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Chapter 14
Medical Records Management
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Medical Records Management
and the TPMS
Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Ownership of Medical Records
• The property of the one creating the record
• Information belongs to the patient and is
protected with privacy and confidentiality
• Patients are allowed access to their medical
records and can ask that certain material be
added or excluded from their file
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Ownership of Medical Records
• Providers who involve their patients in their
medical record keeping foster trust and
respect with their patients
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The Purpose of Medical Records
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The Purpose of Medical Records
• Provide a base for managing patient care
• Provide interoffice and intraoffice
communication as necessary
• Determine any patterns that surface to
signal the provider of patient needs
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The Purpose of Medical Records
• Serve as a basis for legal information
necessary to protect providers, staff, and
patients
• Provide clinical data for research
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Authorization to Release Information
• Even release of information required of a
subpoena requires notification of the patient
• Patients must sign a release form if
information is to be given to others
– May be yearly, when accepting insurance coverage, on
case-by-case basis
– Should be very specific in what information is and what
information is not to be released
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The Importance of
Accurate Medical Records
• Accuracy is essential to patient care
• Critical to the facility’s smooth functioning
• Necessary when referring patient to
specialists
• May be needed in litigation
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Correcting Medical Records
• On paper or in a manual medical record
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Draw single line using red pen through the error
Make the correction
Write Corr. or Correction above the area corrected
Indicate your initials and current date
• Never obliterate
• Forensic experts are able to determine when
and how corrections were made
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Correcting Medical Records
• Errors in EMRs
– Draw a line through the error (using the “tracking”
device in the word processing software)
– The correction is made immediately after the
information lined out
– “Corr.” or “Correction” is indicated with your initials
and date correction made
• EMR software locks out any chart additions
after a specified time
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Correcting Medical Records
• If information or a chart has been sent
elsewhere, make a copy of the corrected
information and send it ASAP
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Manual or EMRs
• Americans are to have EHRs by 2014 and
e-prescribing of Medicare medications may
be mandatory by 2011
• Manual
– Advantages
• Established and understood
• Easier to protect confidentiality
• No worry of computer malfunction
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Manual or EMRs
• Manual
– Disadvantages
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Can be used by only one person at a time
Easily misplaced or misfiled
Great amount of equipment and storage space required
More susceptible to error
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Manual or EMRs
• Electronic
– Advantages
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Multiple users possible
Not easily misplaced or misfiled
Data and patterns in data more easily accessed
Quickly available in emergencies
Office storage space not a problem
Legible and organized patient documentation
Improved medical management
Improved quality of care
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Manual or EMRs
• Electronic
– Disadvantages
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Need protection to prevent loss of data and security
Expensive to establish and maintain
May require on-site assistance
Can require up to 12 weeks for staff to prove productive
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Manual or EMRs
• Chosen records system must fit the facility
and needs of providers
– Must provide easy retrieval
– Must be easily understood and grammatically correct
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Types of Medical Records
• Problem-Oriented Medical Records
(POMRs)
– Identifies problems numerically as listed by patients
– Readily identifies frequency of recurring problems
– Nearly always use SOAP/SOAPER for progress notes
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Types of Medical Records
• Source-Oriented Medical Records (SOMRs)
– Groups information chronologically and by source
– Makes it difficult to quickly assess a patient’s clinical
picture
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Equipment and Supplies
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Vertical files
Open-shelf lateral files
Movable file units
File folders
Identification labels
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Equipment and Supplies
• Guides and positions
– Used to separate file folders
– Single captions and double captions
• Out-guides
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Basic Rules for Filing
• Alphabetizing is key to organizing files and
charts
• Rules facilitate alphabetic process in
maintaining files
• Indexing units
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Basic Rules for Filing
• Filing patient charts
• Filing identical names
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Steps for Filing Medical
Documentation in Patient Files
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Inspect
Index
Code
Sort
File
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Filing Techniques and
Common Filing Systems
• Alphabetic is intrinsic to all methods
– Color coding used a high percentage of time
– Numeric is used in very large ambulatory care and
hospital systems
– Subject filing often used for business records
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Filing Techniques and
Common Filing Systems
• Color-coding
– There are many systems
– Usually have alphabetic base
– Customized color-coding systems
• Tab-Alpha
• Alpha-Z
• Customized Color-Coded Systems
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Filing Techniques and
Common Filing Systems
• Alphabetic filing
• Numeric filing
– Straight numeric
– Terminal digit
– Middle digit
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Filing Techniques and
Common Filing Systems
• Numeric filing
– Components of numeric filing
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Serially numbered dividers with guides
Miscellaneous (general) numeric file section
Alphabetic card file
Accession record
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Filing Techniques and
Common Filing Systems
• Subject filing
• Choosing a filing system
– Consider type, purpose, and use of information
– Take into account number of files or records
– Recognize need for confidentiality
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Filing Procedures
• Cross-referencing
– Helps store files for quick and accurate retrieval
– Especially helpful with foreign names, hyphenated
names, and stepfamilies
– Should be simple
– Steps for cross-referencing
– Rules for cross-referencing
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Filing Procedures
• Tickler files in manual system or calendar
reminders in EMRs
– A reminder that action needs to be taken
– Should contain
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Patient’s name
Tickler date when action should be taken
Required action
Additional relevant information
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Filing Procedures
• Release marks
– Provider’s initials
– Quality control measure
• Check-out system
– Out-sheets or out-guides
– List of information that should be included on out-sheet
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Filing Procedures
• Locating missing files or data
– Conduct a systematic search
– Steps to searching
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Filing Procedures
• Filing chart data
– Types of reports
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Clinical notes
Correspondence
Laboratory reports
Miscellaneous
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Filing Procedures
• Retention and purging
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Record purging
Active files
Inactive files
Closed files
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Correspondence
• Filing procedures for correspondence
– Remove paper clips and staple items together
– Inspect to see if item is ready to be filed
– On incoming correspondence, be sure letterhead is
related to letter
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Correspondence
• Filing procedures for correspondence
– On outgoing correspondence, look at inside address and
reference line
– On incoming or outgoing correspondence, code
indexing units of designated label
– Create a miscellaneous folder for items that do not have
enough in number to warrant individual folder
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Electronic Medical Records
• Mandated and increasing in popularity
• EMRs create, store, edit, and retrieve
patient charts on a computer
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Electronic Medical Records
• Costs are high, but money is saved in
transcription and labor costs, copying
expenses, and malpractice insurance costs
– Purchased as a single computer application or part of a
larger practice management system
– Some clinics purchase a total practice management
system in steps
– EMRs can perform numerous tasks
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Electronic Medical Records
• EMRs require that the providers and all
staff members use the computer for viewing
charts, writing prescriptions, creating
progress notes, recording laboratory results
– May very soon respond to voice recognition rather than
keyed entries
• Confidentiality and privacy must be assured
when using EMRs
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Electronic Medical Records
• Essential system backup assures availability
of charts
• Confidentiality
– Medical assistants must always maintain confidentiality
– Never appropriate to discuss any information outside
the clinic unless authorized to do so
– No discussion of patient information within the facility
when not your concern
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