Allied Health Assisting
Download
Report
Transcript Allied Health Assisting
ALLIED HEALTH ASSISTING
CHAPTER 13: THE MEDICAL RECORD, DOCUMENTATION, AND FILING
THE PURPOSE OF RECORDS
A complete accurate medical record is necessary
Personal information
Medical history
Family history
Social habits
Medications
Occupational exposures
Different types of testing performed
THE PURPOSE OF RECORDS
Personal information includes
Gender
Ethnicity
Religion
Age
Marital status
Living arrangements
Children
Occupation
Insurance information
THE PURPOSE OF RECORDS
Medical record serves as a way to maintain and document the course of medical evaluations, treatments, and
changes in condition
Charting
Lays out a chronological account of the patient reports, providers evaluation, prescribed treatment, and responses to
treatment
Provides legal protection for both the patient and provider
Used for insurance purposes
Conducting research
HIPAA AND THE MEDICAL RECORD
Health Insurance Portability and Accountability Act
Established in 1996
Privacy of patient information is main focus
Pertain primarily to records management
Maintaining the privacy of health information
Establishing standards for any electronic transmission of health information and related claims
Ensuring the security of all electronic health information
HIPAA AND THE MEDICAL RECORD
HIPAA privacy rule for all medical data
Effective in 2003
Provides standards for patients’ confidential, personal information
Medical facilities need to limit what information was released and who it was released to
HIPAA is more lenient than most realize
The privacy rule allows each organization to do what it feels is reasonable within the maintained guidelines
Most institutions employ a HIPAA office
Understand the rulings
Train the staff
Keep up with changes
HIPAA AND THE MEDICAL RECORD
HIPAA security rule
Ensure confidentiality, integrity, and availability of all electronic protected health information (PHI) the providers compose,
receive, or maintain, or send out
Have policies and procedures in place to protect against use or disclosures of the electronic information that is not
required or permitted under the Privacy Ruling
Have policies and procedures in place to protect against threats or hazards to the PHI records
Demonstrate compliance with the Security Ruling within the workplace
HIPAA AND THE MEDICAL RECORD
Centers for Medicare and Medicaid Services (CMS) can audit and ask for documentation of compliance with the
Security Rule
Administrative safeguards
Physical safeguards
Technical safeguards
Organizational requirements
Documentation
New employee orientation and periodic updates should include training in maintaining security of records
ELECTRONIC HEALTH RECORDS
National Alliance for Health Information Technology (NAHIT) has established definitions for:
Electronic Medical Records (EMR)
Electronic Health Record (EHR)
Electronic record of health-related information for an individual that is created, gathered, managed, and consulted by licensed clinicians as
staff that is maintained through a single organization
Differs from EMR is that is it the aggregate electronic record of health-related information that is created and gathered cumulatively
across more that one organization
Personal Health Records (PHR)
Collection of medical records compiled and maintained by the individual
ELECTRONIC HEALTH RECORDS
EHRs provide improved management of patient records
Facilitate more efficient billing services
Federal government provides incentives for practices to convert to EHRs
Provider must satisfy meaningful use
Practice must actually use the system, not just have it in place
40% of prescriptions must be submitted electronically
Provide patients with copies of their health information within 3 days more than 50% of the time
Obtain patient demographic data a minimum of 50% of the time
ELECTRONIC HEALTH RECORDS
Advantages of EHRs
Availability of a searchable database that records patients’ demographics, allergies, lab results, and improved accessibility of
the record to health care providers
Radiology and laboratory departments that can transmit results directly to the provider, reducing the time to treatment and
notification of critical values
Electronically entered prescriptions that minimize errors related to illegible handwriting and reduce the time for
prescriptions to be available to the patient. Software also screens medications for interactions and allergies
Aiding in reminding the health care provider when routine testing should occur, such as mammography, vaccinations, and
cardiovascular procedures
In a multi-specialty facility or practice, facilitating coordination of care among providers and elimination duplicate or
incomplete testing and treatment
ELECTRONIC HEALTH RECORDS
Advantages of EHRs
Chart notes that can be available immediately when a patient needs a referral or consultation with another provider
Voice recognition software that improves availability of printed records and decreases costs by eliminating the need for
transcribing dictated notes
Assigning the CPT and ICD codes at the time of the visit, streamlining the process of insurance filing
A photograph of the patient, which can be included in some software applications to ensure the correct record has been
selected
Trending that might help identify problems that might not be identified as early when using traditional paper records
Does not completely eliminate the need for paper records
PARTS OF THE MEDICAL RECORD
Divided into the following sections
Administrative data
Financial and insurance information
Correspondence
Referral
Past medical records
Clinical data
Progress notes
Diagnostic information
Lab information
medications
PARTS OF THE MEDICAL RECORD
Subjective vs. Objective Information
Subjective
Supplied by the patient
Signs
Symptoms
Complaints
Objective
Can be measured
Seen
touched
PARTS OF THE MEDICAL RECORD
Administrative, financial, and insurance information
Demographic and insurance information should be verified every visit
Good idea to post a sign saying, “Do we have your current address and phone number?”
Maintain accurate documentation of insurance and payment information
PARTS OF THE MEDICAL RECORD
Correspondence and referrals
All correspondence received, whether medical or financial, should be maintained in the record
Referral or follow up letters from specialists
Letters from insurance
Correspondence from the patient
In the EHR, correspondence is scanned and uploaded in the patients chart
PARTS OF THE MEDICAL RECORD
Progress Notes
Documents the progress of each patient
Entered in chronological order
Provider’s “Journal”
Chief Complaint
Brief description of why the patient came in
In the patient’s own words
Diagnostic Imaging Information
Results from X-rays, CT scans, MRI’s, Ultrasounds, etc
Dictated by Radiologist
CD, DVD, Film copies
Must request electronic format, if not just dictated report will be sent
PARTS OF THE MEDICAL RECORD
Lab Information
Any critical values should be highlighted
Placed in chronological order with most current first
Separated into groups
PARTS OF THE MEDICAL RECORD
Medications
All medications administered are documented
Entry includes:
Prescriber
Medication name
Dose
Frequency
Route
Time given
Observation period
Copies of prescriptions
CHARTING IN THE PATIENT RECORD
Problem-Oriented medical record (POMR)
Developed by Lawrence L. Weed M.D. in early 1970’s
Progress notes are organized based on the source from which they come
Works well in group settings
Promotes continuity of patient care
Same system incorporated into the EHR’s of today
CHARTING IN THE PATIENT RECORD
SOAP
Subjective impressions
Objective Clinical Evidence
Assessment or diagnosis
Plans for further studies, treatment, management
CHARTING IN THE PATIENT RECORD
SOAP
Process makes the chart easier to review and helps in follow-up
Example:
Pt complains of two days of severe high epigastric pain and burning, radiating through the back. Pain accentuated after eating
On examination there is extreme guarding and tenderness, high epigastric region, no rebound. Bowel sounds normal. BP 110/7, P 66, R 18
R/O gastric ulcer, pylorospasm
Pt to have upper gastrointestinal series, Start on Cimetidine 300mg daily. Eliminate coffee, alcohol, ASA, and return in two days.
CHARTING IN THE PATIENT RECORD
HPIP
History
Physical exam
Impression
Plan
CHARTING IN THE PATIENT RECORD
HPIP
Similar system to SOAP
Example:
C/O severe H/A Rt side of his head lasting several hours to up to 3 days; has had 4 in the past 6 wks, pain is increasing each time; takes
ASA for pain. Neurologic exam shows slight tremor in both hands. R/O encephaloma. CAT scan o cranium. Refer to Clearbrook
Neurological Associates
CHARTING IN THE PATIENT RECORD
CHEDDAR
Another method for charting that encourages providers to include greater detail than SOAP or HPIP
Chief Complaint:
Presenting problem. Should be recorded in the patients words
Any unusual descriptions should be put in quotes
As much subjective information should be obtained as possible
History
A list of patient’s prior medical history
Social history
Relevant family history
CHARTING IN THE PATIENT RECORD
CHEDDAR
Examination
Details of problems and complaints
Objective findings by the examiner
Results of additional testing
Drugs and dosages
Complete list of ALL medications, both prescription and OTC
Vitamins and supplements too
Assessment
Diagnosis
Appropriate treatment
Further testing
CHARTING IN THE PATIENT RECORD
CHEDDAR
Return visit
Indicate if a return or follow-up visit is required
DATING, CORRECTING, AND MAINTAINING THE CHART
Date and time should always be notes when making any entry in the chart
Always use military time
In EHR’s date and time is automatically stamped
Any entries in the chart must be signed by the person who made them
Corrections and late entries
Single line through incorrect entry
Correct above or following
Initial
Time and date
DATING, CORRECTING, AND MAINTAINING THE CHART
Only use BLACK pen
When you are finished with the chart, straighten and tidy the forms
File the chart appropriately ASAP
Transcribe dictated notes ASAP
DATING, CORRECTING, AND MAINTAINING THE CHART
Use the following steps for proper records
1.
Read accurately and spell names correctly
2.
Print or write legibly with black ink
3.
Record information as soon as possible
4.
Make corrections by drawing one line through the error
5.
Keep charts neat and file them in a timely manner
DATING, CORRECTING, AND MAINTAINING THE CHART
Tracking Medical Records
Every office has a system to track outstanding work
This work must be completed before releasing the chart to be filed
EHR’s may have prompts to show what records are waiting
FILING MEDICAL RECORDS
Even with the use of electronic resources, proper filing is necessary
Include staff needs and limitations in determining what filing system is needed
Safety is an important consideration when working with filing cabinets
Place files in bottom drawers first
FILING MEDICAL RECORDS
Steps in filing
Step one: Inspecting
CMAA is usually first one to inspect reports
Divided into negative/normal and positive/abnormal for provider to read
Provider should review all reports
Provider makes check mark in upper right corner and circles any abnormal findings in red
Makes notation about follow up
FILING MEDICAL RECORDS
Steps in filing
Step two: Indexing
Requires you to make a decision about the name, subject, or other identifier under which you file the material
Materials for patients should be filed under patient name
Research papers can be filed under illness, procedure, treatment, medication, or author
A cross-reference can be helpful in finding things later
FILING MEDICAL RECORDS
Steps in filing
Step three: Coding
Done by marking the index identifier on the papers to be filed
If the name, subject, or a number appears on the paper, underline it, or circle it, or highlight it
If it does not appear, write in the upper right corner
FILING MEDICAL RECORDS
Steps in filing
Step four: Sorting
Place in alphabetical order
FILING MEDICAL RECORDS
Steps in filing
Step five: Storing
Locate the file drawer or shelf with the appropriate caption
Find the folder where the reports are stored
Place on flat surface before adding any material
Place back in drawer or on shelf IN ORDER!!
FILING MEDICAL RECORDS
Filing Supplies
Guides
OUTguides
Folders
Vertical pockets
Index tabs
labels
FILING SYSTEMS
Most filing systems are based directly or indirectly on alphabetic arrangement
Numeric Filing
Material is arranged in numeric order in the main file
Main file is supplemented by an alphabetically arranged card index
Subject filing
Based on an outline or classification of the subject matter
Reference materials
Geographic
Simplest and most common method of filing
Arranged alphabetically by political or geographic subdivisions
Chronologic
Filed according to the date, with the most current first
RULES FOR ALPHABETIC FILING
Rule 1
In filing the names of persons, the surname is considered first, the first name or initial second, and the middle name or initial
third
Ex.
John E. Brown is filed as Brown, John E.
RULES FOR ALPHABETIC FILING
Rule 2
Names are filed alphabetically in an A-to-Z sequence from the first to the last letter, considering each letter in the same
separately and each unit separately
When the surnames of two persons are spelled differently, the first and middle names or initials are not considered
When a shorter surname is identical with the first part of a longer surname, the shorter names is listed first. The rule is
sometimes states as “nothing before something”
When the surnames are alike, the order in filing is determined by the first names or initials. When surnames and first names
are alike, the middle name is used
RULES FOR ALPHABETIC FILING
Rule 2
An initial is listed before a name beginning with the same letter. This again is an example of “nothing before something”
An abbreviated first or middle name is treated as if it were spelled out in full.
RULES FOR ALPHABETIC FILING
Rule 2
Examples:
Allard, Wm.
Allen, E.S.
Allen, Edna
Allen, Wm. A.
Allen, William C.
Allens, M.R.
RULES FOR ALPHABETIC FILING
Rule 3
A prefix, such as Mc, Mac, De, Le, and Von, is considered as part of the surname
Example:
MacAdams, Bruce
McAdams, Helen
RULES FOR ALPHABETIC FILING
Rule 4
Most firm names are filed as they are written. The apostrophe is disregarded in filing.
Example:
Herb’s Auto Service
Walters Printing Company
RULES FOR ALPHABETIC FILING
Rule 5
Firm names that include the full name of an individual are filed with the name of the individual transposed
Example:
Edward Wenger Company is filed as Wegner, Edward Company
RULES FOR ALPHABETIC FILING
Rule 6
When the article the is part of a title, it is placed in parentheses and disregarded in filing
Example:
Sam the Barber is filed as Sam (the) Barber
The Family Steakhouse is filed as Family Steakhouse (The)
RULES FOR ALPHABETIC FILING
Rule 7
And, for, of, and so on are disregarded in filing but are not omitted
Example:
Adams & Smith Pharmacy is filed as Adams (&) Smith Pharmacy
RULES FOR ALPHABETIC FILING
Rule 8
Abbreviations such as Co., Inc., or Ltd., in a firm name are indexed as though spelled out
Example:
Frank Smith Co. is filed as Smith, Frank Company
RULES FOR ALPHABETIC FILING
Rule 9
Hyphenated surnames and hyphenated firm names are indexed as one unit
Example:
Dunning-Lathrop & Assoc. Inc. is filed as Dunning-Lathrop (&) Associates, Incorporated
Lester Smith-Mayes is files as Smith-Mayes, Lester
RULES FOR ALPHABETIC FILING
Rule 10
Numbers are usually filed as spelled out
Example:
5th Avenue Store is filed as Fifth Avenue Store
RULES FOR ALPHABETIC FILING
Rule 11
Professional or honorary titles are not considered in filing but should be written in parentheses at the end of the name for
identification purposes
Example:
Dr. Anne Lewis is filed as Lewis, Anne (Dr.)
Titles are filed as written when they are part of a firm name. Foreign or religious titles followed by one name are also filed
as they are written
Dr. Scholl’s Foot Powder
Prince Phillip
RULES FOR ALPHABETIC FILING
Rule 12
Terms of seniority, such as Junior, Senior, Second, or Third, are not considered in filing. If two names are otherwise identical,
the address is used to make the decision
Example:
Keir, Willard, Sr. (Cleveland, Ohio)
Keir, Willard, Jr. (Columbus, Ohio)
RULES FOR ALPHABETIC FILING
Rule 13
File the names of federal, state, or local government departments first by political division and then by the name of the
department
Example:
Drug Enforcement Administration, Cincinnati, Ohio, is files as Cincinnati, Drug Enforcement Administration, Cincinnati, Ohio
OTHER TYPES OF FILING
Filing Numerically
Used in very large clinics
Provides most patient privacy
Cross reference required
Use same number of digits for each number assigned
Filed in order from smallest to largest
If the zero falls before another number it is disregarded
OTHER TYPES OF FILING
Filing Numerically
Example
If our system uses 6 digits
000001, 000002, 000003, 000004, and so on
OTHER TYPES OF FILING
Filing Numerically
Some systems use “terminal digit filing”
digits used to designate shelves or drawers
Example
Patients are assigned numbers and separated into twos, or threes
Number are then read from the RIGHT side group of numbers
112408-065-2
112406-064-3
112406-065-3
112407-065-3
OTHER TYPES OF FILING
Filing by Subject
Financial records, copies of inventory, copies of orders, equipment records, etc
Material filed in chronological order in each guide
When five items are filed in misc. folder on same subject, a new subject folder should be created
OTHER TYPES OF FILING
Tickler Files
A chronologic file
Used as a follow up method for a particular date
Consists of a divider with the names of all the months and dividers numbered from 1 to 31 for the days of the month
Good place for various reminders
Responsibility of the CMAA
Now have electronic tickler files
OTHER TYPES OF FILING
Desktop Files
Rolodex
Business cards, provider partners, pharmacies, hospitals
OTHER TYPES OF FILING
Desktop Files
Rolodex
Business cards, provider partners, pharmacies, hospitals
OTHER TYPES OF FILING
Finding a Missing Chart
Go to the files where the chart you need should be and look through charts before and after
Check the days schedule and see if chart is out for patient to be seen
Look on the desk of the provider
Check insurance or billing department
Cart of charts to be filed
STORING AND PURGING FILES
Sometimes there is no room for any more charts
You must purge files
Clean out
Inactive charts
May be stored off site
Systematic approach
Follow office policy
HIPAA related documents must be kept for six years
Use good body mechanics when moving large volumes of files