A Health Information Management (HIM) / Medical Records (MR) practitioner will find a series of diagnostic tests or diagnostic procedures – terms used interchangeably, incorporated into the medical record of a patient.
Diagnostic tests or procedures are necessary to formulate a medical diagnosis and the course of treatment based on a patient’s history and presenting symptoms. Diagnostic tests or procedures are also performed to determine abnormalities or disorders of various body systems to identify and to prioritise the treatments and procedures during periodic reassessment and evaluation of the patient’s expected outcomes.
In the post Plan Of Care (this link will open in a new tab of your current window) about individualised care plans, you can read to know about a patient’s care plan which is always related to his or her identified needs. But those needs may change as the result of clinical improvement or new information from a routine reassessment, for example from diagnostic tests such as abnormal laboratory or radiography results.
As diagnostic tests or procedures are expensive, they are prescribed usually selectively by the prescribing practitioner, who is either the doctor in most instances or other authorised prescribing practitioners like advanced practice registered nurses who are authorised to order and perform certain diagnostic tests.
Diagnostic tests or procedures are either noninvasive or invasive. Noninvasive means the body is not entered with any type of instrument. The skin and other body tissues, organs, and cavities remain intact. Invasive means accessing the body’s tissue, organ, or cavity through some type of instrumentation procedure.
If you are working as a HIM/MR practitioner in a Joint Commission International (JCI) accredited hospital or a hospital seeking JCI accredited status or infact at any hospital, the medical records show documentation evidence of doctors who had found an abnormality and had prescribed diagnostic tests or procedures to evaluate findings more closely. The JCI Standard COP.2.3 requires that such evidence be demonstrated in the patient’s medical record.
As the JCI Standard COP.2.3 intent statement specifically lists endoscopy and cardiac catheterisation diagnostic procedures, I shall provide some brief details on these diagnostic precudures.
Endoscopy is an invasive diagnostic technique using specialised instruments called endoscopes such as the sigmoidoscope, colonoscope, gastroscope, bronchoscope, and laryngoscope, for visual observation of internal organs through the intestinal tract. However, no incisions are made for routine endoscopy procedures.
A team of doctors, nurses, and technicians perform a cardiac catheterisation procedure, which takes from 1 to 3 hours to obtain information about congenital or acquired heart defects, measure oxygen concentration, determine cardiac output, or assess the status of the heart’s structures and chambers. Therapeutic treatments may be done during the catheterisation to repair the heart, open valves, or dilate arteries.
Whatever the reason for diagnostic tests or procedures, diagnostic tests or procedures performed and the diagnostic findings (results) are always incorporated into the patient’s medical record. Such documentation on the appropriate forms will indicate details like the identity of the prescribing practitioner and his or her reason for performing the diagnostic and other procedures, if he or she had administered any anesthesia, dye, or other medications, type of specimen obtained and where it was delivered, vital signs and other assessment data such as patient’s tolerance of the procedure or pain and discomfort level as well as any symptoms of complications, patient or family teaching and demonstrated level of understanding and written instructions given to the patient or family members about the diagnostic and other procedures.
A HIM/MR practitioner must will be able to differentiate between diagnostic and other procedures performed and the location of their diagnostic findings(results) from that for surgical procedures, a written surgical report or a brief operative note that can be found in the patient’s medical record.
References:
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Michelle AG & Mary JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA
