Certified Release of Information Specialist Question and answers already passed
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Certified Release of Information Specialist Question and answers already passed Medical Record
Referred to as the who, what, when, where and how of patient care. It is a compilation of documents containing patient info. diagnosis and treatment during and episode of care or admission. Documentation...
Certified Release of Information
Specialist
Medical Record
Referred to as the who, what, when, where and how of patient care. It is a
compilation of documents containing patient info. diagnosis and treatment
during and episode of care or admission. Documentation my be handwritten,
films, graphs and other images
Medical records serves the following purpose
Communication between healthcare providers
Documentation: diagnosis, treatment and care
Provide info. for medical billing and hospital management
For analysis, study and evaluation of quality care to pt.
Protect legal rights of the pt., healthcare facility and other providers
Medical Record consist of three types of data
Personal Data (Demographics)
Financial Data
Medical Data also includes signed consent forms,
Face Sheet
Usually the first page which contains the patient' name, address, family
doctor, insurance info, diagnosis, etc
, Emergency Room (ER) Report
Record of treatment in the Emergency Department. May be part of an
inpatient admission
Discharge Summary
Summary of treatment the patient received. Includes the diagnosis of their
ailment. This is usually a transcribed report.
History and Physical
Reflects the history of the patient's disease of injury, as well as the history of
treatment. Usually transcribed, but may be hand written at the beginning of
the progress notes.
Consultation
Handwritten or transcribed report of examination and recommendations by the
consulting physician.
Progress Notes
Daily notes of a physician visit. May be multi-disciplinary and include notes
from tohe healthcare professionals treating the pt. May be written using a
format called SOAP
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