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Different Types of Medical Records
Transcript of Different Types of Medical Records
By: Veronica Pulido
There are different types of medical reports all containing different information about the patient. Each document should be stored in a safe place away from the public who are not HIPAA certified. Each document is filled by last name then by first name at times also by birth date. Medical records are under release under certain circumstances and at times only with the authorization of the patient.
Medical reords are documentes related to the patient that include past patient history information, current diagnosis and treatment, and correspondence relating to the patient.
Patient's Past Records
This type of medical record contain all the information of the patient's past medical history as in office visits, diagnostics, treatments and so on. All of these information is confidential and disclosed information.
Protecting these information from the public eye if important. HIPAA regulates that these information is not seen by anyone who is not HIPAA certified. These information should be stored in a safe place where it not easy to be seen by the public and if these information is kept electronically it should be protected by a password only employees or employ of the facility can access it.
SOAP (Subjective, Objective, Assessment, & Plan
SOAP is a document that health providers use to create a patient's medical chart.
Subjective: Describes the patient's current condition.
Objective: the patient's status (vital signs, weight, etc.)
Assessment: Diagnoses for the medical visit.
Plan: Treatment of the patient.
Information is fill by the patient's last name and first letter of the name along with the birth date. This type of recording information is east to organize because now it is done by computers so there is less filling to go through and it is protected by passwords only health care providers can access.
Proper Filling of Medical Records.
There are three categories medical records are filled in.
-Active : are files of patients who have been in the office within the last few years. These files are the main and easiest to reach in the office.
-Inactive: are files of patients who have not visit the office within the last few years usually within five years. All of these files are storage way in another location. The inactive files have not been terminated they can still be reach.
-Closed: are files that are sent to an archive. These files are from patients who are no longer patients to the physician or who have passed away. The files are kept by the law.
An operative report is a document produced by a surgeon or physician who have participated in a surgical intervention which has details about the findings, the procedure used, the specimens removed, the preoperative and postoperative diagnoses and the names of the primary surgeon and assistants.
POMR (Problem Oriented Medical Record
POMR is a method of recording data about the health status of the patient. This method helps find the problem and a way to solve it. There are five components of the POMR.
1. Data Base: History, Physical Exam & Laboratory Data
2. Complete Problem List
3. Initial Plans
4. Daily Progress Note
5. Final Progress Note or Discharge Summary
All of these components have proved that it is a great way of diagnosing a patient and finding treatment for them.
Filling Laboratory Reports
Lab reports are keep in the patients file both in the office where the report was requested and where the report was conducted
Lab reports are results of test that were done on clinical specimens in order to get information about the health of a patient as pertaining to the diagnosis, treatment, and prevention of disease.
Handling Medical Records
HIPAA regulations forbid an employee to hand medical records to anyone at anytime. Before one can release any type of information about a patient they must consult the patient first and have the patient sign release forms.
Substance abuse is an exception. The Confidentiality of Alcohol and Drug Abuse, Patient Records prohibits information regarding substance abuse and treatment from being release without specific written authorization from the patient but they can be revoked at the patient's discretion.
The physician legally owns the medical records but the patient has the right to authorize who can and cannot see their medical record. If the person is a minor some information can be kept confidentially but other information the parent or legal guardian can access it.
When the patient's record is need for billing or other administrative purposes there is no need to acquire a release. Also when it comes to government conducting an investigation of physical abuse, substance abuse, communicable diseases, or prescription drugs, the patient does not sign a consent to release theses records.