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1 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. The Paper Medical Record Chapter 14.

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Presentation on theme: "1 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. The Paper Medical Record Chapter 14."— Presentation transcript:

1 1 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. The Paper Medical Record Chapter 14

2 2 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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.

3 3 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. This chapter will examine:  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

4 4 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Why Medical Records Are Important  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

5 5 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Ownership 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.

6 6 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Medical records must be kept confidential and in a secured, locked location.  The record should never leave the medical facility in which it originated. Points to Remember

7 7 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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

8 8 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Types of Records  Paper-based medical records  Computer-based medical records

9 9 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Disadvantages 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.

10 10 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Advantages 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.

11 11 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Organization of the Medical Record  Source-oriented records  Problem-oriented records

12 12 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Source-Oriented Medical Records  Traditional method of keeping patient records  Observations and data are cataloged according to their sources  Forms and progress notes are filed in reverse chronological order  Separate sections are established for laboratory reports, x-ray films, radiology reports, etc.

13 13 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Problem-Oriented Medical Records Divides records into four bases: 1. Database 2. Problem list 3. Treatment plan 4. Progress notes Courtesy Bibbero Systems, Petaluma, Calif.

14 14 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Database Includes:  Chief complaint  Present illness  Patient profile  Review of systems  Physical examination  Laboratory reports

15 15 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Problem List  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

16 16 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Treatment Plan Includes:  Management  Additional workups needed  Therapy Each plan is titled and numbered with respect to the problem.

17 17 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Progress Notes  Structured notes are numbered to correspond with each problem number.  Progress notes follow the SOAP approach.

18 18 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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

19 19 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. CHEDDAR  C—Chief complaint  H—History  E—Examination  D—Details (of problem and complaints)  D—Drugs and dosages  A—Assessment  R—Return visit

20 20 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Contents of the Complete Case History Subjective Information  Patient’s full name  Parents’ names, if a child  Sex  Date of birth  Marital status  Spouse’s name  Number of children  Social Security number  Driver’s license number  Home address and phone  Email address  Occupation and employer  Business address and phone  Healthcare insurance information  Spouse’s employment information  Source of referral

21 21 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Personal and Medical History  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

22 22 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient’s Family History  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

23 23 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient Information Form

24 24 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient’s Social History  Information about the patient’s lifestyle  Alcohol, tobacco, and drug use history  Marital information  Psychological information  Emotional information, if pertinent

25 25 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient’s Chief Complaint  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

26 26 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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?”

27 27 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Objective Information Objective findings, often called signs, are gained from the physician’s examination of the patient.

28 28 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Objective Information  Physical examination and findings  Laboratory and radiology reports  Diagnosis  Treatment prescribed  Progress notes  Condition at the time of termination of treatment

29 29 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Diagnosis  Provisional  Differential  Final

30 30 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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

31 31 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Medical 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.

32 32 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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.

33 33 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Making 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.

34 34 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Laboratory Reports  Often on different colors of paper for easy reference.  May need to be attached to standard-sized paper.  Reports may be shingled, if necessary.

35 35 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Laboratory Reports Courtesy Bibbero Systems, Petaluma, Calif.

36 36 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Radiology 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.

37 37 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Progress 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.

38 38 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Making 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.

39 39 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Correcting an Error Three Steps 1. Draw one line through the error. 2. Insert the correction above or immediately after the error. 3. In the margin, write “correction” or “corr” and initial the entry, if indicated by the office policy and procedure manual.

40 40 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Correcting 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.

41 41 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Keeping 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.

42 42 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Prescriptions  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.

43 43 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Classifications of Records in the Physician’s Office  Active files  patients currently receiving treatment  Inactive files  patients who have not been seen for about 6 months to a year.  Closed files  patients who have died, moved away, or otherwise discontinued treatment

44 44 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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.

45 45 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Retention 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.

46 46 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Retention 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.

47 47 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Retention 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.

48 48 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Releasing 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.

49 49 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Releasing Medical Record Information Courtesy Bibbero Systems, Petaluma, Calif.

50 50 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Filing Equipment Various types of equipment are available for storing medical records in today’s medical offices.

51 51 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Considerations in Choosing Filing Equipment  Office space availability  Structural considerations  Cost of space and equipment  Size, type, and volume of records  Confidentiality requirements  Retrieval speed  Fire protection

52 52 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Types of Filing Systems  Drawer files  Shelf files  Rotary circular files  Lateral files  Compactable files  Automated files  Card files

53 53 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Filing Supplies  Divider guides  OUTguides  OUTfolders  Files and folders  Labels Courtesy Bibbero Systems, Petaluma, Calif.

54 54 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Filing Procedures  Conditioning  Releasing  Indexing and coding  Sorting  Storing and filing

55 55 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Indexing Rules  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.

56 56 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Indexing Rules  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.

57 57 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Indexing 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.

58 58 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Filing Methods  Alphabetic  Numeric  Alphanumeric  Subject

59 59 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Color-Coding  Almost all medical offices use some sort of color-coding in their filing systems.  Numeric color-coding provides a high degree of patient confidentiality.

60 60 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.Color-Coding Courtesy Bibbero Systems, Petaluma, Calif.

61 61 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Transitory 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.

62 62 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Summary of Scenario  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.

63 63 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Closing Comments  Advances in medical records occur rapidly.  Be willing to learn.  Adapt to changes.  Keep a positive attitude.


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