Health Information Management Terminology

Full Answer Section

Progress Note:

• Purpose: Progress notes document a patient's clinical status and treatment progress over time. They capture subjective (patient-reported symptoms) and objective (clinician observations) data, treatment updates, medication changes, and response to interventions.

• Contents Included:

  • Date and time of encounter.
  • Subjective data: Patient's reported symptoms, concerns, and overall well-being.
  • Objective data: Vital signs, physical examination findings, test results.
  • Assessment: Clinician's interpretation of the data and patient's condition.
  • Plan: Treatment interventions, medication adjustments, and next steps.

• Impact of Incompleteness/Inaccuracy: Incomplete or inaccurate progress notes can lead to miscommunication between providers, delays in diagnosis and treatment, and medication errors. For example, a nurse might document that a patient is experiencing chest pain, but if the physician doesn't review the note thoroughly, they might miss this critical information and delay further investigation for a potential heart attack.

• Settings: Progress notes are used in various healthcare settings, including hospitals, clinics, emergency rooms, and nursing homes.

History and Physical (H&P):

• Purpose: The H&P is a comprehensive document that captures a patient's medical history and current physical condition. It serves as a baseline for diagnosis and treatment planning.

• Contents Included:

  • Patient demographics
  • Chief complaint (reason for seeking care)
  • History of present illness (detailed account of current symptoms)
  • Past medical history (previous illnesses, surgeries, medications)
  • Social history (lifestyle factors like smoking, alcohol use)
  • Family history (conditions that run in the family)
  • Allergies and medications
  • Physical examination findings (systemic review of all body systems)
  • Assessment and plan (similar to progress notes)

• Impact of Incompleteness/Inaccuracy: Incomplete or inaccurate H&Ps can lead to misdiagnosis, inappropriate treatment plans, and adverse effects. For instance, if a patient has a history of penicillin allergy that's not documented in the H&P, they might be prescribed an antibiotic that could cause a severe allergic reaction.

• Settings: H&Ps are typically completed during a patient's initial visit with a new healthcare provider or upon admission to a hospital.

Operative Report:

• Purpose: The operative report details the surgical procedure performed on a patient, including the findings, techniques used, and any complications encountered.

• Contents Included:

  • Patient demographics and surgical site
  • Preoperative diagnosis (reason for surgery)
  • Anesthesia type used
  • Operative findings (description of surgical site and relevant tissues)
  • Description of the surgical procedure performed, step-by-step
  • Estimated blood loss and any complications encountered
  • Specimens removed (if any)
  • Postoperative plan (care instructions and follow-up)

• Impact of Incompleteness/Inaccuracy: Incomplete or inaccurate operative reports can hinder proper post-operative care, delay wound healing, and increase the risk of infection. Additionally, inaccurate documentation can create legal issues if there's a discrepancy between the report and the actual procedure performed.

• Settings: Operative reports are crucial documents in hospital settings, specifically in operating rooms and post-surgical recovery units.

Discharge Summary:

• Purpose: The discharge summary provides a comprehensive overview of a patient's hospitalization. It summarizes the reason for admission, significant findings, treatment provided, discharge medications, and follow-up instructions.

• Contents Included:

  • Patient demographics and reason for admission
  • History of present illness and past medical history (brief summary)
  • Significant diagnostic findings and procedures performed
  • Treatment course and response to interventions
  • Discharge medications and dosages
  • Post-discharge instructions, including follow-up appointments and rehabilitation needs
  • Prognosis (predicted outcome)

• Impact of Incompleteness/Inaccuracy: Incomplete or inaccurate discharge summaries can lead to confusion and medication errors during post-discharge care. For instance, if a medication reconciliation process (comparing pre-admission medications with discharge medications) is not documented thoroughly, a patient might be prescribed a medication they were already taking, increasing the risk of overdose.

Sample Answer

Essential Documents in Health Information Management

Health Information Management (HIM) professionals play a vital role in maintaining accurate and complete medical records. These records are essential for providing quality patient care, ensuring continuity of treatment, and facilitating communication among healthcare providers. Here's a look at some key HIM documents and their significance: