Presentation on theme: "The Paper Medical Record"— Presentation transcript:
1The Paper Medical Record Chapter 14Chapter 14The Paper Medical Record
2IntroductionMedical 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.Talk about the students’ own medical records. Discuss the contents of the records and what might be found inside the physical record.
3This chapter will examine: Reasons for keeping accurate recordsOwnership of recordsDifferences among types of recordsDifferences among types of informationMaking corrections in the recordFiling procedures and systemsForms found in medical recordsAssign the chapter and ancillaries to the student if not already assigned.
4Why Medical Records Are Important Assist the physician in providing the best possible care to the patientOffer legal protection to those who provide care to the patientProvide statistical information that is helpful to researchersVital for financial reimbursementDiscuss why documentation is critical to quality patient care. Talk about whether it is better to have too little or too much information in the patient’s record.
5Ownership of the Medical Record 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.Discuss the reasons why the medical record is owned by the physician and not the patient. Talk about whether there are any situations in which the patient should not be allowed access to the medical record.
6Points to RememberMedical records must be kept confidential and in a secured, locked location.The record should never leave the medical facility in which it originated.Discuss why the patient records should not leave the medical facility. Talk about what to do if the physician habitually takes records from the office. Explain how a medical assistant can discourage the physician from doing so.
7Creating an Efficient Medical Record System The system should:provide for easy retrievalbe organized and orderlycontain information that is completely legiblecontain accurate informationshow information that is easily understood and grammatically correctExplain what is meant by ease of retrieval. Talk about the reasons that legible handwriting is so important. Discuss the reasons that a medical record might be referred to many years after the patient has visited the office. Discuss whether patient confidentiality applies to deceased patients.
8Types of Records Paper-based medical records Computer-based medical recordsDiscuss the types of records that students have encountered in medical facilities. Talk about whether they prefer a paper-based or computer-based personal medical record.
9Disadvantages of Paper-Based Medical Records 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.Talk about the reasons why staff members would need to access the medical record at the same time. Discuss ways to look for information that has probably been misfiled.
10Advantages of Computer-Based Medical Records 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.Discuss whether the advantages of computer-based medical records outweigh the disadvantages for a physician’s office.
11Organization of the Medical Record Source-oriented recordsProblem-oriented recordsChoose a medical condition and discuss how it might be charted using a source-oriented organizational method. Choose a different medical condition and talk about its charting in a problem-oriented organizational method.
12Source-Oriented Medical Records Traditional method of keeping patient recordsObservations and data are cataloged according to their sourcesForms and progress notes are filed in reverse chronological orderSeparate sections are established for laboratory reports, x-ray films, radiology reports, etc.Discuss the source in a source-oriented medical record. Who or what is the source? Talk about why reverse chronological order is best for medical records.
13Problem-Oriented Medical Records Courtesy Bibbero Systems, Petaluma, Calif.Divides records into four bases:DatabaseProblem listTreatment planProgress notesDiscuss the advantages of using a problem-oriented medical record. Talk about which method might be more comprehensive or provide better documentation of the patients’ encounters.
14Database Includes: Chief complaint Present illness Patient profile Review of systemsPhysical examinationLaboratory reportsExplain each part of the database and provide examples of how each might be charted in the medical record.
15Problem ListNumbered and titled list of every problem the patient has that requires treatmentMay include social and demographic troubles as well as medical and/or surgical notesTalk about situations that might be considered social or demographic issues that relate to the patient. Choose several problems that a patient might have and demonstrate the way that they might be charted using the problem list.
16Treatment Plan Includes: Management Additional workups needed Therapy Each plan is titled and numbered with respect to the problem.Explain why a treatment plan is necessary and must be included in the medical record. Talk about ways to express the need for compliance to the patient. Discuss why patients might not comply with instructions from the physician.
17Progress NotesStructured notes are numbered to correspond with each problem number.Progress notes follow the SOAP approach.Discuss the SOAP approach and provide examples to the students. Assign a project wherein the SOAP approach to charting is used. Talk about the advantages of using a SOAP approach compared to other methods.
18SOAP Approach to Progress Notes SOAP acronymS—Subjective impressionsO—Objective clinical evidenceA—Assessment or diagnosisP—Plans for further studies, treatment, or managementOptional E—Evaluation or educationR—ResponseTalk about each element of the SOAP method of charting. Discuss the usefulness of the additional “E” and “R” designations.
19CHEDDAR C—Chief complaint H—History E—Examination D—Details (of problem and complaints)D—Drugs and dosagesA—AssessmentR—Return visitDiscuss the CHEDDAR approach and provide examples to the students. Assign a project in which the CHEDDAR approach to charting is used. Talk about the advantages of using a CHEDDAR approach compared to other methods.
20Contents of the Complete Case History Subjective Information Patient’s full nameParents’ names, if a childSexDate of birthMarital statusSpouse’s nameNumber of childrenSocial Security numberDriver’s license numberHome address and phoneaddressOccupation and employerBusiness address and phoneHealthcare insurance informationSpouse’s employment informationSource of referralTalk about each entity and why it is an important component in the medical record.
21Personal and Medical History Often obtained by patient questionnaireProvides information about any past illnesses or surgical operationsExplains injuries or physical defectsInformation about the patient’s daily health habitsInformation about allergies, advance directives, living wills, and so onDiscuss the advantages and disadvantages of obtaining a patient history by questionnaire or by interview. Talk about which method the students believe is more effective and discuss the reasons for their choices.
22Patient’s Family History Physical condition of members of the patient’s familyPast illnesses and diseases family members may have experiencedRecord of causes of family members’ deathsTalk about the reasons that the family history is important to the patient’s medical record. Discuss why deaths play a role in the patient’s current health issues.
23Patient Information Form Provide various patient information forms for scrutiny in class. Talk about what makes one type of patient information form better or worse than another. Discuss when the patient information form might be given to an established patient to fill out.
24Patient’s Social History Information about the patient’s lifestyleAlcohol, tobacco, and drug use historyMarital informationPsychological informationEmotional information, if pertinentTalk about the reasons that the patient’s social history is important to his or her current health issues. Discuss how psychological and emotional situations affect the patient’s physical health.
25Patient’s Chief Complaint Nature and duration of pain, if anyTime when the patient first noticed symptomsPatient’s opinion as to the possible causes of the difficultiesRemedies that the patient may have applied or triedWhether the patient has had the same or similar condition in the pastPast medical treatment for the same conditionDiscuss ways of getting information out of patients about their chief complaint. How might the medical assistant obtain more information from a patient who provides minimal feedback?
26Pain 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?”Discuss pain symptoms that patients might have and practice rating them on the pain scale. Talk about why the pain scale is effective in treating patients.
27Objective Information Objective findings, often called signs, are gained from the physician’s examination of the patient.Discuss examples of signs that can be observed when examining a patient. Talk about whether the medical assistant should note signs in the medical record.
28Objective Information Physical examination and findingsLaboratory and radiology reportsDiagnosisTreatment prescribedProgress notesCondition at the time of termination of treatmentDiscuss the reason that the physician should note the patient’s condition at the time of the termination of treatment. Talk about whether the physician is obligated to “cure” all patients. Discuss liability issues when physicians make an incorrect diagnosis.
29Diagnosis Provisional Differential Final Define the various types of diagnoses.
30Obtaining the History Histories may be obtained by: Patient questionnaireMedical assistant asking the patient questionsPhysician asking the patient questionsCombination of questionnaire and questionsTalk about the advantages of giving patients history forms prior to their first visit to the physician’s office.
31Medical Assistant’s Role When Taking the Patient History Take the 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.Practice asking each other open-ended questions. Discuss whether an examination room is a secure physical location for taking patient histories. Talk about the damage that might occur if patients can hear what is said in adjoining rooms.
32AuthenticationFor 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.Talk about the reasons that physicians may not authenticate records as they are made or dictated.
33Making Additions to the Record 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.Talk about the advantages and disadvantages of directing only abnormal reports to the physician. Discuss whether this could be considered practicing medicine without a license.
34Laboratory ReportsOften on different colors of paper for easy reference.May need to be attached to standard-sized paper.Reports may be shingled, if necessary.Define shingling and explain why it is helpful when filing reports into the medical record.
35Courtesy Bibbero Systems, Petaluma, Calif. Laboratory ReportsDemonstrate the way that reports are shingled in the medical record.Courtesy Bibbero Systems, Petaluma, Calif.
36Radiology Reports Usually typed on standard-sized stationery. Place in reverse chronological order, with the most recent report on top.Medical records often have a separate section for laboratory and radiology reports.Talk about the various forms of radiology reports. Discuss the ownership of reports that come to the office from other facilities. Talk about whether copies of such records should be provided to the patient (if requested) or whether the patient should be directed to the original facility for copies of reports.
37Progress Notes 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.Talk about the type of information that the medical assistant would add to the progress notes. Discuss why the medical assistant should or should not document his or her opinion as to the patient’s wellness or illness.
38Making Corrections and Alterations to Medical Records 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.Talk about the reasons that errors cannot be obliterated. Discuss the problems that can arise when errors are not documented in the right way.
39Correcting an Error Three Steps 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.Provide practice examples for students to use in correcting errors in a medical record. Discuss the ramifications of incorrect documentation.
40Correcting Electronic Records 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.Talk about why an addendum might be the best way to correct the electronic medical record.
41Keeping Records Current 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 or her decisions on the information in the patient’s medical record.Talk about the reasons that the patient’s health is at risk because of unfiled reports. Discuss how often filing should be done in the facility.
42PrescriptionsSome 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.Talk about why a patient might want to steal a prescription pad. Discuss ways to prevent the theft of prescription pads.
43Classifications of Records in the Physician’s Office Active filespatients currently receiving treatmentInactive filespatients who have not been seen for about 6 months to a year.Closed filespatients who have died, moved away, or otherwise discontinued treatmentExplain how a physician might determine the difference between active, inactive, and closed files. Talk about the reasons that a file might be closed or might be reactivated.
44Transfer of RecordsFollow 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.Discuss how often files should be purged in the medical office. Talk about options when space runs out for files in the office.
45Retention and Destruction 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 he or she reaches legal age.Use year stickers on patient files.Talk about the ways to determine whether individual states have regulations about records retention. How might the student find information about such regulations?
46Retention and Destruction 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.Talk about why HIPAA does not specify medical record retention requirements. Discuss reasonable policies for record retention in a medical office in the student’s specific state of residence.
47Retention and Destruction 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.Talk about why medical records must be kept on patients who are deceased. Explain why Medicare and Medicaid have a 6-year record retention regulation. What might be the significance of a 6-year period?
48Releasing Medical Record Information 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.Talk about why phone requests for the release of medical records should not be honored. Discuss the reasons for releasing only the records specified on the request.
49Releasing Medical Record Information Discuss the form pictured and allow students to practice filling out a copy of the form.Courtesy Bibbero Systems, Petaluma, Calif.
50Filing EquipmentVarious types of equipment are available for storing medical records in today’s medical offices.Talk about the advantages and disadvantages of the various types of filing equipment.
51Considerations in Choosing Filing Equipment Office space availabilityStructural considerationsCost of space and equipmentSize, type, and volume of recordsConfidentiality requirementsRetrieval speedFire protectionDiscuss how the medical assistant might research filing equipment prior to recommending purchase to the physician. Talk about why the people who will use equipment should be consulted prior to the purchase.
52Types of Filing Systems Drawer filesShelf filesRotary circular filesLateral filesCompactable filesAutomated filesCard filesAllow the students to express their opinions on the efficiency of each filing system. Research examples on the Internet and compare costs in class.
53Courtesy Bibbero Systems, Petaluma, Calif. Filing SuppliesDivider guidesOUTguidesOUTfoldersFiles and foldersLabelsTalk about the difference between OUTguides and OUTfolders. Explain how software programs such as Microsoft Word can help the medical assistant to make labels for patient files.Courtesy Bibbero Systems, Petaluma, Calif.
54Filing Procedures Conditioning Releasing Indexing and coding Sorting Storing and filingDefine and explain each filing procedure listed.
55Indexing RulesLast 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.Allow the students to index the names of all classmates into one document. Talk about the issues concerned with various names and how they made the decision to place the names in the order that they chose.
56Indexing RulesIndex 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.Talk about how the medical assistant might determine which is a patient’s first or last name.
57Indexing Rules 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.Talk about why titles might be an important filing unit at the physician’s office.
58Filing Methods Alphabetic Numeric Alphanumeric Subject Discuss the advantages and disadvantages of each filing method. Talk about which are the most and least efficient. Discuss the types of files that might necessitate each filing method.
59Color-CodingAlmost all medical offices use some sort of color-coding in their filing systems.Numeric color-coding provides a high degree of patient confidentiality.Talk about why a color-coding system is helpful and adds to the efficiency of the office. Discuss why it is easy to see a file that is misfiled when using a color-coded system.
60Courtesy Bibbero Systems, Petaluma, Calif. Color-CodingDiscuss the photo and review the ease of finding a file that is out of place.Courtesy Bibbero Systems, Petaluma, Calif.
61Transitory or Temporary Files 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 is no longer needed.Useful when seeing patients from another geographic area who are not expected to return to the office.Talk about situations in which a transitory or temporary file might be used for a patient. Discuss whether it is acceptable to store several transitory patient records in one file.
62Summary of ScenarioAll 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.Talk about the scenario. Explain why filing is a critical duty and why the medical assistant should not downplay its importance or delay its execution. Discuss why the medical assistant must always admit and report errors.
63Closing Comments Advances in medical records occur rapidly. Be willing to learn.Adapt to changes.Keep a positive attitude.Assign additional projects and review for testing. Perform all procedures detailed within the chapter.