Health Record Documentation

Objective:

Review Oliver H. Perry’s medical record and answer the following questions:

1. Have you seen a health record prior to beginning this course? If you have, what data did you know belonged in the record? If not, what data did you think belonged in it?
2. Which page(s) were new to you as a part of a health record? Be specific and list at least five examples.

First is the inpatient record form, progress notes, nursing admission assessment , medications and date of order, graphic sheet of the blood pressure.

1. What final impressions (diagnoses) for the patient are described in the H&P?

Chest Pain with shortness of breath, and left sided chest pain.

1. Identify five data elements you would find on a Nurses’ Admission Record.

Respiratory problem, prosthesis, hearing problem, Auditory prosthesis, Dentures Dental Prosthesis

1. Three laboratory reports are included in your sample record. What is a unique feature of these laboratory reports compared to the other reports in the record?
2. Other than the reports noted above, list five health record reports found in your sample record.
3. List five purposes for a patient record.
4. List five guidelines that should be followed for patient record documentation.
5. List three organizations concerned with documentation requirements for patient records.
6. List fourteen elements of the Uniform Hospital Discharge Data Set (UHDDS). Analyze the sample record to find out how many of these elements are present and identify where each data element is located.