Analyzing A Patient Record
Analyzing A Patient Record
Analyzing A Patient Record
Overview: This case study will allow you to practice examining a patient record, which will aid you in your final project preparation.
The focus of this case will be on musculoskeletal and integumentary medication therapy.
Consider the following circumstance as an example:
Ms. Craft, 59, was taken to the medical department by ambulance because she believed she was dying.
She had trouble breathing and felt dizzy when she tried to sit up. She also had a sense of impending doom.
Ms. Craft, like the admitting emergency hospital workers, assumed she was having a heart attack.
However, the situation was more convoluted.
Ms. Craft was found to have weakness, malaise, warm skin, and hypotension during her physical examination.
Ms. Craft stated that she was feeling nauseous.
The blood glucose level was really high.
Cardiac indicators and an EKG did not indicate that she was experiencing a heart attack.
Ms. Craft stated that she had not seen a doctor in some years and was unaware that she had diabetes when her medical history was obtained.
Her respirations were deep and rapid, like Kussmauls.
The ER doctor diagnosed decompensated diabetes mellitus with metabolic acidosis in this case.
The following drugs were prescribed:
Hypertonic IV fluids Oxygen by mask
Insulin is taken orally, and a hydrochloric acid solution is given intravenously.
The following key components must be addressed in a brief paper:
Determine which medication/drug classification/treatment is inappropriate and explain why.
Instead, what drug classification would you use?
For each medicine classification, give an example of a generic pharmaceutical.
What effect would each of the medications/treatments have on the patients body?
Use relevant materials to back up your answer.
The Examining of Medical Records
Sara, a nurse at Sickly Hospital, just received a promotion after 15 years on the job.
A new job description, including that of Health Care Record Analyst, comes with this promotion.
Sara is overjoyed, but apprehensive about her new responsibilities.
What what is health-care record analysis, and how should she go about doing this new task?
What is the purpose of a health-care record analysis?
Simply described, health record analysis is a thorough examination of a patients medical records.
Because it describes everything that happened during a patients treatment, the medical record can be thought of as a story.
The exact analysis varies depending on the size of the medical facility and the purpose for the request, but a health care record analysis usually includes the following:
All medical records related with a single patients location and organization.
Nurses and physicians review clinical documentation to ensure that it complies with federal, state, accreditation, and possibly Hospice standards; that all documentation and paperwork, including the medical facilitys required forms, is complete; and that all files are properly entered into the facilitys database.
Interpretation of all clinical paperwork to confirm that the billing codes presented were justified and accurate for both the facilitys actions and each patients individual illness.
An examination of the information contained in the patients medical record.
It is vital that all of this is completed with extreme precision.
The review of medical records could be a critical step in avoiding lawsuits and/or insurance reimbursement issues.
Clinical Documentation in Healthcare Records Analysis
The main meat of a medical chart analysis is documentation accuracy!
When the medical record is divided into five categories, this part of the analysis becomes clearer.
Physical and historical context (H&P)
The H&P part of the chart provides information gathered during the patients initial evaluation, which is normally done by the physician.
This usually contains everything from the patients initial indications and symptoms through a treatment plan for each ailment that has been diagnosed.
The H&P part is crucial since it will act as a reference record, containing complete information regarding the patients medical history and initial examination.
This area, for example, is frequently consulted whenever drugs are provided to check that no allergies exist.
Notes on Progress
If a patients medical record were a story, the Progress Notes section would be the central theme.
This part is a form of timeline of events, from the time the patient walks into the institution until they walk out, because the progress notes are structured in chronological order.
The progress notes offer useful information about the treating physicians and nurses evaluation and care of the patient, as well as the patients response to therapy.
The following information should be included in every progress report:
Information that is subjective.
In this area, the physician should note statements made by the patient, such as how the patient feels today or what the patient has to say regarding treatments, and so on.
Information that is objective.
This contains the physical examinations performed by the physician at that visit, as well as the findings of those examinations.
Each diagnosis that the patient is suffering from is described.
Describe the treatment plan for each of the diagnoses in the assessment.
The creator of the report should appropriately sign and date each progress note.
Orders from a Doctor
Physician orders are similar to a checklist of tasks that must be completed.
If a patients blood pressure increases above a given level, a physician may issue an order to deliver a certain drug, complete with dosage and frequency.
The health record analyst should check for various factors when examining this section:
Is there any evidence that these directives were carried out by the appropriate staff member?
Were the orders completed in a timely way (if record of completion exists)?
Is the physicians order related to the diagnosis of the individual patient?