ppt课件-chapter fourteen medical records management（十四章医疗记录管理）.pptVIP

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Slide * Laboratory Reports (cont’d) Slide * Radiology Reports Usually typed on standard-sized stationery. Place in reverse chronologic order, with the most recent report on top. Medical records often have a separate section for laboratory and radiology reports. Slide * Progress Notes Continually added to the medical record. Must list each patient visit and any notations about the visit. Instructions, prescriptions, and telephone calls for advice should be noted in the progress notes. Always initial entries in progress notes. Slide * Making Corrections and Alterations to Medical Records Never use correction fluid, erasers, or any other type of obliteration methods. Do not mark through information to obliterate it. Do not hide errors. If errors could affect the health and well-being of the patient, bring it to the physician’s attention immediately. Slide * Correcting an Error Three Steps Draw one line through the error. Insert the correction above or immediately after the error. In the margin, write “correction” or “corr” and initial the entry. Slide * Correcting Electronic Records If an error is made while typing, simply backspace and correct the error. If the error is discovered later, make an additional entry with corrected information. Do not delete or change previous entries on electronic records. Slide * Keeping Records Current Records must be methodically kept current. Do not allow histories and reports to accumulate for long before filing them. The patient’s health is jeopardized when current, accurate records are not available to the physician. Remember that the physician bases his decisions on the information in the patient medical record. Slide * Prescriptions Some prescription pads are printed on NCR paper, which automatically makes a copy for the medical record. All prescriptions must be noted in the medical record, including refills called in to the patient’s pharmacy. S