Patient Registration Record

The patient registration record (Figure 36-1) consists of demographic and billing information. All new patients must complete a patient registration record form. After the patient completes the registration record, the medical assistant enters the information into a computer. This allows the demographic and billing information to be used for numerous computerized functions, such as scheduling appointments, posting patient transactions, and processing patient statements and insurance claims. With a paper-based patient record (PPR), the original patient registration record is then usually placed in the front of the patient’s medical record. With an electronic medical record (EMR), the original registration record is usually shredded.

NPP Acknowledgment Form

A Notice of Privacy Practices (NPP) is a written document that explains to patients how their protected health information will be used and protected by the medical office. The patient must sign a form acknowledging that he or she has received the NPP. The NPP form is then filed in the patient’s chart.

Correspondence

Correspondence is an important part of the medical record. Correspondence regarding a patient may be received from various individuals or facilities, such as the patient’s insurance company, the patient’s attorney, and the patient himself or herself. Insurance correspondence includes such documents as a precertification authorization for a hospital admission and a request for additional information from the insurance company. Correspondence also includes copies of letters concerning the patient that are sent out of the office; examples are a copy of a letter referring the patient to a specialist and a copy of a collection letter sent to the patient.

Putting It All into Practice

My name is Dawn Bennett, and I work for an orthopedic surgeon. I work in the front area of the office as an administrative supervisor in billing and collections.

Working in billing and collections is very challenging and sometimes stressful. It can even be embarrassing. We are a new practice, and when we opened, there was no collection system. When it came time to review our accounts, we realized that, like every other business, we needed a collection system. We immediately jumped in and took charge.

The primary physician at our office is from New York, and we were unfamiliar with his family members. One day he walked into our office with a very puzzled look. I asked him what was wrong. He replied, “You guys are doing a great job with our collection rate. I asked you to be stern, but thoughtful, when sending out patient collection letters, but did you have to send one to my mother-in-law?!” Needless to say, we fixed the error immediately. This incident prompted us to restructure our collection system, and we added a comment screen to our computer system on all of our patients’ accounts. Going into a medical office that already has a system in place may be easier, but you can learn a lot more by setting up an office system yourself. 

Health History Report

A health history report is a collection of subjective data about the patient. Most of this information is obtained by having the patient complete a preprinted form that is then reviewed for completeness by the medical assistant. Some of the information included in the health history is obtained by the physician or medical assistant by interviewing the patient.

Along with the physical examination and laboratory and diagnostic tests, the health history is used for the following reasons: to determine the patient’s general state of health, to arrive at a diagnosis and to prescribe treatment, and to document any change in a patient’s illness after treatment has been instituted. The term diagnosis refers to the scientific method of determining and identifying a patient’s condition.

A thorough history of personal health is obtained for each new patient, and subsequent office visits provide additional information regarding changes in the patient’s condition or treatment. A complete discussion of the health history report is presented later in this chapter.

Physical Examination Report

A physical examination is an assessment of each part of the patient’s body. The purpose of the physical examination is to provide objective data about the patient, which assists the physician in determining the patient’s state of health. (The physical examination is described in detail in Chapter 20.)

The physical examination report is a summary of the physician’s findings from the assessment of each part of the patient’s body and includes the following:

Progress Notes

Progress notes involve updating the medical record with new information each time the patient visits or telephones the medical office. Progress notes serve to document the patient’s health status from one visit to the next. It is important that the date and time be included with each progress note, along with the signature and credentials of the individual making the entry. A thorough discussion of charting progress notes is presented later in this chapter.

Medication Record

A medication record consists of detailed information related to a patient’s medications. The record may include one or more of the following categories: prescription medications, over-the-counter (OTC) medications, and medications administered at the medical office. Most medical offices use one form to record prescription and OTC medications and another form to record medications administered to the patient at the medical office.

Medication Administration Record Form

A form for recording medications administered to the patient at the medical office (Figure 36-2) includes the following:

• Patient’s name and date of birth

• Drug allergies

• Name of the medication

• Dosage administered

• Route of administration

• Injection site

• Date of administration

• Manufacturer, lot number, and expiration date of the medication

• Signature and credentials of the individual administering the medication

Consultation Report

A consultation report is a narrative report of a clinical opinion about a patient’s condition by a practitioner other than the primary physician, known as a consultant (Figure 36-3). The consultant is usually a specialist in a certain field of medicine (e.g., cardiology, endocrinology, urology). The consultant’s opinion of the patient’s condition is based on a review of the patient’s record and an examination of the patient. The consultation report must include the following:

Home Health Care Report

Home health care is the provision of medical and nonmedical care in a patient’s home or place of residence. The purpose of home health care is to minimize the effect of disease or disability by promoting, maintaining, and restoring the patient’s health. There is a growing preference for home health care over equivalent health care options. Research shows that familiar surroundings contribute positively to a patient’s emotional and physical well-being.

Home health care must be ordered by the patient’s physician and is provided by skilled professionals. Home health care professionals include nurses, home health aides, dietitians, physical therapists, occupational therapists, speech therapists, and social workers. Examples of specialized services available through home health care include cardiac home care, intravenous (IV) therapy, respiratory therapy, pain management, diabetes management, rehabilitation, and maternal-child care. Home health care providers must periodically provide a summary report (Figure 36-4) to the patient’s physician that includes the following:

Electrocardiogram Report

An electrocardiogram (ECG) report is a narrative description of a cardiologist’s interpretation of an ECG, including the implications for the patient. The graphic tracing is usually included with the report.

Holter Monitor Report

A Holter monitor report is a narrative description of the interpretation of a 24-hour ambulatory ECG, including the evaluator’s impressions. Portions of the graphic tracing are usually included with the report.

Sigmoidoscopy Report

A sigmoidoscopy report is a narrative description of the interpretation of a sigmoidoscopic examination, including the practitioner’s impressions.

Colonoscopy Report

A colonoscopy report is a narrative description of a colonoscopic examination, including the practitioner’s impressions.

Spirometry Report

A spirometry report is a narrative and graphic description of the interpretation of a patient’s breathing capacity using a spirometer.

Radiology Report

A radiology report is a narrative description of a diagnostic or therapeutic radiologic procedure (Figure 36-5). A radiologist examines the radiograph and provides a written report, which includes a detailed interpretation of the radiograph and his or her impressions. The patient’s physician receives a copy of the radiology report; the actual radiographic film or digital images are kept on file in the hospital’s radiology department but are available for review by the patient’s physician.

Diagnostic Imaging Report

A diagnostic imaging report is a narrative description of a diagnostic imaging procedure (Figure 36-6). The report includes a detailed interpretation of the diagnostic image, along with the practitioner’s impressions. Examples of common diagnostic imaging procedures include ultrasonography, computed tomography (CT) scan, and magnetic resonance imaging (MRI). The diagnostic computer image is kept on file at the hospital but is available for review by the patient’s physician.

Physical Therapy

Physical therapy involves the use of therapeutic exercise, thermal modalities, cold, hydrotherapy, electrical stimulation, massage, and other physical agents to restore function and promote healing after an illness or injury. A physical therapist might help a football player with a knee injury to regain normal functioning of the knee or assist a patient recovering from a stroke to use his or her legs to walk again. Figure 36-7 shows an example of a physical therapy report.

Occupational Therapy

Occupational therapy helps a patient learn new skills to adapt to a physically, developmentally, emotionally, or mentally disabling condition. This enables the patient to perform activities of daily living and to achieve as much independence as possible. An occupational therapist might help an individual with a physical disability learn how to get dressed and how to prepare meals.

Speech Therapy

Speech therapy refers to treatment for the correction of a speech impairment resulting from birth, disease, injury, or previous medical treatment.

History and Physical Report

The term inpatient refers to a patient who has been admitted to the hospital for at least one overnight stay. A health history must be obtained and a physical examination performed on all inpatients. There is one exception to this: If a patient history and physical examination are performed at the medical office within 1 week before admission, a copy of these documents may be used. In the event that a reliable health history cannot be obtained from the patient, it must be obtained from the person best able to relay the facts.

The history and physical report is a physician’s narrative report of the patient’s history and physical examination, along with the physician’s medical impressions (Figure 36-8). The purpose of the history is to document the patient’s current complaints and symptoms, whereas the purpose of the physical examination is to assess the patient’s current health status. Medical impressions, or simply impressions, are conclusions drawn from an interpretation of data. In this case, the physician interprets the data from the health history and physical examination and draws conclusions as to the patient’s state of health. Other terms for impressions include provisional diagnosis and tentative diagnosis.

Operative Report

An operative report (Figure 36-9) must be completed for all patients who have had a surgical procedure. This report describes the surgical procedure and must be completed and signed by the surgeon who performed the operation. The operative report must include the following:

Discharge Summary Report

The discharge summary report is a brief (usually one-page) summary of the significant events of a patient’s hospitalization (Figure 36-10). The report must be completed and signed by the attending physician. The discharge summary report includes a concise account of the patient’s illness, course of treatment, and response to treatment, as well as the condition of the patient at the time of discharge from the hospital. The purpose of this report is to document information needed by the patient’s physician to provide for the continuity of future care. It also is used to respond to authorized requests for information regarding the patient’s hospitalization. The discharge summary report must include the following:

Pathology Report

A pathology report consists of a macroscopic (gross) and a microscopic description of tissue removed from a patient during surgery or a diagnostic procedure. The macroscopic description includes information about the size, shape, and appearance of the specimen as it appears to the naked eye. The report also includes a diagnosis of the patient’s condition (Figure 36-11). A pathologist is required to examine the tissue specimen, complete the report, and sign it.

Emergency Department Report

The emergency department report is a record of the significant information obtained during an emergency department visit (Figure 36-12). The report is prepared and signed by the emergency department physician, and a copy is sent to the patient’s family physician for the purpose of providing follow-up care. The emergency department report includes the following:

Consent to Treatment Form

Completion of a consent to treatment form (Procedure 36-1) is required for all surgical operations and nonroutine therapeutic and diagnostic procedures (e.g., sigmoidoscopy) performed in the medical office. The form must be signed by the patient or his or her legally authorized representative and must provide written evidence that the patient agrees to the procedure or procedures listed on the form (Figure 36-13).

 Procedure 36-1   Completion of a Consent to Treatment Form

Outcome

Complete a consent to treatment form.

Equipment/Supplies

• Consent to treatment form

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Related posts:

1. Digestive System
2. Interacting with Patients
3. Scheduling Appointments
4. Eye and Ear Assessment and Procedures

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