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Aug 6th, 2022
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How to Join cross in the Professional Medical History

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so we talked about the chief complaint and the HPI and I want to just share with you how I look at the past medical history a little bit different than you've probably been taught in medical school the past medical history is predictive of the president and also of the future so past is prologue you need to know what the past is before you can determine what the person's present is and so for example if someone has a history of lung cancer we'd like to know how high of a chance is this lung cancer to be causing whatever they're here to see me and neuron fourth and so the in order to do that I need to have the stage of the tumor which means I need to know how extend how extensive is the cancer it can either be confined to the lung it can be outside of the lung it can be any widespread metastasis so in a patient who has stage 1 lung carcinoma that's a totally different risk than someone who has stage 4 lung cancer for whatever their complaint is and we'd like to know what treatment the...

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When an error is made in a medical record entry, proper error correction procedures must be followed. Draw line through entry (thin pen line). ... Initial and date the entry. State the reason for the error (i.e. in the margin or above the note if room). Document the correct information.
A patient's medical chart may contain different note types, documenting office or telemedicine visits (encounters) and patient calls, such as: Consultation notes. Second-opinion notes. Progress notes.
Contact information for the doctors and treatment centers involved in your diagnosis and treatment, as well as others who have cared for you in the past, such as your family doctor. Dates and details of other major illnesses, chronic health conditions, and hospitalizations. Family medical history.
ing to several HIM experts, the top four documentation mistakes are: Mixed messages from a physician vis á vis misunderstood dictation or illegible handwriting. Misuse of copy and paste or copy forward functions in the electronic health record (EHR) Incomplete or missing documentation. Misplaced documentation.
Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.
What do I do if something is incorrect or missing? Step 1: Contact your provider. Contact your provider's office and find out what their process is for updating or correcting your health record. ... Step 2: Write down what you want fixed. ... Step 3: Make a copy of your request. ... Step 4: Send your request.
Don'ts Don't chart a symptom such as “c/o pain,” without also charting how it was treated. Never alter a patient's record - that is a criminal offense. Don't use shorthand or abbreviations that aren't widely accepted. Don't write imprecise descriptions, such as "bed soaked" or "a large amount"
What Are The 10 Components Of A Medical Record? Identification Information. One of the first important components you can find in medical records is identification information. ... Medical History. ... Medication Information. ... Family History. ... Treatment History. ... Medical Directives. ... Lab results. ... Consent Forms.
In general, Stewart says poor documentation is defined as that which is lacking clarity, specificity, or completeness, and is of overall poor quality.
The Dos & Don'ts of Documentation DON'T copy information. Write each transport as if this is the first time you have seen or treated this patient. ... DON'T use vague terms. ... DON'T use P.U.T.S. ... DO support medical necessity. ... DO be specific. ... DO be truthful. ... DO document treatment results.

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