eSign Patient Medical Record Made Easy

Esign patient medical record

okay class I'm going to try by use of the video to show you how to put the medical record together so I hope this is going to help you with accomplishing the procedure 14-1 so we'll get started and the first thing I'm going to do is to show you the parts of the paper medical record it starts with a folder and when you open up the folder of course you have clips on both sides and the left side is used to hold the patient registration form and generally offices that's all that they use that left side form but again as I will continue to tell you offices may have different procedures also I might mention this as I go through and I may mention some of the different forms that go in the medical record you don't have to worry about trying to remember all that from this video because I've also put a document that will tell you what each form and where it goes in the medical records so here we are we started out with this paper form this manila folder and it's a it's a blank slate right now and then I'm going to show you how to add each part of it so I think let's go to the labels first now just to tell you a little bit about the labels one of the things that we do in the index side of the paper medical record we usually most offices will put two letters which would be the first letters of the last the first two letters of the last name and this is a typical book of labels and you see that each name is our each letter is going to have a different color alright so that's how you arrive at that it is some offices we'll use three but in our procedure we're just going to use one you also in in you have labels for your the year that you're in okay alright so let me show you how you're going to put those labels on so we go to the side here and so now we've turned the record around and so looking at this even edge up here at the top that's where our date is going to go now these labels as you can see they are they have the like in this example the years there are twice so what you're going to do is you're going to wrap that around and if you just bear with me a second I'll try to do this so you can still see it okay there you go and I hope hopefully you can see that me wrapping that around so there's the year up at the top okay and then you do that same procedure with the letter and in this case the first two letters are s and W and I'm going to put those on there okay and so now there you see that is the way that it would look with the year label and also with the first two letters of the person's last name now as I mentioned some offices might use three names three letters and so that would be four sno that would be the way that that would look right you also of course want to put the full name of the patient and so I you would put that here in the middle put that in the middle between the letters and the date the advantages of the caller coding is that once these medical records are alphabetized in the file system you can very easily look down and see where the changes are in your your name so you would look down and you would see the SW San they're all colored this way and it actually makes it a lot easier to find your records that you need okay so what's going to go on the inside on the inside and as I said before you want to put the registration form here and that's that's it but on this side which is your right my left you would put the tabs and this is a set of tabs here right as I mentioned there's a document that tells you each of the tabs and what goes in that and so I just want to physically show you how to put that in your medical record okay so you lift up these clips like this and then you put them through and so you have it like that and then you're going to open it that way you're going to fix it down that way so every time you get in the record you're going to have to open it up like that and then put your document in there now I am going to show you about the progress notes that goes into the record when you're getting ready for the patient the first day that the patient comes to the office if they've never been in your office before you would want to have progress notes already ready to go in there and so you would have blank progress notes like this ready to go and the office would use this type of a hole punch in order to make those holes happen so this is a special hole punch that's used for the two the two holes okay so to put the progress note in first off you're going to have to find the tab the progress note tab and the progress note tab is yellow so you're going to lift up the pieces of the record and you want the progress note to go in and then you're going to put get back now be sure you you understand this part because this very important whatever goes in that particular tab part of that medical record you want to be able to lift that up and then see the contents so don't make the mistake of putting for example put the progress note on top of that tab so because that is that would that would be just the opposite of what it should be okay so be sure that you do that also and I've mentioned this when we had our wimba session and we've talked about it everything is reversed chronological order so when I open up the progress note if there were notes already in here I would want to see the most recent so the first sheet that I see needs to be the most recent information and then the oldest information is to go to the back I want to tell you one more thing and this is going to be unique to the way that we're going to do this exercise some offices do different things with this blank tab there's one tab here at the end and it's blank and that leaves the office the option of doing whatever they would like to with that tab and so what we're going to do and you can just do this in your form that you do you can just do it with an ink pen that I used a label and we're going to put our consent forms in this very back tab and so I believe that's everything that you're going to need to know to put your record together and then from this point you will just take the forms that you have been given with your record you'll follow the scenario and also be sure to refer to the document that tells you what goes under each one of the tabs so that's very important it is very explicit and I think that you shouldn't have any problems but feel free to email me if there's something that's not clear and so good luck