Transcript ASTD Training Certificate Program Module I

Business for Health
Business Skills for Private Medical Practices
Module 8: Manage Medical Records
SHOPS is funded by the U.S. Agency for International Development.
Abt Associates leads the project in collaboration with
Banyan Global
Jhpiego
Marie Stopes International
Monitor Group
O’Hanlon Health Consulting
A Quick Start Welcome!
While you are
waiting for the class
to begin, please take
the Pre-Test and
make sure your
name is on it before
you hand it to the
facilitator.
Thank you!.
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Agenda
Welcome
Outpatient Medical Records
Medical Records Policies and Procedures
Medical Records Audits
Medical Records Management
Manage Medical Records
Summary and Evaluation
Close
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Learning Objectives
During this session, you will:
1. propose the patient information and
forms that should be included in
outpatient medical records;
2. recommend how an outpatient medical
record can be organized;
3. assess the content of your current medical
records;
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Learning Objectives
4. discuss your current medical records
policies and procedures;
5. assess your current medical records
policies and procedures;
6. design a checklist for auditing the
completeness of medical records;
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Learning Objectives
7. design a peer review checklist for
auditing the quality of medical records;
8. assess your current medical records
management;
9. decide how to handle issues related to
medical records management;
10. discuss the next step; and
11. state your key take-away from this
session.
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Introduction
You will have 1 minute to introduce yourself:
1.
2.
3.
4.
Your name
Your position
Your business
How long you have been in business
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Outpatient Medical Records
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Outpatient Medical Forms
Design a well organized and complete
outpatient medical record. Please identify:
1. The forms you need in the medical
record
2. The information that should be collected
on each form
3. The order in which the forms should be
placed in the medical record, with # 1
being the first form you would see
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Medical Records Content Assessment
Medical Records Should Contain:
1. Problem list
2. Medications
3. Adverse drug reactions
7. Personal data
8. Pertinent history
9. Physical exams
4. Allergies
5. Smoking status
6. Alcohol/drug abuse
10. Documentation for each visit
11. Lab/other studies
12. Working diagnoses
Etc.
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Example of Primary Care Medical
Record Documentation Standards
Criteria
Biographical/Personal Data
General Chart Organization
Personal History
Social Habits
Office Visit/Follow Up
Preventive Services
Description
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Points
8
5
38
12
29
20
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Medical Records Policies and
Procedures
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Medical Records Policies and Procedures
 Who prepares a new patient medical
record?
 What system is used for filing and
retrieving medical records?
 Who is allowed to make entries into
the record?
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Medical Records Policies and Procedures
 What procedure do you use to
indicate the need to follow up on
patient referrals or external
diagnostic test results?
 What are your security procedures
regarding medical records?
 How do you maintain patient
confidentiality?
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Medical Records Policies and Procedure
Assessment
Patient
Medical
Record
Information
Management
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References
 Simple Ambulatory Medical Record
Documentation Standard
 Sample Clinical Records Management
Policy
 Policy and Procedures Writing Guide
and Template
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Medical Record Audits
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How to Conduct Medical Record Audits
What are the best
ways to conduct audits
of medical records for
completeness of data
and documentation of
quality of care?
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Auditing for Completeness of Medical
Records
Create a peer review audit checklist.
For example:
1. Are all of the necessary forms in the
record?
2. Are all clinical notes signed, dated
and timed?
3. Are patient vital signs recorded for
each visit?
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Reference
 Sample Peer Review Policy and
Procedure: Quality Audit
Sample Peer Review Worksheet
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Quality Issues in Medical Records
Identify five issues that need a medical
record peer review. For example:
1. Did the provider prescribe the
correct drug?
2. Were the blood tests that were
ordered the correct tests?
3. Was the chest x-ray consistent with
the differential diagnosis?
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Auditing for Quality of Medical Records
Create a peer review audit checklist
based on the issues listed
in the previous activity.
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Reference
 Sample Peer Review Policy and
Procedure: Quality Audit
 Sample Peer Review Worksheet
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Medical Record Management
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Medical Record Management
Assessment
✔ 1. The practice maintains complete and
accurate medical records
✔ 2. Medical records are stored in a secure
location
✔ 3. There is a unique medical record for each
patient
✔ 4. Records are organized for easy retrieval
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Manage Medical Records
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Case Study: Filing Folly
Working with your table, please identify:
1. the issues
2. the causes
3. how to avoid them in the future; and
4. what the hospital should do to manage
the current situation.
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Case Study: Filing Folly
1. Issues
2. Causes
3. How to Avoid
4. How to Handle the Current Situation
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Summary and Evaluation
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Evaluation Sheet
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The Next Step
1. Develop a Medical Record Data Quality
Checklist
2. Ensure your Medical Record Policies and
Procedures include file management,
confidentiality, and record retention
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The Next Step
3. Design a monthly Patient Medical Record
Peer Review process for quality and
appropriate use of services
4. Randomly pull five patient medical records
and conduct a review for data
completeness and quality of service.
Document results and take action when
needed.
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Let’s See How Much You’ve Learned
Please take the Post-Test.
We will compare it to your Pre-Test
to see how much you’ve learned in
this session.
Thank you.
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My Key Take-Away
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