Medical and Surgical Documentation
The medical and surgical health record is found in a variety of settings including inpatient care units, long-term care facilities, home health, surgical centers, and ambulatory care units. Medical and surgical health record documentation pertains to adult patients with various acute and active disease processes or injuries. The medical and surgical health record contains documentation originating from physicians, nurses, diagnostic procedures, as well as from the dietary, pharmacy, social services, and other departments. The categories of information found in the medical and surgical record include clinical data, administrative data, and consents, authorizations, and acknowledgments. Consents and authorizations are discussed in chapter 8. An acknowledgment is a document that the patient’ or the patient’s authorized personal representative sign, confirming the receipt of important information.
Clinical data is the information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services; it is also the basis for the reimbursement of the treatment and service rendered to the patient. The clinical data portion of the acute-care record constitutes the largest portion of the health record and consists of nine separate and distinct parts. These parts are: medical history, physical exam, diagnostic and therapeutic procedure orders, clinical observations, diagnostic and procedure reports, surgical procedure documentation, consultation report, discharge summary, and patient instructions and transfer record.
The medical history portion of clinical data addresses the patient’s current complaints and symptoms and describes his or her past medical, personal, and family history. In inpatient care, the medical history is the responsibility of the attending physician. The history generally focuses on the body systems involved in the patient’s current illness. Table 4.2 shows the information that is usually included in a medical history.
