2 Objectives 9-1 Explain the purpose of compiling patient medical records. 9-2 Describe the contents of patient record forms. 9-3 Describe how to create and maintain a patient record. 9-4 Identify and describe common approaches to documenting information in medical records. Maintaining Patient Records
3 9-5 Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records. 9-6 Discuss tips for performing accurate transcription. 9-7 Explain how to correct a medical record. 9-8 Explain how to update a medical record. 9-9 Identify when and how a medical record may be released. Objectives (cont.)
4 Maintaining Patient Records Patient Records Also known as charts containing: Past and present medical conditions Communications between health team members Name & address Insurance coverage Occupation Medical treatment plan Health-care needs Response to care Lab and radiology reports The chart is a legal document, and can play a role in patient and staff education. It may also be used for quality control and research.
5 Importance of Patient Records Legal Guidelines for Patient Records As a general rule, if information is not documented theres no proof it was ever done. Charts are used in court. Standards for Records Complete, accurate and well-documented records can serve as convincing evidence that the doctor provided appropriate care. Incomplete, inaccurate, altered or illegible records may imply poor standards.
6 Importance of Patient Records Additional Uses of Patient Records Patient EducationQuality of Treatment Research
7 Contents of Patient Charts Standard Chart Information Patient Registration Form Date of current visit Demographic data (age, date of birth, SS#, address, telephone number, marital status, etc.) Medical insurance information Emergency contact person Family medical history List of medical problems
8 Past Medical History Illnesses, surgeries, allergies and current medications Family medical history Social history (use of drugs and alcohol, cigarette smoker, etc) Occupational history Statement of current patient complaint recorded in patients own words Contents of Patient Charts Standard Chart Information (cont.)
9 Physical Examination Results Containing results of a general physical exam Results of Laboratory and other Tests Results from lab tests performed on patient Records from other Physicians or Hospitals Include along with these records a copy of the patient consent authorizing release of information Contents of Patient Charts Standard Chart Information (cont.)
10 Doctors Diagnosis and Treatment Plan Lists doctors diagnosis, medications prescribed and overall treatment plan Operative Reports, Follow-Up Visits, and Telephone Calls A continuous record of all care provided to the patient while under the doctors care Also document calls made to and from the patient Contents of Patient Charts Standard Chart Information (cont.)
11 Informed Consent Forms Signed consent forms show that the patient understands procedure, outcomes and options Patient may still change their mind even after signing the consent form Hospital Discharge Summary Forms Includes information summarizing the patients hospitalization Follow-Up care after discharge is also included and the physician signs it Contents of Patient Charts Standard Chart Information (cont.)
12 Correspondence With or About the Patient All written correspondences regarding the patient should be included Be sure to record date each was received on the actual form Contents of Patient Charts Standard Chart Information (cont.) Information Received by Fax Request an original copy, if not available make a photocopy of the fax. Dating and Initialing Be sure to date and place your initials on everything you place in the chart.
13 Initiating and Maintaining Patient Records Initial Interview Completing Medical History Forms Documenting Patient Statements Documenting Test Results Examination Preparation & Vital Signs
14 Follow-Up Duties Transcribe notes the doctor dictates Post results of laboratory and examinations on summary sheet Record all telephone communication with the client Record all medical or discharge instructions given to the client Initiating and Maintaining Patient Records (cont.)
15 Apply Your Knowledge The medical assistant is obtaining the initial information from a patient. The patient informs the medical assistant that he/she has used intravenous drugs for the past 3 years. Which section of the chart will this be recorded in?
16 The medical assistant is obtaining the initial information from a patient. The patient informs the medical assistant that he/she has used intravenous drugs for the past 3 years. Which section of the chart will this be recorded in? This should be recorded in the past medical history section. More specifically under the social history section. Answer Apply Your Knowledge - Answer
17 larity Be precise and use accepted medical terminology when describing a patients condition. The Six Cs of Charting
18 lients words Be sure to record the clients exact words and do not rephrase their statements. The Six Cs of Charting
19 onciseness Be as brief and to the point as possible. Use medical abbreviations to save time. The Six Cs of Charting
20 hronological order Date entries in the order they occur. This shows consistency with accurate documentation. The Six Cs of Charting
21 onfidentiality All information in patient record must be kept confidential to protect patient privacy. The Six Cs of Charting
22 ompleteness Fill out all forms in the patient record completely so others will understand your notations and entries. The Six Cs of Charting
23 Types of Medical Records (POMR) makes it easier to track specific illnesses Consists of: Data base Problem list Educational, diagnostic and treatment plan Progress notes Also called conventional Information is arranged according to who supplied the data Problems and treatments are described on the same form Presents some difficulty with tracking progress of specific events. Problem-Oriented Medical Records Source-Oriented Medical Records
24 SOAP Documentation Incorporated with POMR Utilizes an orderly series of steps for dealing with any medical case Lists the following: Patient symptoms Diagnosis Suggested treatment
25 ubjective data bjective data ssessment lan Subjective data is information the patient tells you about their symptoms. Objective data is data observed by the physician during the examination. Assessment is the impression of the patients problem that leads to a diagnosis. Plan of action consists of the treatment plan to correct the illness or problem. SOAP Documentation
26 Appearance, Timeliness, and Accuracy of Records Use a good quality pen, black ink preferably. Make all writing legible. Never use white out in charts. Record all findings as soon as they are available For late entries, record both original date and current date Record date and time of telephone calls and information discussed Check information carefully Double check accuracy of information Make sure most recent information is recorded Follow correct procedure for correcting errors
27 Professional Attitude and Tone Maintain a professional tone with your writing by: Recording patient comments in their own words Not recording your personal, subjective comments, judgments, opinions or speculations You may call attention to a problem by attaching a note to the chart but do not make such comments part of the chart.
28 Computer Records Advantages Can be accessed by more than one person at-a- time Can be used in teleconferences Useful for tickler files Security Concerns Protecting patient confidentiality is a major area of concern
29 Medical Transcription Transcription means transforming spoken words into written format. Dictated information is part of the medical record and must be kept confidential. Always date and initial each transcription page. Strive for ultimate accuracy and completeness of transcribed information.
30 Transcribing Recorded Dictation Organize your work area Adjust transcription machine speed, tone and volume as needed Listen initially to entire recording before transcribing and document areas with difficult interpretations Listen to voice tones to determine correct punctuation Never try to guess at meanings Re-read for accuracy and correct spelling and punctuation Physicians should initial all transcribed doctors notes Medical Transcription (cont.)
31 Transcribing Direct Dictation Use a writing pad and good pen that will not smear Use incomplete sentences and phrases to keep up with physicians pace Use abbreviations Ask for clarification immediately if something is unclear Read the dictation back to verify accuracy Medical Transcription (cont.)
32 Medical Transcription (cont.) Transcription Aids Transcription Reference Books Medical Terminology Books Secretarial Books Medical Reference Books
33 Label the following items as either (S) subjective or (O)objective. headache vomiting nausea chest pain respirations = 22 and non-labored skin color Apply Your Knowledge or
34 headache vomiting Label the following items as either (S) subjective or (O)objective. chest pain nausea respirations = 22 and non-labored skin color Answer Apply Your Knowledge -Answer headache vomiting nausea chest pain skin color respirations = 22 and non-labored
35 Correcting and Updating Patient Records Medical records in legal terms are regarded asdue course meaning information is to be entered at the time of occurrence and not conveniently later. Use care with corrections because it is more difficult to explain a chart that has been altered after something was documented. Date and initial each addition to the medical record.
36 Release of Records Procedures for Releasing Records Obtain a signed and newly dated release form authorizing the transfer of their information, and place in file. Make photocopies of original materials. Copy and send only documents covered in the release authorization. Special Cases Divorce and death Confidentiality Children age 18 in many states are to be treated as adults and their parents do not have the right to see their records without authorization.
37 Apply Your Knowledge The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another physicians office. What would you do in this situation?
38 The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another fax number. What would you do in this situation? It is difficult to know the actual originator of a fax transmittal and to verify the signature. The safest solution would be not to release any information ever via fax. Answer Apply Your Knowledge -Answer