Transcript Reverse Chronological Order

Medical Records
Management
1
Why are Medical Records
important?
 Assist
physician in providing best possible
care.
 Provides a complete history.
 Provides critical information for others.
 Provides continuity of care.
2
Why are Medical Records
important?
 Offer
legal protection for those who are
providing care.
 Remember: “If it isn’t documented, it didn’t
happen.”
3
Why are Medical Records
important?
 Provide
statistical information.
 Provides information about medications
taken and reactions to them.
 Evaluate effectiveness of treatment.
 Track drug effectiveness and side effects.
4
Why are Medical Records
important?
 Vital
for financial reimbursement.
 Usually required by third-party payors.
 Supports medical necessity for billing and
payment.
5
Who Owns the Medical Record?
 The
physician or medical facility owns it.
 They are the “maker” of the record.
 The patient has the right to demand
access to the information contained in the
record, but does not own it.
6
Security
 Originals
should never leave the premises.
 Should an original leave the premises, a
copy should be retained in the record and
marked as such until the original is
returned.
 Records should be kept in a locked
cabinet or locked room.
7
So tell me what you know…
 Why
are medical records important?
 Who owns the medical record?
 How should medical records be kept
secure?
 Who knows how to complete this
statement – “If it isn’t documented, ____.”
 Why is this statement important?
8
Management of Records
 Files
should be organized at all times.
 Adding documents to a chart should be
able to be done efficiently.
 A physician or provider should always
have the most up-to-date information.
 Above all, the system must work for the
facility.
9
Types of Records
 Paper
based
 Electronic based/Computer-based
10
Paper based

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Only one person can use the record at a time.
Not readily available for use by others.
Misfiled information is common.
Entire record can be misfiled or misplaced.
Data is difficult to retrieve for statistical and
quality control purposes.
It is good evidence of patient care.
11
Paper based
 If
you have patients who stay for a period
of time and discharge (nursing home or
hospital)…

It is generally a good idea to have a different
color chart for each calendar year to allow for
rapid year location.
•
•
•
•
2008 – green
2009 – blue
2010 – red
2011 – yellow
12
Paper based
 Master
Card File: This is a master file of
all charts and storage location.
 Master Card Files are often a 3x5 cardex
type file and includes identifying patient
information, dates of service, medical
record number, etc.

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Master file is to be updated as files are
relocated (closed files, relocated to make
more room for current files).
Master Card is to be noted with date of chart
destruction.
13
Computer based

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Differs from Electronic based
The bulk of the record is computerized but may
not include everything, such as x-rays or lab
reports.
Guarding patient confidentiality is difficult.
Computer malfunctions may limit access to the
record.
Access to records will be available even if the
patient is not in his/her home town.
14
Electronic based
 All
records are stored electronically.
 Includes x-rays, MRIs, etc.
 Anything not provided in an electronic
format is scanned into the record.
15
So tell me what you know…
 What
are the pros/cons of a paper-based
record system?
 What are the pros/cons of a computerbased record system?
 What are the pros/cons of an electronicbased record system?
 How do you know which one is best for
your office/hospital?
 What is the purpose of a Master Cardex?
16
Chart Order
 Forms
are filed in Reverse Chronological
Order
 This means the most recent document is
on top.
 All like documents are kept together.
 All physician's orders are together, all lab
reports, all nurses’ notes and so on.
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SOAP / SOAPE (SOAPIE)
 Many
doctors (or Nurse Practitioners) use
the SOAP or the SOAPE (SOAPIE)
approach to their progress notes.
 This essentially forces a rational approach
to patient problems and assist in
formulating a logical and orderly plan of
patient care.
18
SOAP
S
= Subjective Impressions
 O = Objective Clinical Evidence
 A = Assessment or Diagnosis
 P = plans for further studies or treatment
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SOAPE (SOAPIE)
S
= Subjective Impressions
 O = Objective Clinical Evidence
 A = Assessment or Diagnosis
 P = plans for further studies or treatment
 (I = Intervention)
 E = Evaluation
20
So tell me what you know…
 Explain
what reverse chronological order
means.
 What does each letter of “SOAP” mean
and give an example of information that
would be written for each.
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Demographic Information

Personal Demographics
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Full name (spelled correctly)
Name of parents (if a child)
Patient’s sex
Date of Birth (DOB)
Marital Status
Name of spouse, if married
Number of Children, if any
Home address, telephone number and email
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Demographic Information
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Occupation
Name of employer
Business Address and telephone number
Employment information for spouse
Healthcare Insurance Information
Source of Referral
Social Security Number
23
So tell me what you know…
 Why
is demographic information
important?
 How many examples of demographic
information can you name? (Hint: You
were just given 15 – no peeking!)
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Personal and Medical History
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Often obtained by completing a questionnaire
Past illnesses and surgeries
Physical defects (congenital or acquired)
Allergies
Daily habits
Advanced Directives
Anything that needs to be in the forefront of the
providers mind while providing care.
25
Family History
 Illnesses
or diseases
 Causes of death for immediate family
members
 Many diseases and illnesses have
hereditary patterns.
26
Social History
 Information
about a patient’s lifestyle
 Do they consume alcohol? How much?
 Do they smoke? How much?
 Do they use drugs? How often?
 Do they wear a seat belt?
 Married? Single? Sexually active?
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So tell me what you know…
 Why
is a patient’s personal and medical
history important?
 Why is their family history important?
 How much of an impact does a patient’s
social history have on their medical care?
 What if the patient does not tell the truth?
28
Chief Complaint

General information may be taken by a Medical
Assistant, but should be reviewed in detail by the
Physician/Nurse Practitioner.
 Concise account of patient’s symptoms,
explained in the patient’s own words.
 Should include:
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Nature and duration of the pain, if any
Time when patient first noticed the symptoms
Patient’s opinion as to the cause of the difficulty
Remedies patient tried before coming to see the
doctor
Other medical treatment rec’d for the same condition
in the past
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Objective Information
“Signs” that become evident from the physician’s
examination of the patient.
 Physical findings
 Test results or requests for tests
 Diagnosis can be made.
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If some doubt remains, a provisional diagnosis can be
made.

Treatment is prescribed.
 Timeframe for follow-up is noted.
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Obtaining the History

Can be done orally, if privacy allows, to become
better acquainted with the patient.
 Can be done in writing.
 If the records are kept electronically or the
questionnaire is lengthy the form may be mailed
prior to the appointment to allow for time to enter
the information prior to the visit.
 Will the office provide return postage?
31
Forms

Often different colors are used to make forms
easy to locate within a paper record.
 Such as: yellow for urinalysis, pink for blood
counts, etc.
 Shingling: Small forms taped to a 8 ½ by 11
sheet of paper one on top of another
approximately ½ inch above each another
starting from the bottom. This method allows for
the most recent form to always be on top.
 Shingle small forms such as half sheets,
messages, post it notes, etc.
32
Keeping Records Current
 Never
Procrastinate!!!
 File Daily!!!
 Make certain the physician has received
all abnormal lab reports and urgent
messages.
33
So tell me what you know…
 Why
is the chief complaint significant to
the physician?
 When you are responsible for maintaining
records, why is consistent color coding
important?
 Why do you shingle records?
 Can you think of records that would be
beneficial to shingle?
34
Transfer, Destruction and
Retention of Files
 Active
files: Patients currently receiving
care
 Inactive files: Patients the doctor has not
seen in six months or longer
 Closed files: Patients who have died,
moved away, or otherwise terminated their
relationship with the doctor.
35
Transfer, Destruction and
Retention of Files

No nationwide standard for retention
 Medicare and Medicaid have their own
guidelines.
 When no restrictions exist it is best to keep
records for ten years.
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Applies to Adult Charts
Minor Charts should be kept until minor is age 18,
plus several more years according to state law.
In all cases, records should be kept for at least
as long as the statute of limitations for medical
malpractice claims.
36
Releasing Medical Record
Information
 The
patient must sign a release for
information to be given to any third party
(except insurance companies).
 All medical records requests should be in
writing and retained with the record.
37
Releasing Medical Record
Information
 Take
extreme care with telephone calls.
 Just because I say I am – Am I really???
38
So tell me what you know…
 What
kind of patients have active files?
 What kind of patients have inactive files?
 What kind of patients have closed files?
 How long should a medical record be
maintained?
 When is it okay to release a copy of the
medical record?
 Where should record of the release be
stored?
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Have questions? Still unclear?
40