11 Sep This assignment develops skills in conducting chart reviews, both through standardized forms and by presenting findings in a multimedia format. This assignmen
This assignment develops skills in conducting chart reviews, both through standardized forms and by presenting findings in a multimedia format. This assignment will help you learn how to extract and communicate key information from medical records, which helps to ensure that the records are complete, accurate, and compliant. Before beginning the assignment, watch the medical records tour for patient Clea Clemens.
Chart Review #1 Directions:
Download the QI Review form Download QI Review formand complete all areas on the form using the information from patient Jesse Stewart's chart Download Jesse Stewart's chart. Submit your completed form as a word document or pdf.
Grading: 30 possible points, 1 point per answer space
Chart Review #2:
Select a medical record from the Example Medical Records module (located at bottom of the Modules page) and review all documents within the record. Create a PowerPoint presentation with voiceover on each slide that guides viewers through the patient's chart. Submit your presentation as a PowerPoint file (do not convert to PDF as you will lose your voiceover).
Your PowerPoint must include at minimum:
- Chart ID (use file name – if this is missing, I will not grade and you will receive a zero for the entire review!!)
- A brief summary of the patient (demographics)
- History of present illness
- Information from progress notes (how did the patient's hospital stay go)
- Information from orders (what types of medications and other treatments were ordered)
- Description of treatment given, including therapy and/or (operative) procedures
- What did the pathology show if a specimen was removed?
- Was the patient discharged to home or another location?
- What was the final diagnosis?
Your voiceover must add substantial information beyond what is on the slides – do not read directly off the slides as you will lose points! If your presentation does not include voiceover, you will receive a zero!
Medical Records QI Review by (name)_________________________________________
MR#____________ ACCT# ____________________________ D/C Date _________
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YES |
NO |
N/A |
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Discharge summary/clinical resume dictated within 48 hours of discharge |
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Discharge summary includes reason for hospitalization |
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Discharge summary includes significant findings |
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Discharge summary includes procedures and care provided |
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Discharge summary includes patient’s condition at discharge |
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Discharge summary includes instructions to patient and family, if applicable |
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Completion of H&P and/or admitting note w/in 24 hours of admission |
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Allergies to foods and medicine documented |
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Reason for admission for care, treatment or services documented |
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Progress notes dated and signed |
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Progress notes timed |
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Progress notes written every day by attending or consulting physician |
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Progress notes legible |
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Method of signature/authentication: written, electronic, computer key |
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Orders dated and signed |
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Orders timed |
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Orders legible |
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Each verbal order is dated and identifies the names of the individuals who gave and received it and the record indicates who implemented it |
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DO NOT USE abbreviations present? |
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Pre-, intra-, and post-anesthesia information documented by responsible individual |
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Informed consent signed and dated by patient |
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Operative report dictated/written on day of surgery |
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Operative report contains pre- and post-op diagnosis |
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Operative report indicates specimen(s) removed, if applicable |
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Operative report indicates estimated blood loss |
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Pathology report present, if applicable |
