Assignment Expectations:
- Length: At least 1500 words (6 double-spaced pages); answers must thoroughly address the questions in a clear, concise manner. Each topic should be discussed in your essay.
- Structure: Include a title page and reference page in APA style. The title page and the reference page are not counted toward the required word count. Be sure to answer all questions. There should be clear headings in your paper that show each section you are addressing.
- References: As used, include the appropriate APA style in-text citations and references for all resources utilized to answer the questions.
- Format: Save your assignment as a Microsoft Word (.doc or .docx), Open Office (.odt) or rich text format (.rtf) file type.
- Submission: Submit your assignment to the DropBox
Assignment:
- Explain various charting methods.
- Explain how to chart patient communication.
- Define cross-referencing and how it should be used.
- List the steps to take to find a missing file.
- Describe why an office would choose to use numeric filing.
- Differentiate between active, inactive, and closed patient files.
- Name ways to store inactive patient files.
- Describe the steps to correct a mistake in the electronic medical record.
- Explain the basic principles of computer ergonomics.
Expert Solution Preview
Introduction:
This assignment focuses on various aspects of medical charting and medical record management. As a medical professor, I am responsible for creating college assignments and providing answers for medical college students. This assignment aims to explain the different charting methods, patient communication charting, cross-referencing, finding missing files, numeric filing, active, inactive, and closed patient files, storage of inactive patient files, correcting mistakes in electronic medical records, and the basic principles of computer ergonomics.
1. Explain various charting methods:
Charting methods are the ways of documenting patient records. The different charting methods are:
a. Narrative charting – is the most traditional charting method where the chart notes follow a chronological order of patient care. This method does not follow any specific format, and the records are in paragraph form. Usually, the information entered in the chart is relevant to treatment, assessment, and diagnosis.
b. SOAP charting – stands for Subjective, Objective, Assessment, and Plan. This method is widely used and is helpful for documenting patient care. The subjectivity of the patient and diagnosis, objective factors such as diagnostic tests, physical examination, and observations, assessment of the condition or diagnosis, and future plans for addressing the diagnosis or condition are documented in this method.
c. PIE charting – stands for Problem, Intervention, and Evaluation. This charting method focuses on patient problems, the interventions used to address these problems, and evaluations to measure the effectiveness of the interventions.
d. Focus charting – focuses on the patient’s problems, goals, and interventions used to achieve the goals. The charting notes also highlight the patient’s response to the interventions.
2. Explain how to chart patient communication:
Charting patient communication is essential to document the patient’s progress, significant observations, and other valuable information. Here are some tips on how to chart patient communication:
a. Begin by documenting the date and time of the interaction.
b. Record the subject of the conversation and the reason for the communication.
c. Document the patient’s response and any expressed concerns or observations.
d. Record the patient’s understanding of the information and any questions or issues that arise during the communication.
e. Be accurate and concise, and avoid using broad descriptive terms.
3. Define cross-referencing and how it should be used:
Cross-referencing is a method used to locate a missing file or record. In cross-referencing, two or more references are made to the same file. Here are some tips on how to cross-reference:
a. Begin by documenting the original file number, including its location.
b. Create a new file with a new file number and location.
c. On the new file, document the original file number and location, which serves as a cross-reference.
d. The physician in charge of the file should sign and date each cross-referenced document.
4. List the steps to take to find a missing file:
Finding a missing file can be a daunting task, but here are some steps to follow:
a. Check the area where the file is usually stored.
b. Ask colleagues to check their areas and surrounding areas for the misplaced file.
c. Check the filing system for misfiled records.
d. Check the cross-referencing system to locate the file.
e. Review the charting notes of other patients who may have information or treatment connected to the missing file.
5. Describe why an office would choose to use numeric filing:
Numeric filing is the most commonly used filing system in medical offices. Here are some reasons why offices choose to use a numeric filing system:
a. Numeric filing ensures privacy, confidentiality, and security of patient records.
b. Numeric filing allows for the sort of the files in various categories by using specific numbers.
c. Numeric filing creates a uniform filing system.
d. Numeric filing ensures that the files are easy to locate and track when needed.
6. Differentiate between active, inactive, and closed patient files:
Active files are current patient files used for ongoing treatment and care. Inactive files are files of patients who have not been seen for a long time and whose care is temporarily halted, while closed patient files are files of patients whose treatment has been completed, and they have left the hospital or clinic.
7. Name ways to store inactive patient files:
Inactive patient files can be stored in various ways, depending on the facility’s needs and available space. Here are some ways that inactive patient files can be stored:
a. In storage cabinets, which are lockable, secure, and suited for paper filing.
b. In compact shelving, which makes good use of available space and maximizes filing capacity.
c. In off-site storage units that are climate-controlled, secure, and suitable for storing medical records.
8. Describe the steps to correct a mistake in the electronic medical record:
Correcting a mistake in an electronic medical record is essential to ensure accurate and up-to-date patient information. Here are some steps on how to correct a mistake in the electronic medical record:
a. Identify the mistake by carefully reviewing the electronic medical record.
b. Determine the extent of the mistake and the impact it has on the patient’s care.
c. Make the necessary corrections, such as editing the entry or deleting the incorrect information.
d. Document the correction made and the reason for the modification.
e. Sign and date the modification.
9. Explain the basic principles of computer ergonomics:
Computer ergonomics is about designing the workplace to maximize productivity, reduce discomfort, and prevent musculoskeletal injuries. Here are some basic principles of computer ergonomics:
a. Ensure that the computer monitor is at eye level to prevent neck strain and fatigue.
b. Position the keyboard and mouse in a way that minimizes wrist and arm strain.
c. Use a comfortable and adjustable chair that supports the back and neck and allows the feet to rest flat on the floor.
d. Take breaks frequently to stretch muscles and relieve tension.
Conclusion:
In conclusion, this assignment has explained the various charting methods, patient communication charting, cross-referencing, finding missing files, numeric filing, active, inactive, and closed patient files, storage of inactive patient files, correcting mistakes in electronic medical records, and the basic principles of computer ergonomics. As a medical professor, I believe that this assignment is essential for medical college students to understand the significance of effective charting methods and how to manage medical records effectively.
