Transcript Chapter Fourteen Medical Records Management

The Paper Medical Record
Chapter 14
Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Introduction
Medical records management systems are only as
good as the ease of retrieval of the data in the
files.
Organization and adherence to set routines will
help to ensure that medical records are accessible
when they are needed.
Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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This chapter will examine:
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Reasons for keeping accurate records
Ownership of records
Differences among types of records
Differences among types of information
Making corrections in the record
Filing procedures and systems
Forms found in medical records
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Why Medical Records Are Important
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Assist the physician in providing the best
possible care to the patient
Offer legal protection to those who provide care
to the patient
Provide statistical information that is helpful to
researchers
Vital for financial reimbursement
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4
Ownership of the Medical Record
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The maker, who initiated and developed the
record, owns the physical medical record.
The maker can be a physician or a medical
facility.
Patients have a right of access to the
information in the record.
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5
Points to Remember
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Medical records must be kept confidential and
in a secured, locked location.
The record should never leave the medical
facility in which it originated.
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6
Creating an Efficient Medical
Record System
The system should:
 provide for easy retrieval
 be organized and orderly
 contain information that is completely legible
 contain accurate information
 show information that is easily understood and
grammatically correct
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7
Types of Records
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Paper-based medical records
Computer-based medical records
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Disadvantages of Paper-Based
Medical Records
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Only one person can use the record at a time,
unless multiple people are crowding around the
same record.
Items can be easily lost or misfiled or can slip
out of the record if not securely fastened.
The record itself can be misplaced or be in a
different area of the facility when needed.
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9
Advantages of Computer-Based
Medical Records
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More than one person can use the record at a
time.
Information can be accessed in a variety of
physical locations.
Records can often be accessed from another
city or state.
Complete information is often available in
emergency situations.
Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.
10
Organization of the Medical Record
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Source-oriented records
Problem-oriented records
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11
Source-Oriented Medical Records
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Traditional method of keeping patient records
Observations and data are cataloged according
to their sources
Forms and progress notes are filed in reverse
chronologic order
Separate sections are established for laboratory
reports, x-ray films, radiology reports, etc.
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12
Problem-Oriented Medical Records
Courtesy Bibbero Systems,
Petaluma, Calif.
Divides records into four bases:
1.
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3.
4.
Database
Problem list
Treatment plan
Progress notes
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13
Database
Includes:
 Chief complaint
 Present illness
 Patient profile
 Review of systems
 Physical examination
 Laboratory reports
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14
Problem List
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Numbered and titled list of every problem the
patient has that requires treatment
May include social and demographic troubles
as well as medical and/or surgical notes
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15
Treatment Plan
Includes:
 Management
 Additional workups needed
 Therapy
Each plan is titled and numbered with respect to
the problem.
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16
Progress Notes
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Structured notes are numbered to correspond
with each problem number.
Progress notes follow the SOAP approach.
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17
SOAP Approach to Progress Notes
SOAP acronym
S—Subjective impressions
O—Objective clinical evidence
A—Assessment or diagnosis
P—Plans for further studies, treatment, or
management
Optional E—Evaluation or Education
R—Response
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18
CHEDDAR
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C—Chief Complaint
H—History
E—Examination
D—Details (of problem and complaints)
D—Drugs and dosages
A—Assessment
R—Return visit
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19
Contents of the Complete Case History
Subjective Information
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Patient’s full name
Parents’ names, if child
Sex
Date of birth
Marital status
Spouse’s name
Number of children
Social Security number
Driver’s license number
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Home address and
phone
email address
Occupation and
employer
Business address and
phone
Healthcare insurance
information
Spouse’s employment
information
Source of referral
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20
Personal and Medical History
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Often obtained by patient questionnaire
Provides information about any past illnesses or
surgical operations
Explains injuries or physical defects
Information about the patient’s daily health
habits
Information about allergies, advance directives,
living wills, and so on
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21
Patient’s Family History
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Physical condition of members of the patient’s
family
Past illnesses and diseases family members
may have experienced
Record of causes of family members’ deaths
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Patient Information Form
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Patient’s Social History
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Information about the patient’s lifestyle
Alcohol, tobacco, and drug use history
Marital information
Psychologic information
Emotional information, if pertinent
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24
Patient’s Chief Complaint
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Nature and duration of pain, if any
Time when the patient first noticed symptoms
Patient’s opinion as to the possible causes of
the difficulties
Remedies that the patient may have applied or
tried
Whether the patient has had the same or similar
condition in the past
Past medical treatment for the same condition
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25
Pain Scale
“How bad is your pain on a scale of 1 to 10,
with “1” being like a mosquito bite, and “10”
being the worst pain you have ever
experienced?”
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26
Objective Information
Objective findings, often called signs, are
gained from the physician’s examination of the
patient.
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27
Objective Information
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Physical examination and findings
Laboratory and radiology reports
Diagnosis
Treatment prescribed
Progress notes
Condition at the time of termination of treatment
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28
Diagnosis
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Provisional
Differential
Final
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Obtaining the History
Histories may be obtained by:
 Patient questionnaire
 Medical assistant asking the patient questions
 Physician asking the patient questions
 Combination of questionnaire and questions
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30
Medical Assistant’s Role When
Taking Patient History
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Take history in a physical location that ensures
patient confidentiality.
Ask open-ended questions.
Obtain details of the patient’s condition and
symptoms.
Keep all information about the patient
confidential.
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31
Authentication
For a chart to be admissible as evidence in court,
the person dictating or writing the entries must be
able to attest that they were true and correct at
the time they were written.
This is “authentication” and is best done by
initialing entries made to the medical record.
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32
Making Additions to the Record
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Place the most recent information on top.
Physicians should read and initial reports before
they are filed.
Some offices direct only abnormal reports to the
physician.
Follow the office policy as to which method is
used in that particular office.
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33
Laboratory Reports
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Often on different colors of paper for easy
reference.
May need to be attached to standard-sized
paper.
Reports may be shingled, if necessary.
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34
Laboratory Reports (cont’d)
Courtesy Bibbero Systems, Petaluma, Calif.
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35
Radiology Reports
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Usually typed on standard-sized stationery.
Place in reverse chronologic order, with the
most recent report on top.
Medical records often have a separate section
for laboratory and radiology reports.
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36
Progress Notes
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Continually added to the medical record.
Must list each patient visit and any notations
about the visit.
Instructions, prescriptions, and telephone calls
for advice should be noted in the progress
notes.
Always initial entries in progress notes.
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37
Making Corrections and
Alterations to Medical Records
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First, verify the correct procedure as detailed in
the policy and procedure manual.
Never use correction fluid, erasers, or any other
type of obliteration methods.
Do not mark through information to obliterate it.
Do not hide errors.
If errors could affect the health and well-being of
the patient, bring it to the physician’s attention
immediately.
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38
Correcting an Error
Three Steps
1.
2.
3.
Draw one line through the error.
Insert the correction above or immediately after the
error.
In the margin, write “correction” or “corr” and initial the
entry, if indicated by the office policy and procedure
manual.
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39
Correcting Electronic Records
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If an error is made while typing, simply
backspace and correct the error.
If the error is discovered later, make an
additional entry (addendum) with corrected
information.
Do not delete or change previous entries on
electronic records.
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40
Keeping Records Current
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Records must be methodically kept current.
Do not allow histories and reports to accumulate
for long before filing them.
The patient’s health is jeopardized when
current, accurate records are not available to
the physician.
Remember that the physician bases his
decisions on the information in the patient
medical record.
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41
Prescriptions
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Some prescription pads are printed on NCR
paper, which automatically makes a copy for the
medical record.
All prescriptions must be noted in the medical
record, including refills called in to the patient’s
pharmacy.
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42
Classifications of Records in the
Physician’s Office
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Active files
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Inactive files
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patients currently receiving treatment
patients who have not been seen for about 6 months
to a year.
Closed files
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patients who have died, moved away, or otherwise
discontinued treatment
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43
Transfer of Records
Follow office policies regarding transferring
medical records from active to inactive or closed
categories.
This process is called “purging.”
Files may need to be physically rearranged to
accommodate transfers.
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44
Retention and Destruction
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Most physicians keep medical records for 10
years at a minimum.
Some records may warrant longer retention
periods.
Records for minor patients should be kept for at
least 3 years after they reach legal age.
Use year stickers on patient files.
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45
Retention and Destruction
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Follow local, state, and federal guidelines for
retention and destruction of records.
HIPAA does not specify medical record
retention requirements.
In most cases, keep medical records at least as
long as the length of time of the statute of
limitations for medical professional liability
claims.
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46
Retention and Destruction
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Medicare and Medicaid patient records must be
kept for at least 6 years.
Keep records on patients who are deceased for
at least 2 years.
Follow office policies for record retention and
destruction.
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47
Releasing Medical Record Information
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Requests must be made in writing for release of
records.
Patients must sign an authorization for release
of medical records.
Patients can revoke previously signed
authorizations for release of records.
Release only records that are specified on the
request.
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48
Releasing Medical Record Information
(cont’d)
Courtesy Bibbero Systems, Petaluma, Calif.
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49
Filing Equipment
Various types of equipment are available for
storing medical records in today’s medical
offices.
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50
Considerations in Choosing
Filing Equipment
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Office space availability
Structural considerations
Cost of space and equipment
Size, type, and volume of records
Confidentiality requirements
Retrieval speed
Fire protection
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51
Types of Filing Systems
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Drawer files
Shelf files
Rotary circular files
Lateral files
Compactable files
Automated files
Card files
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52
Filing Supplies
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Divider guides
OUTguides
OUTfolders
Files and folders
Labels
Courtesy Bibbero Systems, Petaluma, Calif.
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53
Filing Procedures
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Conditioning
Releasing
Indexing and coding
Sorting
Storing and filing
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54
Indexing Rules
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Last name first, then first name, then middle
name or initial.
Initials precede names beginning with the same
letter.
Hyphenated names are treated as one unit.
Apostrophes are disregarded.
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55
Indexing Rules
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Index each part of foreign names if confused as
to first and last names.
Names with prefixes are filed in regular
alphabetic order.
Abbreviated parts of a name are indexed as
written.
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56
Indexing Rules
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Name of a married woman is indexed by legal
name.
Titles may be used as the last filing unit if
needed to distinguish from another identical
name.
Terms of seniority are indexed only to
distinguish from an identical name.
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57
Filing Methods
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Alphabetic
Numeric
Alphanumeric
Subject
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58
Color-Coding
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Almost all medical offices use some sort of
color-coding in their filing systems.
Numeric color-coding provides a high degree of
patient confidentiality.
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59
Color-Coding (cont’d)
Courtesy Bibbero Systems, Petaluma, Calif.
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60
Transitory or Temporary Files
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Transitory or temporary files are used for
materials having no permanent value.
Materials in these files are kept there
temporarily, usually until the document is dealt
with and no longer needed.
Useful when seeing patients from another
geographic area that are not expected to return
to the office.
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61
Summary of Scenario
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All duties performed in the practice are
learning opportunities.
Ask for additional responsibilities.
Always be ready to assist a co-worker.
Earn the trust of patients.
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62
Closing Comments
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Advances in medical records occur rapidly.
Be willing to learn.
Adapt to changes.
Keep a positive attitude.
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63