Charting and Documentation Intro : Medical Assistants Class



  • The proper correction used to make an alteration or deletion of an entry in a medical chart is called

    A Strikethrough

    Rationale: Accountability is of huge importance in healthcare. It goes without saying that the protection of the patients is of top concern. However, you must be cautious to protect yourself by maintaining total accuracy in your charting. In the event of a misinterpreted documentation a very negative impact could occur on the part of the patient. So, you should always strive to make no mistakes when entering information into a patient chart. But, if you do, never try to hide it by using an eraser, scribbling through the error with pen, or correction fluid. The only correction that needs to be made is drawing a single line through the inaccurate word or statement, initial and date the error, then write the correct statement next to the error. Using the strikethrough allows anyone reading the chart to see the error, understand why it was wrong, and understand why the correction was made. This shows there was no attempt to hide anything to avoid blame.

  • A chart used as a quick, graphical source to review itemized vital signs, lab results, and tests ordered is called a


    Rationale: Depending on the critical nature of a patient’s condition, medical charts can quickly become overrun with orders and reports. To avoid the difficulty of having to search out certain order numbers or results, the flowsheet is used as a quick resource. The flowsheet can catalog everything from a patient’s vital signs (temperature, BP, heart rate, etc.), blood work lab results, medication type and quantity given, even waste output. By having this resource readily available, the physician can get a rapid snapshot of the patient’s current condition without having to hunt through the chart for the information. As with all charting, accuracy is critical to maintain a state of proper patient care.

  • The typical amount of time required for the diagnostic images of non-minor patient to be legally kept on file is

    5-7 Years

    Rationale: Diagnostic imaging is a small part of the continuity of care, but the images taken are of vital importance to the continuity of care. There is a movement in the medical community to augment imaging departments to involve more digital equipment. With the inclusion of digital equipment comes the storage of digital imaging. This allows all the x-rays, CT scans, MRIs, and ultrasounds to be kept on computer servers instead of file rooms. However, there are many smaller facilities that still primarily use x-ray film for their diagnostic imaging. The x-rays are stored under strictly controlled atmospheric conditions in large filing departments. It is inconceivable to expect every image taken to be stored indefinitely. The state laws typically require that diagnostic imaging be kept on file for 5-7 years. If the patient is a minor, the 5-7 years begin once the patient has turned 18.

  • The final set of recommendations and instructions for the patient, and the last documents entered to the chart before the patient leaves the hospital are called the

    Discharge Paperwork

    Rationale: Discharge paperwork is part of the final steps to a patient leaving a healthcare facility. Typically a physician has spoken with the patient; given them a final diagnosis, aftercare instructions and touched base with them about any medications they will be prescribed. It would be ignorant to assume that everything the physician told the patient will be recalled word for word. This is where the discharge paperwork comes into play. The discharge paperwork typically sums up everything that happened during the patient’s stay in the facility. A detailed layout of the aftercare instructions is laid out step by step. Any follow-up recommendations should also be included such as following up with a PCP, or returning in one week if the status remains unchanged, or visiting an ER if pain gets worse. Included with the discharge package should be any prescriptions for medication or referrals for additional treatment.

  • A directive given by a physician or other qualified healthcare team member that contains a specified medication, treatment, or exam is called an


    Rationale: Every function of a healthcare worker’s job is created by the orders in a patient’s chart. Physicians, nurse practitioners, and physician’s assistants can all place orders into a patient’s chart. These orders can be communications to any department within the healthcare facility. The orders can be requests for everything from blood work to cultures, urinalysis, diagnostic imaging and lab work. It is highly improper and unethical to add orders into a patient’s chart unless that order was verbally given to you by a physician or other certified health official. Verbal orders can be acted on immediately, but are still required to be signed and approved by the physician within specified amounts of time dictated by the healthcare facility. Currently, there are no state or federal laws limiting the amount of time required for the verbal order to be verified by the physician.

  • Documents required before non-emergency treatment in a healthcare facility including medical consent, contact information, billing information, insurance information, and legal paperwork are called

    Admissions Paperwork

    Rationale: In emergency trauma situations, the identification of the patient is of secondary concern. Every attempt is made to gain this information, but sometimes it is just not possible to find it. Race, creed, identity, religion, wealth, none of these matters in the ER. The team comes together to save a life, no questions asked. In every other aspect of healthcare, information is required before treatment. This collection of information is known as the admissions process. The office manager or secretary will typically have a packet of information ready to be handed to the potential patient. This information will include paperwork for identification, insurance information, health concerns, health history, medications, and consent to be treated. This allows the office manager to not only begin the payment process for the patient, but this also begins the process of updating or creating a patient’s chart.

  • The common medical abbreviation letting the healthcare professional know the patient doesn't have any known drug allergies is


    Rationale: NKDA is a universal medical abbreviation meaning No Known Drug Allergies. This communicates to the physician prescribing medication that at this point, with the history of medications the patient has taken, there have been no allergic reactions. If the patient has had a reaction, there are different levels of allergic reactions that the healthcare professional will need to know. Allergic reactions fall into one of four categories. These are vasomotor effects, anaphylactic reactions, vasovagal reactions, and acute renal failure. Vasomotor effects are generally quite mild such as nausea or lightheadedness. Anaphylactic reactions are moderate to severe and can involve low BP, high heart rate, and severe hives. Vasovagal reactions involve low BP and very low heart rate. Acute renal failure will exhibit diminished or total absence of urine output.

  • The common medical abbreviation that means by mouth is


    Rationale: P.O. comes from the Latin per os, which means “by mouth”. This is generally used with prescriptions to identify the route of administration for the medication. For example, Dilaudid 10mg #100, iii P.O. qday. This means three 10mg dilaudid will be taken by mouth every day. There are certain exams that cannot be administered if the patient has eaten or drank anything in specific amounts of time. A restriction can be placed into the chart that states N.P.O., which comes from the Latin non per os, which means nothing by mouth. This lets the healthcare professionals know that no food or water is permitted during a set period of time because it could interfere with results of the exam ordered.

  • The common medical abbreviation for every morning is


    Rationale: The ability to use shortcuts and abbreviations when charting is extremely helpful, especially when you are writing down a history while the patient is talking. It is also helpful for physicians to use medical abbreviations when charting to communicate details about orders. The letter “Q” is a very common letter used to denote several different things. The most common use of the letter “Q” is for time frames. “Q” stands for every. For example, Q.a.m. means every morning, Q.d. means every day, and Q.h. means every hour. However, if you do not write legibly, the “Q” could possibly be misconstrued as a different notation. Q.s. and Q.t. both stand for shunt fraction. Q.t. also stands for total cardiac output. Context and legibility matter a great deal if you choose to use medical abbreviations over longhand documentation.

  • An extensive accumulation of information about all aspects of an individual’s medical history such as imaging reports, diagnoses, medications and lab reports is called a

    Medical Chart

    Rationale: The medical chart is debatably the most critical tool in healthcare. This is a constantly updated resource that communicates to the healthcare professionals the ongoing state of care to an individual patient. In a hospital environment, the chart can be used to communicate between different shifts of care workers, even different departments within the hospital. Because of this, the reports, updates, and comments left in the chart must always be double-checked for the utmost accuracy. In the event an inaccuracy is left in the chart, it is possible a large amount of time may pass before the physician views it again. A small clerical error can lead to huge medical problems. In smaller facilities, such as urgent cares or doctor’s offices, the medical chart is used as a resource to check on the history of the patient, and how it may be involved with or affect their current state of health. Accuracy is critical here as well, because it will be used in their long-term treatment.


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