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Medical Record - Coggle Diagram
Medical Record
Goals
Quality management
Reimbursement
Legal issues
Verify the delivery of care
Quality assurance
Research
Clinical Goals
Training of students and residents
Decision-making support
Communication and continuity of care
Among HPOs
In the institution
Reminder assistance
Organisation assistance
Research
information and knowledge logistics
Controlling
Digital Documentation
Interface Engines
Hardware is required
Database schema
Development of user-friendly software
Makes the documentation more abstract
Errors are more difficult to detect
Must support CPT (procedures codes) and ICD (diagnoses codes)
Electronic signatures are acceptable, but not the stamped signatures
General principles or MR documentation
Medical records should be complete and legible
The written plan of care
Referrals and consultations.
Patient/family education.
Treatments and medications
Specific instructions for follow-up.
Documentation of each patient encounters should include
Assessment, clinical impression, diagnosis and plan for care
Review of lab, x-ray data and other ancillary services, where appropriate
Resons for encounter and anamnese
Relevant health risk factors should be identified.
Past and present diagnoses should be accessible to the treating and/or consulting physician
The reasons for and results of x-rays, lab tests, and other services should be documented or included in the medical record.
The patient's progress, including treatment, change in treatment, change in diagnosis and patient non-compliance
intensity of the patient evaluation and/or treatment
All entries should be dated and authenticated
All patient contacts
Office visits
Missed appointments
Scheduled appointments
The entries must be timely and accurate
Types
Dictated
Typed
hand-written
Computer generated
Text or email communication with patients
X-ray
Definition
Collection
Exploiting
Organising
Storing
Documentation methodology is independant of the storage medium
Must be stored for a particular time dependent on the type of record