Transcript Chapter 7 - Horizon Medical Institute

CHAPTER
7
Facility and Records
Management
UNIT
1
Preparing for the Day
7-2
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Tasks to Do Before
Opening the Office






Unlock the reception room door.
Observe the physical environment of the
reception room.
Retrieve telephone messages.
Pull charts.
Inspect exam rooms.
Check common work areas.
7-3
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Things to Check in a Reception
Office Environment






Temperature
Room’s appearance
Safety check
Reading material available
Clean and safe toys available
Smoking policy is displayed
7-4
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Why the Receptionist Is Important


The receptionist
is the first person
a patient
encounters in a
medical office.
The receptionist
sets the tone for
the patient’s
experience.
7-5
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Responsibilities of the Receptionist







7-6

Opens and closes the office
Answers phones
Makes routine calls
Schedules appointments
Deals with patients
Monitors the climate of the reception
area
Prepares charge slips
Obtains new patient information
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Completed Charge Slips



Patient’s name and account number
List procedures with codes
List diagnoses with codes
7-7
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
New Patient Charts

Items in a patient chart



Patient demographic information
Insurance information
Copy of insurance card (both sides)
7-8
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Closing the Office







Restock and clean exam rooms.
Collect charts, check for completeness, and file
them.
Turn off all equipment.
Take receipts to the bank or lock them in the
office safe.
Tidy reception area and pull next day’s records
(if there is time).
Activate answering system.
Activate alarm system and lock door.
7-9
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Unit Summary


Why is it important for the receptionist to
be discreet when asking patients for
information at the front desk?
Why are insurance cards requested
when patients check in?
7 - 10
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
UNIT
2
The Patient’s Medical
Record
7 - 11
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
The Medical Record As
a Legal Document


7 - 12
The medical record is a legal document
admissible in a court of law.
April 2003: Health Insurance Portability
and Accountability Act (HIPAA) privacy
standards became effective to control the
release of medical information.
(continued)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
The Medical Record As
a Legal Document

All health care organizations must have
policies and procedures in place to
document compliance, including the
assignment of a HIPAA officer and
scheduling of ongoing training.
7 - 13
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Four Core Areas of HIPAA
Security Rules
1.
2.
7 - 14
Ensure the confidentiality, integrity, and
availability of all electronic protected
health information.
Have policies and procedures in place
that protect against use or disclosure of
electronic information that is not
permitted under the privacy ruling.
(continued)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Four Core Areas of HIPAA
Security Rules
3.
4.
Have policies and procedures in place
that protect against threats or hazards to
the protected health information records.
Demonstrate compliance with the
security ruling within the workplace.
7 - 15
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Examples of Subjective Information

Includes information supplied by the
patient:




Past personal history
Medical history
Family history
Chief complaint
7 - 16
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Examples of Objective Information

Objective information includes:






Examination findings and results
Results of laboratory studies
Special procedures
X-rays
Diagnosis and treatment
Progress notes
7 - 17
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Methods of Recording
Progress Notes



7 - 18
All progress notes should be arranged in
chronological order with the most recent
date on top.
The chart should be carefully dated for
each visit.
The last entry on each page should be
the most recent.
(continued)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Methods of Recording
Progress Notes


7 - 19
All no shows, cancellations, telephone
calls, and prescriptions are recorded and
include the date they took place and the
signature of the individual making the
entry.
The initial visit for any condition is written
as a brief description of what is wrong
and is known as a chief complaint on the
progress notes.
(continued)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Methods of Recording
Progress Notes

The entry should also include a history of
the present illness, list of any
medications taken, and an update of any
allergies to medications or drugs.
7 - 20
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Correct Procedure for
Making Corrections

In handwritten chart notes:




Draw a single line through the incorrect
entry.
Write the correct entry above or following
the correction.
Indicate the reason for the correction in the
margin.
Date and sign the correction.
7 - 21
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Conventional Medical Records


Progress notes are recorded according
to the source they come from, such as
the physician and/or the lab.
No attempt is made to record a
relationship between the source and the
entry.
7 - 22
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
The Problem-Oriented
Medical Record


7 - 23
Begins with a standard database of
patient information that includes the chief
complaint, examinations, and lab reports
A page listing chronic problems and the
dates the patient was seen for them
usually appears near the front of the
chart.
(continued)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
The Problem-Oriented
Medical Record


The page may also include a medication
list, a preventive care list, and an
education list that is also dated.
This allows the physician to quickly
review the medical history of the patient.
7 - 24
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
SOAP Method of Charting

Traditional method of charting where each
entry includes:




7 - 25
S: Subjective information (chief complaint)
O: Objective information (exam and lab)
A: Assessment (diagnosis)
P: Plan (treatment, education, medication)
(continued)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
SOAP Method of Charting
7 - 26
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
The History Physical
Impression Plan (HPIP)

Charting method that includes:





H: History
P: Physical exam
I: Impression
P: Plan
Note the similarities to SOAP charting.
7 - 27
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Major Sections of the
Medical Record





Administrative
data
Financial and
insurance
information
Correspondence
Referrals
Past medical
records





Clinical data
Progress notes
Diagnostic
information
Lab information
Medication
7 - 28
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Tickler Files


Often a small recipe card-sized filing unit
Files are used to keep track of referral
appointments, follow-ups, and rechecks.
7 - 29
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Chart Audits


Periodic review of charts to ensure
compliance
Areas reviewed include:





Administrative safeguards
Physical safeguards
Technical safeguards
Organizational requirements
Documentation
7 - 30
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Unit Summary


What is the difference between
subjective and objective information?
How would you define the HPIP method
of recording a patient’s medical
information?
7 - 31
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
UNIT
3
Filing
7 - 32
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Basic Filing Methods

Alphabetical


Files are arranged by last name from A to Z.
Numerical

Files are assigned a number when they are
created. This system provides privacy, but
requires an alphabetical cross-reference file.
7 - 33
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Steps Used in Filing
1.
Inspect

2.
Index

7 - 34
Review reports and divide into normal and
abnormal reports.
Make a decision whether to use the name,
subject, or another caption to file the
material under.
(continued)
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Steps Used in Filing
3.
Code

4.
Sort

5.
Mark the index caption
on the papers to be
filed.
Arrange the papers in
alphabetical order.
Store

Locate the file and insert
the most recent material
on top.
7 - 35
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Methods of Removing and
Replacing Patient Files


Locate the file and use an OUTguide or
folder to temporarily replace the folder
that has been removed.
This folder can hold items to be filed
when the original folder is returned.
7 - 36
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Storage Media Used for
“Paperless” Filing Systems


Store microfiche, microfilm, and back-up
files in card files, drawers, open shelves,
or racks.
The office may also use floppy disks,
CD-ROMs, memory sticks, DVDs, etc.
7 - 37
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Sections of a Medical Chart

Right side of an opened chart


Progress notes and lab reports
Left side of an opened chart



Immunization records
Medication lists
Patient data
7 - 38
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Purging Files



Purging is the process of removing
inactive files.
Files are generally purged when the
shelves become too full.
Take out the inactive file and either place
it in a storage box or arrange for the file
to be microfilmed.
7 - 39
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Locating Missing Charts



Go to where the file should be and look
through several charts in front of and
after this location.
Check the name and see if the chart was
filed by first name instead of last name.
Check to see if the chart has been pulled
for the patient to be seen that day.
7 - 40
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Alphabetical Filing Systems


Alphabetic filing systems are designed to
file charts according to the patient’s
name.
Generally, the last name is filed first, then
the first name, then the middle name or
middle initial.
7 - 41
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Numerical Filing Systems



Numerical filing provides the most
privacy for the patient.
Patients are assigned a chart number
when they first enter the practice.
This system requires an alphabetical
cross-references to be maintained.
7 - 42
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Unit Summary


What are the basic steps used in filing?
When would you use an OUTguide in the
medical office?
7 - 43
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Keys to Career Success



The successful medical assistant pays
attention to details.
Careful attention to charting provides
legal protection to all members of the
practice and to the patient.
Filing charts correctly saves time and
increases office efficiency.
7 - 44
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Hot Links to Career Success

www.kardex.com


Kardex Information and Materials
Management Systems
www.smeadsoftware.com

Smead Software Solutions
7 - 45
Copyright © 2008 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.