Medical Records

LWBK135-c6[274-295].qxd 8/1/08 3:33 PM Page 275 Aptara Inc. Part 6 Medical Records The information contained in the patient’s medical record is used to assess previous treatment, to ensure continuity of care, and to avoid unnecessary tests or procedures. These documents also create a legal record that benefits the patient and his or her healthcare providers. A patient’s medical record can be an invaluable tool for healthcare providers, but to live up to its full potential, the different parts of the medical record must be as complete and as accurate as possible. General Guidelines Although every hospital or office has specific policies regarding the placement of various portions of text on the page, the following guidelines concerning the format and style of the documents that comprise a patient’s medical record should prove acceptable in most situations. Page Numbering Page numbers help keep reports in correct page order. • Pages are numbered consecutively. • Page numbers can appear in the top or bottom of the document and can be aligned at the left, center, or right margin. • Generally, the first page of a document is not numbered. • The number can be part of the document text, or it may appear in the document’s header or footer. Part 6: Medical Records 275 LWBK135-c6[274-295].qxd 8/1/08 3:33 PM Page 276 Aptara Inc. Part 6 Medical Records Headings Section headings are used to document the evaluation and management of a patient in a logical fashion. A typical medical report contains most or all of the following section headings, or a variation of them, which outline the patient’s history, diagno- sis, and plan of care: • Chief Complaint (CC): States the specific reason the patient sought medical care. • History of Present Illness (HPI): Documents the complete story of why the patient is seeking medical attention. It is usually arranged in chronological order beginning with the earliest relevant facts and proceeding to the point where the patient was admitted or seen in an office visit. • Past Medical History: Includes information about the patient’s previous illnesses, injuries, or chronic conditions. • Past Surgical History: Contains information about past surgical procedures the patient has undergone. • Medications: Lists the medications that the patient is currently taking and the dosages of each. • Allergies: Lists the patient’s allergies. Some physicians also dictate sensitivities to foods or other items here, such as rashes that may result from seafood or latex. • Family History: Outlines information about hereditary or family illnesses, and provides evidence for considering that the patient may be suffering from those diseases, as well as infections or contagious illnesses to which the patient may be exposed. • Social History: Details a patient’s marital status and work and living situation, and may also include social habits such as smoking, alcohol use, or illicit drug use. 276 Stedman’s Pocket Guide to Medical Language LWBK135-c6[274-295].qxd 8/1/08 3:33 PM Page 277 Aptara Inc. General Guidelines • Review of Systems (ROS): Contains a brief overall review of the medical condition of the patient’s body organs systems, which may or may not be relevant to the HPI. The systems review may be contained in one paragraph, or may be subdivided into separate categories (such as pulmonary, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, lymphatic, skin, hematologic, neurologic, and/or psychiatric). • Physical Examination (PE): Outlines the physician’s thorough examination of the patient, including observations and findings. The physical exam section may be written in paragraph form, or may be laid out using subheadings. The subsections of the PE are addressed in a standard order from head to toe. They can appear in paragraph form after the main heading, or as subheadings flush left under the main heading. These subsections may include the following: • Vital Signs (VS): Indicates the patient’s vital signs such as temperature, blood pressure, pulse, respirations, height, and weight. Extra items such as body mass index (BMI) or oxygen saturation might also be indicated here. • General Appearance: Indicates the general appearance of the patient, such as physical build, personal hygiene, and mood. • HEENT: Denotes the findings of the head, eyes, ears, nose, and throat. • Neck: Palpated for abnormal enlargement of lymph nodes or jugular veins, or abnormal carotid artery pulses. • Lungs: Indicates the amount and quality of air moving in and out of the lungs as evaluated by auscultation through a stethoscope. Part 6: Medical Records 277 LWBK135-c6[274-295].qxd 8/1/08 3:33 PM Page 282 Aptara Inc. Part 6 Medical Records A: Chronic pain. Lumbar radiculitis. P: Medication agreement is in his chart. Refill on his medications as above. Return to clinic in 2 months and as needed. Thomas L. Mansford, MD TLM/xx D: 03/03/20xx T: 03/03/20xx History and Physical Report A history and physical examination (also called an H&P) is dic- tated by an attending physician when a patient is admitted to the hospital. It is the starting point of the patient’s inpatient care and contains a summary of the patient’s information known at the time of admission, including the problem or reason for admission, history of the present illness, a review of systems, and the patient’s prior history. The physical examination portion includes a thorough examination, both subjective and objective, by the provider to assess the patient’s condition in order to for- mulate an assessment and plan for treatment during the hospital stay. Sample History and Physical Patient Name: Jose Manuel Aguillar Medical Record Number: 988-23100 Date of Admission: 07/15/20xx Attending Physician: Eduardo G. Marcos, MD CHIEF COMPLAINT: Fistula. 282 Stedman’s Pocket Guide to Medical Language LWBK135-c6[274-295].qxd 8/1/08 3:33 PM Page 283 Aptara Inc. Types of Medical Reports HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male with past medical history significant for gluten intolerance and rectal prolapse who subsequently underwent LAR and sphincteroplasty. His postoperative course has been complicated by the development of a fistula, and he is to undergo a fistulotomy in the morning with Dr. Beard. He denies any com- plaints with bowel movements. No blood per rectum. He has had two formed soft bowel movements every day; however, he did note some minimal pain at the fistula site. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Blood pressure 110/80, pulse 79, respirations 16, and temperature 98.6. GENERAL: He is in no acute distress, alert and oriented ϫ3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact. LUNGS: Clear to auscultation. HEART: Normal S1, S2. No murmurs, rubs, or gallops. ABDOMEN: Soft, nondistended and nontender. Normoactive bowel sounds. EXTREMITIES: No clubbing, cyanosis, or edema. LABORATORY DATA: White count 5.9, hematocrit 44.3, platelets 324, sodium 139, potassium 3.9, chloride 104, bicarb 28, BUN 14, creatinine 1.5, and glucose 101. Alkaline phosphatase 69, AST 19, ALT 23 and total bilirubin 1. ASSESSMENT: The patient is a 48-year-old male with past medical history significant for rectal prolapse status post LAR and sphincteroplasty, now presenting with a fistula and is to undergo fistulotomy in the morning. PLAN: Clear liquid diet today. The patient is n.p.o. after midnight. Check his preoperative labs, chest x-ray, and EKG. Part 6: Medical Records 283.

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