Medical Terminology & Charting Resources: Mnemonics & Rules and Guidelines

PART 1:

OVERVIEW:

Previously in the course the 5W1H influencing factors for charting practices, was reviewed. This section you will be expanding on these concepts. You will  examine èat, how, when, who4o document in a way that upholds charting guidelines and familiarizing yourself with èere and why#ertain information will be filed in the subsections of a chart. 

RESOURCES:

. Charting for midwives- Getting credit for all you do. NACPM [Webinar-Vimeo]. https://vimeo.com/21900709

.SBAR tool. http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx

. A practical guide to clinical medicine; History of present illness.  https://meded.ucsd.edu/clinicalmed/history.htm

.History and outline of charting. Blog. https://weareallmedhere.com/2019/02/23/scribe-series-history-outline-of-charting

. Example medical demonstration flank pain- ProvideràSOAP note.https://www.youtube.com/watch?v=48mhO_dbDHI

. 

INSTRUCTIONS:

Use a format of your choice (PowerPoint, word doc, etc.)

For this class we will be focusing on HEM and SOAP and SBAR as charting mnemonics to consolidate midwifery relevant that will be documented. However, there are a few additional charting mnemonics used as tools to transcribe the clinical information and may be subsections of the HEM/SOAP.

Write a small summary of what information would be collected. essentially define how to uphold each of the charting prompts (ex: HEM= History- patient experience/symptoms, Exam- vitals and hand-on care from provider, Medical decision- plan of care addressing symptoms and exam) (44 pts)

HEM: History, Exam, Medical Decision (6pt)

SOAP: Subjective, Objective, Assessment, Plan (8pt)

SBAR: Situation, Background, Assessment, Plan (8pt)

HPI: History present illness (2pt)

ROS: Review of systems (2pt)

PMH: Past medical History (2pt)

OLD CARTS: Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity

PART 2:

OVERVIEW:

You are creating a Charting Resource through this module, which can be used for the èarting Guidelines Quiz!nd your ongoing charting practice.

RESOURCES:

Documentation guidelines for registered nurses.https://www.crnm.mb.ca/wp-content/uploads/2022/05/Documentation-Guidelines-for-Nurses_added-links-0522.pdf

Medical record documentation standards and performance measures. https://provider.carefirst.com/carefirst-resources/provider/pdf/medical-record-documentation-standards-bok5129.pdf

The nice ó/strong> (AAPC). https://www.aapc.com/blog/34361-the-nine-cs-of-clinical-documentation-improvement/

Med. charts. https://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/medical-charts-0

Documentation: Accurate and legal. RN.org. http://www.rn.org/courses/coursematerial-66.pd

. Documentation and record keeping: Be safe. https://www.midwiferycouncil.health.nz/common/Uploaded%20files/Be%20series/Be%20Safe%204%20Documentation%20and%20record%20keeping%20F.pdf

.Introduction, HIPAA and Charting guidelines/p>

• INSTRUCTIONS:
• In a format of your choice (ex: powerpoint; grid, inforgraph, etc.), reply to the following prompts summarizing charting guidelines, which will outline how to uphold each of the charting prompts  (95pts)
• (Ex: Abbreviations: what are recommendations on use of and how chart abbreviations?). 
• HIPAA: Review the resources and examine
• According to Lockwood (2015), what right does HIPAA provide the individual and require of the healthcare provider? (4 pts)
• Describe professional record keeping and storage systems for electronic & other formats as outlined by Midwifery Council (2018). (4 pts)
• According to Midwifery Council, what are 11 types of records that are included as part of the chart? (6 pts

2. CHARTING GUIDELINES: Examine supplied resources and summarize charting guidelines that relate to the following prompts: (72 pts.)

Writing, Text color, 

Vocabulary

Abbreviations

Objective Descriptions

Writing actual statements said by the client

“Professional documentation includes”. (Midwifery Council, 2018)

Time & Date Format

ClientàIdentifiers on all pages (include forms of identification)

How to demonstrate who is the author of each chart entry

Chronological Order

How to write Continued notes

What to do with Excess Empty Space

How to apply Error Correction

Addendum

How to apply Late Entry

Maintenance (how long to keep chart, HIPAA compliant.)

Disposal (how to destroy a chart when no longer within HIPAA maintained time-frame)

Confidentiality

3. Describe your understanding about each of the 9ó of Clinical documentation improvement (9 pts):

1.Clarity 2. Consistency 3. Completeness 4. Cohesion 5. Coder Friendliness 6. Concision 7. Compartmentalization 8. Cleanliness 9. Credibility