Patient case study: abnormal uterine bleeding and surgical intervention

Gynecologist

In this presentation, the author will give an overview of the procurement and analysis of medical records required for a patient who needs to see a gynecologist for abnormal uterine bleeding at a gynecological office. This previously would have been purely a paper process, including the internal office process with regard to patient forms (information and release paperwork), the internal hospital facility process of form processing and finally the same process in the gynecologist's office. However, the rise of the Obama health care plan has mandated a transition to electronic records over the next five years, so this must be factored into the process now as well (Childs, Chang, & Grayson, 2009). Both electronic and paper records will however have the same basic features as listed below.

The patient has called the office requesting an appointment. The patient said that the gynecologist admitted her to the hospital, performed the surgery and said she should follow up with her own physician. This author needs to obtain the hospitalization medical records for this patient. In the following description is are the relevant components of the family physician will want to see as well as a sequenced overview of what documentation one would expect to see:

Obtain hospitalization medical records for the patient.

The handling of patient medical records and other private information is governed under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules HIPPA. In the U.S. Department of Health & Human Services, the Office for Civil Rights of the enforces the HIPAA Privacy Rule. This protects the privacy of individually identifiable health information. The HIPAA Security Rule sets national standards for the security of electronically protected health information. The confidentiality provisions of the Patient Safety Rule protect identifiable information being used to analyze patient safety events and improve patient safety. All along the medical record procurement and deployment process, U.S. law demands absolute confidential handling of patient information and mandates strict safeguarding of that information. Release of that information without the patient's express consent is strictly forbidden ("Health information privacy," 2011).

Under HIPPA, a patient release form/letter will be necessary to facilitate ordering the records for the facility records to be released to the patient's family physician.

Describe the relevant components of the medical record.

Patients name:

Doctor:

Account#:

History of Present Illness/Chief Complaint:

Patient issue. medical history, surgery if any the reason for it and the history behind it.

Review of Body Systems: Cardiovascular, Respiratory, etc..

Allergies: If any

Surgical History: any and all surgeries listed

Medical History: All past diseases and medical issues

Family History: Diseases of patient's family

Social History: Alcoholism, smoking, illicit drug use, etc.

Physical exam: preformed by physician (family or other) and their findings

Lab Results: Lab findings and work done

Assessment and Plan: What physician intends for treatment and the overall patient.

Dictation and signature of the doctor/nurse on duty (Appleby, & Tarver, 2006, 2-11-2-12) .

Sequenced overview of documentation