medical record for medical scribes

The Medical Record

The Medical Scribe’s Role

The medical record is an important part of the patient’s care in the clinic or emergency room.

The information a scribe records on the chart could affect how the patient is managed currently or in the future.

The Medical Record

To communicate relevant information to other medical personnel.

It is a legal document that can be presented in a court of law.

Functions of the Medical Record

A physician may be asked to testify in cases of:◦Rape◦Homicide◦Assault◦Child abuse◦Civil procedures involving personal injury

The method used in charting the patient’s stay through the clinic/ED must follow a logical progression.

The most common method is to consider the chart to have four generalized sections:◦Subjective◦Objective◦Assessment◦Plan

SOAP

The Subjective portion includes: ◦Chief Complaint (CC)◦History of Present Illness (HPI)◦Review of Systems (ROS)◦Past Medical History (PMHx)◦Family History (FHx)◦Social History (SHx)

Subjective

The Subjective section pertains to any information that the patient and/or family states.

This information is dependent upon the patient’s condition, beliefs, personality, etc.

This section will contain the patient’s story in his/her own words.

Subjective

Chief Complaint◦The main reason the patient has come to the clinic/ED.

◦Every chart must have a Chief Complaint.◦A short statement in the first sentence of the HPI identifying why the patient has come to the clinic/ED.

◦Should be in the patient’s own words (if possible).

SubjectiveChief Complaint (CC)

History of Present Illness (HPI)◦Explains the Chief Complaint.◦Describes why the patient is in the clinic/ED and lists any pertinent positives and negatives.

◦This should be in a narrative paragraph consisting of 4-5 sentences depending on the severity of the patient’s condition.

◦The HPI is a chronological description of the development of the patient’s present illness from the first sign/symptom or from the previous encounter to the present.

SubjectiveHistory of Present Illness (HPI)

8 dimensions of HPI - directly related to Chief Complaint◦Location◦Quality◦Severity◦Duration◦Timing◦Context ◦Modifying factors◦Associated signs and symptoms


Location◦A place on the body Examples: R flank, midsternal chest, etc.

Quality ◦Description of the complaint Constant, dull, crampy, intermittent, etc.

Severity◦How bad is it? ◦Usually on a scale of 1 to 10 Examples: Acute, mild/moderate/severe,

7/10, 3 pads in the last hour, etc.


Duration◦How long do the episodes last? Examples: 30 seconds each, 5 years, etc.

Timing◦When did it start? Examples: 3:00 AM, this afternoon, etc.

Context◦What were you doing when it happened? Examples: Running laps, just ate 7 doughnuts, awoken from sleep, etc.


Modifying factors◦What makes it better or worse? Examples: Worse with activity, improve with nitroglycerin, increased pain with movement.

Associated signs and symptoms◦Any other symptoms Examples: If CC is chest pain, associated with diaphoresis and N/V.


A review of the patient’s past medical, social history, and family medical history.

Depending on the circumstances or encounter, the patient’s Chief Complaint could be an indication of a complication of, or a result of, a preexisting condition or the patient’s past medical history.

SubjectivePast Medical, Social, and Family History

Past Medical History (PMHx)◦Includes injuries, chronic illnesses, and surgeries.

Social History (SHx)◦Identifies behavioral risks such as tobacco alcohol, or drug use.

Family History (FHx)◦Includes relevant past family medical information.


Past Medical History (PMHx)◦ Hypertension (HTN), coronary artery disease

(CAD), chronic obstructive pulmonary disease (COPD), diabetes (DM), coronary artery bypass graft (CABG), cancer (Ca).

Past Surgical History ◦ A subcategory under PMHx.

Social History (SHx)◦ Tobacco use (Tob), alcohol use (EtOH),

intravenous drug use (IVDA), living situation (lives alone, lives with others, nursing home, or lives at home with parents).

Family History (FHx)◦ Includes genetic traits, DM, Ca, cardiac disease,

etc.


Common ROS:◦ General◦ Eyes◦ ENT◦ CVS◦ Resp◦ GI◦ GU

SubjectiveReview of Systems (ROS)

Identifies any recent symptoms the patient may have other than the current illness.

A Review of Systems is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.


General Symptoms ◦ e.g. diaphoresis, cold symptoms, fever, chills.

Eyes◦ e.g. Visual changes, blindness, ophthalmoplegia, blurry, eye pain,

discharge. Ear, Nose, Throat, Mouth

◦ e.g. dysphagia, tinnitus, epistaxis, rhinorrhea. Cardiovascular

◦ e.g. palpitations, edema, cyanosis, dyspnea on exertion, CP. Respiratory

◦ e.g. SOB/dyspnea, wheezing, cough. Gastrointestinal

◦ e.g. dysmenorrhea, dyspareunia, dysuria, vaginal bleeding. Musculoskeletal

◦ e.g. arthralgia, myalgia.


Skin/Breast◦e.g. rashes, hives, discoloration, pallor,

mastectomy. Neurological

◦e.g. H/A, dizziness, LOC, numbness, paresthesia.

Psychiatric◦e.g. suicidal, depressed.

Endocrine◦e.g. cold intolerance, heat intolerance,

polydipsia, polyuria. Hematologic

◦e.g. active bleeding, easy bruising.


EXCEPTIONS: ◦ If a patient is unable to provide any information

due to severity of illness, inebriation, intubation, unconscious, etc., you may check the “Unable to obtain HPI/ROS/PMFHSH secondary to pt’s condition.

◦Be careful when using this caveat, and only use it if it really applies (HPI, Past Medical/Social/Family History, and ROS only).

◦Ask the physician for clarification when needed. ◦Speaking another language is not an exception.◦Physical exam must be documented.


The Objective portion includes:◦Physical Exam◦Medical Decision-Making Elements

Objective

The Objective section contains information that is obtained through observation and testing and is independent of an individual’s interpretation.

Objective

Physical Examination (PEx)◦Information is more medically-oriented ◦Information elicited through observation, palpitation, percussion, and auscultation.

Medical Decision Making (MDM)◦Documented under “Progress Notes” and contains Differential Diagnosis, Progress notes, attending note.

Objective

Differential Diagnosis (DDx)◦Lists the different conditions that testing will rule out.

Progress Notes◦Any new subjective information provided by the patient and any new or changed findings upon reexamination of the patient.

Objective

Example:Re-eval at 1532 – Pt states she is improved. Nausea resolved. PEx: Abd soft, NT/ND, nl active BS. Pt will be discharged and f/u with PMD advised within 24 hours.

ObjectiveProgress Notes

Attending Note◦Recorded when a physician oversees a resident case.

◦This will follow the SOAP format. ◦Example:

A) Attending Note: Reviewed and agree c Hx.B) PEx – GI: abd soft, NT, CVS: RRR s MGR. RESP: Lungs CTA.C) A: UTI vs. Kidney stoneD) P: Labs, CT abd/pelvis r/o stone

Objective

The Assessment portion includes:◦Diagnosis: The physician’s impression of the patient after combining the information in both the Subjective & Objective sections.

Assessment

The Plan consists of:◦How the physician manages the patient’s care after the final diagnosis has been identified and can include:

Admission◦Ensure that the chart has been coded to the appropriate level and enter admission information.

Discharge Instructions◦Lists the various treatments, medications prescribed, work status, precautions, and followup care the patient needs.

Plan

Level 1: Visits requiring very minor care. This level is seldom used in the ED but would be used in a clinic setting.◦ Removal of sutures from a well-healed, uncomplicated laceration.◦ Tetanus toxoid immunization; Depo-Provera injection; hormone injections.◦ Several uncomplicated insect bites.

Level 2: Diagnosis reached without the aid of any labs or x-rays. ◦ Painful sunburn with blister formation on the back in an otherwise healthy

patient.◦ Child presenting with impetigo localized to the face.◦ Minor traumatic injury of an extremity with localized pain, swelling, and bruising.◦ Red, swollen cystic lesion on patient’s back in an otherwise healthy patient.◦ Rash on both legs after exposure to poison ivy.◦ Inflamed sclerae and purulent discharge from both eyes without pain, visual

disturbance, or history of foreign body in either eye in an otherwise healthy patient.

Five E/M Coding Levels

Level 3: Visits requiring minor lab work such as CBC, U/A, or a few x-rays.◦ Well-appearing child who has a fever, diarrhea, and

abdominal cramps and is tolerating oral fluid.◦ Inversion ankle injury, patient is unable to bear

weight on the injured foot and ankle. ◦ Acute pain associated with a suspected foreign body

in the painful eye.◦ Blunt head injury with local swelling and bruising

without subsequent confusion, loss of consciousness, or memory deficit in an otherwise young and healthy adult.

Level 4: Visits requiring extensive lab workup or CT scan.◦ Child sustaining a head injury (falling off bicycle)

with brief loss of consciousness.◦ Elderly patient who has fallen and complaining of

pain in the right hip with inability to ambulate. ◦ Flank pain and hematuria without fever.◦ Lower abdominal pain and a vaginal discharge.


Level 5: Visits requiring admission into the hospital, critical care patients.◦ Complicated overdose requiring aggressive

management to prevent side effects from the ingested materials.

◦ New onset of palpitations/tachycardia requiring IV drugs.

◦ Active upper gastrointestinal bleeding.◦ Motor vehicle accident with intraabdominal injuries or

multiple extremity injuries.◦ Acute onset of chest pain compatible with symptoms

of cardiac ischemia and/or pulmonary embolus.◦ Sudden onset of “the worst headache of my life” with

associated meningismus, nausea, and vomiting.◦ New onset of a cerebral vascular accident.◦ Acute febrile illness in an adult, associated with

shortness of breath and an altered level of alertness.


medical record for medical scribes

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