Ch 7 - Medical Records and Informed
Consent with verified solutions 2024
Medical Record - answer A collection of data recorded when a
patient seeks medical treatment.
Medical Record Purposes - answer *1.* Required by licensing
authorities and provide a format for tracking, documenting, and
maintaining a patient's communication data, both inside and
outside a health care facility.
*2.* Provide documentation from birth - death.
*3.* Provide a foundation for managing a patient's health care.
*4.* Serve as legal documents in lawsuits.
*5.* Provide clinical data for education, research, statistical
tracking, and assessing the quality of health care.
Medical Record Information - answer • *Contact and identifying
information:* full name, social security number, DoB, full address; if
applicable, e-mail, home & work numbers, marital status, name &
address of employer.
• *Insurance information:* Name of policy member and relationship
to patient, details such as certificate and group members, telephone
numbers, copy of insurance card, Medicaid or Medicare numbers if
applicable, and secondary insurance.
• Driver's license information, state, and number.
• Person responsible for payment and billing address.
• Emergency contact information
• The patient's health history
• Dates and times of the patient's arrival for appointments.
• A complete description of the patient's symptoms and reason for
making an appointment.
, • The examination performed by the physician.
• Physician's assessment, diagnosis, recommendations, treatment
prescribed, progress notes, and instructions given to the patient,
plus a notation of all new prescriptions the physician writes for the
patient and of refills the physician authorizes.
• X-rays and all other test results.
• A notation for each time the patient telephoned the medical
facility or was telephoned by the facility, listing date, reason for the
call, and resolution.
• A notation of copies made of the medical record, including date
copied and the person to whom the copy was sent.
• Documentation of informed consent, when necessary.
• Name of the guardian or legal representative to be contacted if
the patient is unable to give informed consent.
• Other documentation, such as complete written descriptions;
photographs; samples of body fluids, foreign objects, and clothing
in cases involving criminal investigations; and so on. All items
should be carefully labeled and preserved.
• Condition of the patient at the time of termination of treatment,
when applicable, and reasons for te
Five Cs of Medical Records - answer 1. Concise
2. Complete (and objective)
3. Clear (and legible)
4. Correct
5. Chronologically ordered
Photographs, videotaping, patient imaging consent statements -
answer • Patient understands that photographs, videotapes, and
digital or other images may be taken to document care.
• Patient understands that ownership rights to the images will be
retained by the health care facility, but that he or she will be
allowed to view them or to obtain copies.
Consent with verified solutions 2024
Medical Record - answer A collection of data recorded when a
patient seeks medical treatment.
Medical Record Purposes - answer *1.* Required by licensing
authorities and provide a format for tracking, documenting, and
maintaining a patient's communication data, both inside and
outside a health care facility.
*2.* Provide documentation from birth - death.
*3.* Provide a foundation for managing a patient's health care.
*4.* Serve as legal documents in lawsuits.
*5.* Provide clinical data for education, research, statistical
tracking, and assessing the quality of health care.
Medical Record Information - answer • *Contact and identifying
information:* full name, social security number, DoB, full address; if
applicable, e-mail, home & work numbers, marital status, name &
address of employer.
• *Insurance information:* Name of policy member and relationship
to patient, details such as certificate and group members, telephone
numbers, copy of insurance card, Medicaid or Medicare numbers if
applicable, and secondary insurance.
• Driver's license information, state, and number.
• Person responsible for payment and billing address.
• Emergency contact information
• The patient's health history
• Dates and times of the patient's arrival for appointments.
• A complete description of the patient's symptoms and reason for
making an appointment.
, • The examination performed by the physician.
• Physician's assessment, diagnosis, recommendations, treatment
prescribed, progress notes, and instructions given to the patient,
plus a notation of all new prescriptions the physician writes for the
patient and of refills the physician authorizes.
• X-rays and all other test results.
• A notation for each time the patient telephoned the medical
facility or was telephoned by the facility, listing date, reason for the
call, and resolution.
• A notation of copies made of the medical record, including date
copied and the person to whom the copy was sent.
• Documentation of informed consent, when necessary.
• Name of the guardian or legal representative to be contacted if
the patient is unable to give informed consent.
• Other documentation, such as complete written descriptions;
photographs; samples of body fluids, foreign objects, and clothing
in cases involving criminal investigations; and so on. All items
should be carefully labeled and preserved.
• Condition of the patient at the time of termination of treatment,
when applicable, and reasons for te
Five Cs of Medical Records - answer 1. Concise
2. Complete (and objective)
3. Clear (and legible)
4. Correct
5. Chronologically ordered
Photographs, videotaping, patient imaging consent statements -
answer • Patient understands that photographs, videotapes, and
digital or other images may be taken to document care.
• Patient understands that ownership rights to the images will be
retained by the health care facility, but that he or she will be
allowed to view them or to obtain copies.
