

Medication giving while in the hospital and also for home care is documented in a medical record.

Medical Procedures

All of these test can be done to determine what is wrong with

the patient.

These are included

in the record

Post-Examination is when the patient is see by the doctor and the doctor does the examination, the treatment and finalized the home health care.

Medication required

MRI, CT Scan, Biopsy, ultrasound. etc.

A course of action intended to help care for a persons health problems.

No medication required

Nurse Area

Yes, prescription prescribed must

be given to Walgreen's

Medication given from

pharmacy on site

The nurse takes vitals such as body temperature, pulse rate

(or heart rate), blood pressure, and respiratory rate.

Follow up Appointments

Medical Record Flow Chart

The doctor need to see the patient again after two weeks of being discharged to make sure they are healing better.

Take vital signs if nurse available

Patient to room if doctor is available

Leave Patient in waiting room

if nurse/room is not available

Follow up visit required

Unit 9:

HI 165 Health Information Practicum

Waiting Room

Patient instructed to call

with status update

Patient supplied with doctor's

contact information

Check schedule and issue

an appointment

All patients wait in the waiting room unless its a life & death problem.

Billing/Insurance

Request contact information

Confirm data base information is current

(request updates if not)

Created By,

Maggie Hord

Confirm patient's existence in data base

(request completion of forms if not)

While in the health care facility, a member of the billing department comes to speak with you about the bill.

Billing Options:

Patient's Arrival

Work/Personal Insurance plans

Payments

Low income insurance from the State

The Medical staff calculates the times of when the patient sits in the waiting room and when they are welcomed in the back.

Discharge/Home-bound

The Final Steps

All discharge papers are mandatory in the record

1. After the patient is gone, there is about 30 days until the record becomes permanent.

2. A Record staff member sits down with the record and goes over every file to make sure there is nothing missing or misspelled.

3. If the member finds any flaws with the record they call or visit the doctor to clarify the record.

4. If there are no problems with the record, the staff then withdrawals the stables and scans the records into the the computer to make the record electronic and easier to access.

After the patient is discharged from the medical facility, the paper record is taking to staff lunch room where the staff/doctors can review and place missed files in record.