2 Learning Outcomes After completing Chapter 15, you will be able to: 15.1 Explain the importance of accurate patient medical records.15.2 Explain the differences between SOMR and POMR records, and define SOAP and CHEDDAR.15.3 List the documents commonly used in the medical record.15.4 Explain the purpose of the initial patient interview, including the name of the document completed in that interview that becomes the basis for the patient’s medical record.15.5 List and describe the components of the six Cs of medical charting.15.6 Compare the paper medical record to the electronic health record.15.7 Explain and demonstrate the process used to correct errors in the medical record.15.8 Outline the procedure used to correctly and legally release patient medical information.
3 IF IT HASN’T BEEN DOCUMENTED, IntroductionPatient RecordsContinuity of CareParts of the Medical RecordIF IT HASN’T BEEN DOCUMENTED,IT HASN’T BEEN DONE!Learning Outcomes:15.1 Explain the importance of accurate patient medical records.15.2 Explain the differences between SOMR and POMR records, and define SOAP and CHEDDAR.15.3 List the documents commonly used in the medical record.15.4 Explain the purpose of the initial patient interview, including the name of the document completed in that interview that becomes the basis for the patient’s medical record.15.5 List and describe the components of the six Cs of medical charting.15.6 Compare the paper medical record to the electronic health record.15.7 Explain and demonstrate the process used to correct errors in the medical record.15.8 Outline the procedure used to correctly and legally release patient medical information.• The administrative medical assistant plays a major role in writing, creating,documenting, and maintaining patient records.These records act as a chronological history of the evaluation and treatment given to the patient.• Patient medical records are critical to patient continuity of care.Without accurate and complete patient records, medical care could easily be compromised.• Patient medical records have many parts or sections that describe thesefacets of every patient:Personal information or dataPhysical and mental conditionMedical, family, and social historiesMedical careMedical future if the patient is referred to other physicians• You will understand that if the medical care is not documented, in a legal sense, the medical care did not occur at all.
4 Importance of Patient Records Legal Guidelines for Patient RecordsStandards for RecordsAdditional Uses of Patient RecordsPatient EducationQuality of CareResearchLearning Outcome:15.1 Explain the importance of accurate patient medical records.One of the most important duties of an administrative medical assistant is initiating and maintaining accurate and thorough patient records.Patient records, also known as charts, contain important information about a patient’s medical history, present condition, and treatment plans.The medical record in either paper or electronic format is initiated by the administrative medical assistant or another staff member and is consistently updated whenever the patient has contact with the office.The medical facility owns the physical record in either its paper or electronic format, but the patient owns the information contained within that record as it is his information.The patient chart, whether paper or electronic, provides physicians and other medical care providers with all the important information, observations, and opinions that have been recorded about a patient.The medical record serves as supporting documentation for billing and coding purposes and as a legal document that is admissible in a court of law.The overarching guidelines and standards apply to both hard copy and the EHR.Medical records include the following general information about the patient:Address and phone numberOccupationPatient medical historyPast, family, and social historiesCurrent complaint or conditionHealth-care needsMedical treatment plan or services receivedMedical imaging and laboratory reportsResponse to careLegal Guidelines for Patient RecordsPatient records are important for legal reasons.As a general rule, if information is not documented, no one can prove that an event or procedure took place.Medical records are used in lawsuits and malpractice cases to support a patient’s claim of malpractice against a doctor and to support the doctor in defense against such a claim.Medical records must be kept for 7 years and pediatric records for 7 years past the age of majority.Because financial records must be kept for 10 years and medical records must back any billing records, many legal experts suggest that medical records should also be kept for 10 years instead of the legally required 7.All medical care, evaluation, and instruction given to the patient by the physician must be documented.Every chart entry must be clear, accurate, legible, and dated.The patient chart is a legal document.Always consider how the patient record would present if it was called into a court of law for review.Additionally, it is very important to document when a patient is noncompliant .Noncompliant is a medical term used to describe a patient who does not follow the medical advice he or she is given.After a clear record has been made of the directions given to a patient for optimum health, it is essential to record the level of patient compliance.The physician may wish to withdraw from the care of a patient because of the patient’s noncompliance.Without a proper and accurate documentation of the patient’s noncompliance, the physician may not be able to withdraw care without becoming legally liable.Additionally, documented noncompliance can be used in the physician’s defense in a malpractice suit if it can be proved that, due to patient noncompliance, the physician was not solely responsible for inadequate medical care or result.Standards for RecordsRecords that are complete, accurate, and well documented can be convincing evidence that a doctor provided appropriate care.On the other hand, altered, incomplete, inaccurate, or illegible records may imply that a doctor’s entire medical practice is below standard.If an employee of the practice charts inappropriately or inaccurately in a patient’s chart, the physician is held legally responsible for that action.All records, both medical and financial, are the responsibility of the physician.As the administrative medical assistant, you are responsible to the patient and the physician for any administrative procedures you perform and the accurate recording of those procedures.Additional Uses of Patient RecordsEach patient record serves as an ongoing reference about that individual's medical care.It is also a valuable resource for patient education, quality of patient care, and research.Patient EducationA patient’s record can be used to educate the patient about medical conditions and treatment plans.The physician can point out how test results have changed or how the patient’s general health has improved or worsened.The physician can also emphasize the importance of following treatment instructions.The record may also be used to educate the health-care staff about unusual medical conditions, patient progress, or results of treatment plans.Quality of CareThe patient record may also be used to evaluate the quality of patient care provided by a physician or facility.Auditing groups, such as peer review organizations or The Joint Commission (TJC), may review select patient charts to monitor whether the care provided and the fees charged meet accepted standards.Records also provide statistics for health-care analysis and future health-care plans and policy decisions.ResearchSome patient records may also play an important role in medical research.Carefully kept medical records are valuable sources of data about patient responses, behavior, symptoms, side effects, and outcomes.Information in charts may spur researchers to begin a study.
5 Checkpoint LO 15.1Why is it important to document noncompliant patient behavior in the medical record?Learning Outcome:15.1 Explain the importance of accurate patient medical records.Instructor: Break the class into groups of 2 or 3 students, and ask the groups to discuss this checkpoint. After a few minutes, ask the spokesperson of each group to share the group’s answer with the class.
6 Types of Medical Records Conventional or Source-Oriented RecordsProblem-Oriented Medical RecordsDatabaseProblem ListEducational, Diagnostic, and Treatment PlanProgress NotesSOAP DocumentationCHEDDAR FormatLearning Outcome:15.2 Explain the differences between SOMR and POMR records, and define SOAP and CHEDDAR.Conventional or Source-Oriented RecordsIn the conventional record, or source-oriented medical record (SOMR), patient information is arranged according to who supplied the data—the patient, doctor, specialist, laboratory or x-ray department, or other source.Used with paper medical records, the SOMR often uses colored tabs to separate the different categories of information that are placed in the chart in reverse chronological order.This means that the most recent information or test result is placed on top of the previously filed information within the appropriate category.Although this method is still popular in offices that use paper records because it is easy to maintain, there is a disadvantage to this system.Because information is placed in groups, it is difficult to quickly get an overall picture of the patient's treatment or illness course for a particular date because the information is often found in several different locations.Problem-Oriented Medical RecordsOne way to overcome the disadvantages of the SOMR is to use the problem-oriented medical record (POMR) system for medical records.This approach makes it easier for the physician to keep track of a patient’s progress.The information in a POMR includes the database; problem list; educational, diagnostic, and treatment plans; and progress notes.DatabaseThe database includes a record of the patient’s history; information from the patient’s initial interview; all findings and results from physical examinations; and the results of any tests, x-rays, and other procedures.Problem ListEach problem (condition of diagnosis) a patient has is listed separately, given its own number, and dated.The problem is then identified by its number throughout the record.Work-related, social, or family problems that may be affecting the patient’s health are also often listed.When you document problems, be careful to distinguish between patient signs and symptoms.Signs are objective, or external, factors—such as blood pressure, rashes, or swelling—that can be seen or felt by the doctor or measured by an instrument.Symptoms are subjective, or internal, conditions felt by the patient, such as pain, headache, or nausea.Educational, Diagnostic, and Treatment PlanEach problem should have a detailed educational, diagnostic, and treatment summary in the record.The summary contains diagnostic workups, treatment plans, and instructions for the patient.Progress NotesProgress notes are entered for each problem listed in the initial record.The documentation always includes—in chronological order—the patient’s condition, complaints, problems, treatment, and responses to care.SOAP DocumentationMany medical records, such as the POMR format, emphasize the SOAP approach to documentation, which provides an orderly series of steps for dealing with any medical case.SOAP documentation lists the patient’s symptoms, objective findings by exam or testing, the diagnosis, and the suggested treatment.Information is documented in the record in the following order.S: Subjective data come from the patient; the patient describes his or her signs and symptoms and supplies any other opinions or comments. A good way to remember subjective information is that it comes "from the subject," but there is no way to touch, smell, taste, see, or hear what the subject is telling you.O: Objective data come from the physician and other staff members and include examinations and test results, such as BP readings, “cholesterol level elevated at 250,” and “right wrist is swollen and red.” Objective findings are those that can be seen, felt, heard, smelled, or tasted; they are measurable.A: Assessment is the diagnosis or impression of a patient’s problem.P: Plan of action includes treatment options, chosen treatment, medications, tests, consultations, patient education, and follow-up.Whether you keep conventional or POMR charts, you can include these steps for each problem.If you abbreviate any term when charting (entering data into the records), use only approved medical abbreviations.Several resources, including those published by TJC and the American Medical Association, list approved medical abbreviations for measurements, instructions for taking medication, and other topics.Keep these references readily available in the office.CHEDDAR FormatThe CHEDDAR format of medical records documentation takes the SOAP format a step further. CHEDDAR stands for:C: Chief complaint, presenting problems, subjective statementsH: History; social and physical history of presenting problem as well as contributing informationE: Examination, including extent of body systems examinedD: Details of problem and complaintsD: Drugs and dosage—for example, a list of current medications used, with dosage and frequencyA: Assessment of the diagnostic process and the impression (diagnosis) made by the physicianR: Return visit information or referral, if applicable
7 Checkpoint LO 15.2 What does SOAP stand for? Learning Outcome: 15.2 Explain the differences between SOMR and POMR records, and define SOAP and CHEDDAR.Instructor: Ask the class, “Who can answer this checkpoint?” Then allow a student to share her or his answer with the rest of the class.
8 Contents of Patient Charts Standard Chart InformationPatient Registration FormPatient Medical HistoryPhysical Examination ResultsResults of Laboratory and Other TestsRecords from Other Physicians or HospitalsPhysician’s Diagnosis and Treatment PlanOperative Reports, Follow-Up Visits, and Telephone CallsLearning Outcome:15.3 List the documents commonly used in the medical record.You will create a medical record for each new patient who comes to the office.Although each office has its own forms or screen completion requirements for electronic health records and medical charts or health record format, in general, all records must contain certain standard information.Standard Chart InformationStandard chart information covers a spectrum of different, carefully detailed notes and facts about a patient.You must have an understanding of not only what each part means but also its importance in each patient's continuity of care.Patient Registration FormInitial patient information includes the registration form and the patient medical history form.Both forms are completed by the patient prior to, or collected at the beginning of, the first patient visit.The patient registration form should list the date of the patient’s current visit, the patient’s age, DOB (date of birth), address, Social Security number, medical insurance information, occupation and employer, marital status, number of children, and the name and telephone number(s) of the person to contact in an emergency.The completed registration form (with front and back copies of the patient’s insurance card) is the base document for each patient’s financial record.Patient financial and medical records are separated into two distinct records, which are filed separately from one another.The medical record is kept in the medical record or HIM (health information management) department, and the financial chart is kept in the patient accounting or billing department.Patient Medical HistoryThe medical history form, the second part of the registration process, includes the patient’s past medical history (including illnesses, surgeries, known allergies, and current medications), family medical history, and social and occupational history (including diet, exercise, smoking, and use of alcohol or drugs).Usually, the history form ends with a section for the patient to describe the condition or complaint that is the reason for her visit.Medicare and managed care plans now require that the patient’s complaint be entered into the medical record.Known as the chief complaint, this information should be recorded in the patient’s own words.The patient medical history form is used as the foundation for the patient’s medical record in both electronic and paper formats.Physical Examination ResultsSometimes a form is used to record the results of a general physical examination.If a form is not used, the physician often dictates or writes the physical exam results using a "head to toe" approach to documentation.Results of Laboratory and Other TestsTest results include findings from tests performed in the office and those received from other physicians, hospitals, independent laboratories, or other outside sources.Test results received from sources outside the practice are best organized in sections within this part of the medical chart.Each section should be arranged in reverse chronological order, with the latest report on the top.Records from Other Physicians or HospitalsIncoming records from other sources must be entered into the patient’s chart.A copy of the patient’s written request authorizing release of the records from the other sources must also be included.Many offices also group these types of records together as well, again, in reverse chronological order.If electronic health records are used in both offices, the medical records may be transmitted between the offices electronically.If your office uses electronic health records, but the office sending the records is using a paper record format, your office will likely scan these records into the computer for inclusion in the patient's electronic health record.Physician’s Diagnosis and Treatment PlanThe physician’s diagnosis and the treatment plan, which may consist of treatment options, the final treatment list, instructions to the patient, and any medications prescribed, must be clearly documented in the patient medical record.The doctor may also put specific comments or impressions on record.All of this information is recorded for every patient visit and contact, including phone calls.This is vitally important because, as discussed earlier, legally, if it is not written down, it did not happen.Operative Reports, Follow-Up Visits, and Telephone CallsContinuation of the record lasts as long as the patient is under the doctor’s care.You should record and date all procedures, surgeries, follow-up care, and additional notes the doctor makes regarding the patient’s case.In addition, record all phone calls to and from the patient, either within the patient's chart notes or in a separate log of telephone calls.Be sure that the patient's name and/or medical record number is included on all pages of information.One of the conveniences of the electronic health record is that of the "never-ending page," as the information is simply continued on the next screen.If messages or notes are handwritten, many offices will then scan them into a predetermined area of the medical record.
9 Contents of Patient Charts (continued) Informed Consent FormsHospital Discharge Summary FormsCorrespondence with or about the PatientInformation Received by FaxDating and InitialingLearning Outcome:15.3 List the documents commonly used in the medical record.Informed Consent FormsInformed consent forms verify that a patient understands the treatment offered and the possible outcomes or side effects of the treatment.Consent forms should also specify what the outcome might be if the patient receives no treatment.They also describe alternative treatments and possible risks.The patient signs the consent form but may withdraw consent at any time.Hospital Discharge Summary FormsThe discharge summary form generally includes information that summarizes the reason the patient entered the hospital; tests, procedures, or surgeries performed in the hospital; medications administered in the hospital; and the disposition, or outcome, of the case.Correspondence with or about the PatientAll written correspondence from the patient or from any other doctors, laboratories, health-care facilities, or independent health-care agencies must be kept in the patient’s chart.Each piece of correspondence should be marked or stamped with the date the doctor’s office received the document.Information Received by FaxSome information may be received by fax transmission.With more and more offices using computer programs, faxed records are being replaced by electronic files or even by ed PDF files.However the information is received, it should always be filed appropriately in the medical record.If a fax copy is followed up by a paper copy in the mail, be sure to shred the faxed copy after filing the new copy in the record.Dating and InitialingYou must be careful not only to date everything you put into the patient chart but also to initial the entry.This system makes it easy to tell which items the assistant enters into the chart and which items others enter.In many practices, the physician initials reports before they are filed to prove that he saw them.
10 Checkpoint LO 15.3Name the financial and medical forms found in the medical record.Learning Outcome:15.3 List the documents commonly used in the medical record.Instructor: Divide the class into two groups, and assign each group either the medical or financial forms. After a few minutes, ask the spokesperson for each group to share the group’s answer with the class.
11 Initiating and Maintaining Patient Records Initial InterviewCompleting Medical History FormsDocumenting Patient StatementsDocumenting Test ResultsExamination Preparation and Vital SignsFollow-UpLearning Outcome:15.4 Explain the purpose of the initial patient interview, including the name of the document completed in that interview that becomes the basis for the patient’s medical record.During or before the first contact, as you initiate the patient record, you will record the information the new patient gives to you.Recording information in the medical record is called documentation.Complete, thorough documentation ensures that the doctor will have detailed notes about each contact with the patient and about the treatment plan, patient response (progress), and treatment outcomes.Initial InterviewDepending on the office policies and on your experience level, as the office administrative medical assistant you may complete any or all of the following tasks related to the initial interview. Familiarize yourself with each task.Completing Medical History FormsMaking sure that the medical history form—the base document in the medical chart—is completed fully is an important aspect of initiating the medical chart.Type the patient's name and other identifying information on the first page, as well as on subsequent pages of any forms.In some offices, the administrative assistant or another member of the staff interviews the patient based on the medical history form and completes the form based on the patient's answers.Others have the patient complete the form himself but go over it carefully, making sure no blanks are left.Some doctors prefer to ask patients questions themselves.Others believe that people sometimes talk more freely with an assistant than they do with the doctor, but the doctor will usually confirm the information on the form when he first interviews the patient.Documenting Patient StatementsYou will record any signs, symptoms, or other information the patient wishes to share.It is important that you document this information in the patient’s own words, not your interpretation of the words.Record this data in specific detail.Conduct any interviews in a private room or in a semiprivate office away from the reception area to protect patient confidentiality.Your opinion of the patient, such as “the patient seems mentally unstable,” is your own and should not be discussed or documented (as fact) in the medical record.Documenting Test ResultsInsert in the medical record copies of any test results, x-ray reports, or other diagnostic results that the patient has brought with him.Examination Preparation and Vital SignsDepending on office policy, the administrative medical assistant may prepare patients for their examinations.If this is the case, you will record vital signs, medication the patient is currently taking, and any responses to treatment.The patient may be more comfortable sharing further information with you than with the doctor, but be sure to document what the patient tells you and share it with the physician.Follow-UpAfter you record the initial interview and background information, the doctor decides what entries will be made regarding examinations, diagnosis, treatment options and plans, and comments or observations about each case.You will then maintain the patient medical record by performing some or all of the following duties:Transcribing notes the doctor dictates about the patient’s progress, follow-up visits, procedures, current status, and other necessary informationNote that transcription by the administrative medical assistant does not occur in all practices.Posting laboratory results, other test results, or results of examinations in the paper or electronic medical record or on the summary sheetRecording telephone calls from the patient and, if requested, summaries of calls that the doctor or other office staff members make to the patientTelephone calls can be an important part of good follow-up care. Calls must be dated, and the content of the conversations must be documented and initialed by the person recording the contents of the call. If you are recording the contents of the call but are not the person who spoke to the patient, be sure to include the appropriate staff person's name within the documentation. Even if the doctor did not reach the patient, the call should be recorded and dated. State whether the doctor got an answer, left a message on an answering machine or with a person, and so on. It will be equally important to document when or if the patient returns the call and the results of the call at that time.Recording medical instructions or discharge instructions the doctor givesAt the doctor’s request, you may counsel or educate the patient regarding the treatment regimen or home-care procedures the patient must follow. This information must be entered into the record, dated, and initialed. Some offices have software that produces general instructions for the patient which can be customized to fit the individual. Others may make photocopies of patient instructions, which are initialed by the patient after the instructions are given, as proof the instructions were given and understood by the patient. The original is given to the patient, and the copy is filed in the medical record.
12 Checkpoint LO 15.4 What is documentation? Learning Outcome: 15.4 Explain the purpose of the initial patient interview, including the name of the document completed in that interview that becomes the basis for the patient’s medical record.Instructor: Allow the class a few minutes to formulate answers to this question, and then ask a few students to share their answers with the rest of the class.
13 Accuracy, Appearance, and Timeliness of Records The Six Cs of ChartingNeatness and LegibilityTimelinessAccuracyProfessional Attitude and ToneLearning Outcome:15.5 List and describe the components of the six Cs of medical charting.The Six Cs of ChartingTo maintain accurate patient records, always keep these six Cs in mind when filling out and maintaining patient records:Client’s words. Be careful to record the patient’s exact words rather than your interpretation of them. For instance, if a client says, “My right knee feels like it’s thick or full of fluid,” write that down. Do not rephrase the sentence to say, “Client says he’s got fluid on the knee.” Often the patient’s exact words, no matter how odd they may sound, provide important clues for the physician in making a diagnosis.Clarity. Use precise descriptions and accepted medical terminology when describing a patient’s condition. For instance, “Patient got out of bed and walked 20 feet without shortness of breath” is much clearer than “Patient got out of bed and felt fine.”Completeness. Fill out completely all the forms used in the patient record. Provide complete information that is readily understandable to others whenever you make any notation in the patient chart.Conciseness. While striving for clarity, also be concise, or brief and to the point. Abbreviations and specific medical terminology can often save time and space when recording information. For instance, you can write “Patient got OOB and walked 20 ft w/o SOB.” OOB and SOB are standard abbreviations for “out of bed” and “shortness of breath,” respectively. Every member of the office staff should use the same abbreviations to avoid misunderstandings.Chronological order. All entries in patient records must be dated to show the order in which they are made. This factor is critical, not only for documenting patient care but also in case there is a legal question about the type and date of medical services.Confidentiality. All the information in patient records, including forms, is confidential. To protect the patient’s privacy, only the patient, attending physicians, and medical staff (who need the record to tend to the patient and/or to make entries into the record) are allowed to see the contents of the medical record without the patient’s written consent. Never discuss the information within a patient’s record, forward information to another office, fax information or show the record (or any content of the record) to anyone but the physician unless you have the patient’s written permission to do so. Confidentiality includes protecting the computer from the view of others.Neatness and LegibilityOne of the advantages of the EHR is that legibility is not an issue, but some form of paper informational sources will remain.The administrative medical assistant should be sure that every word and number in the record is clear and legible.These tips will keep charts neat and easy to read:Use a good-quality pen that will not smudge or smear.HIPAA requires that original documents be maintained in the patient’s hard-copy medical record and all original entries in the EHR. Blue ink is suggested for charting because it will copy as black, making the original and copy look different, which can reduce the possibility of error. Blue ink is also more difficult to match, making any additions to the medical record easy to spot. Most medical offices with paper records, however, use black ink instead of blue because of the consistency of its appearance.Use highlighting pens to call attention to specific items such as allergies. Be aware, however, that unless the office has a color copier, most colored ink will photocopy black or gray. Highlighting-pen marks may not be visible on a photocopy. The electronic medical record usually has a method of automatically emphasizing vital information such as color or flashing, which must also be considered when sending a hard-copy version.Make sure all handwriting is legible. Take time to write names, numbers, and abbreviations clearly. If at all possible, information and chart notes should be typed. Again, this is not an issue with the EHR.Make any corrections to the chart by following your office's policies and procedures for corrections.TimelinessMedical records should always be kept up to date and readily available.Follow these guidelines to ensure that the most recent information on a patient can be located easily when it is needed:Record all findings from exams and tests as soon as they are available.If a test result, finding, or communication is not entered into the record when it occurs or when it is received by the office, record both the original date of receipt and the date of the actual documentation into the record.To document telephone calls, record the date and time of the call, who initiated it, the information discussed, and any conclusions or results. Depending on office policy, the telephone call documentation may be made directly into the record, or a notation may be made referring the doctor to a separate telephone log located within the paper or electronic record.Establish a procedure for retrieving a file quickly in case of emergency. Should the patient be in a serious accident, for example, the emergency doctor will need the patient’s medical history immediately. The EHR provides a major advantage in this situation.AccuracyThe physician must be able to trust the accuracy of the information in the medical records.Make it a priority to check the accuracy of all data you enter in a chart either manually or electronically.To ensure accurate data, follow these guidelines:Never guess at or assume knowledge of names, procedures, medications, findings, or any other information about which there may be a question. Always check all the information carefully. Make the extra effort to ask questions of the patient, physician, or senior staff member and to verify information.Double-check the accuracy of findings and instructions recorded in the chart. Verify that all numbers are recorded accurately and any patient instructions, including those for medications, are clear and complete.Be sure the most up-to-date information has been entered into the chart so that the physician has an accurate picture of the patient’s current condition.Professional Attitude and TonePart of timely, accurate records is maintaining a professional tone in your writing when recording information.Record information from the patient using his own words.Also record the doctor’s observations and comments as well as any laboratory or test results if this is part of your job.Never record personal, subjective comments, judgments, opinions, or speculations about a patient’s words, problems, or test results.Attention may be called to a particular problem or observation by attaching a note to the chart, but do not make such comments part of the patient’s permanent medical record.
14 Checkpoint LO 15.5Why should comments or opinions not be part of the patient’s permanent record?Learning Outcome:15.5 List and describe the components of the six Cs of medical charting.Instructor: Allow the class a few moments to answer this checkpoint, and then ask a few students to share their answers with the class.
15 Electronic Health Records versus Paper Health Records Electronic Medical RecordsAdditional Advantages of Computerizing RecordsSafety ConcernsLearning Outcome:15.6 Compare the paper medical record to the electronic health record.Electronic health records (EHRs), or electronic medical records (EMRs), are becoming increasingly essential to the quality of health care and the improvement of patient safety.The federal government is encouraging all health-care entities to make the switch by 2014.Listed below are some of the advantages and disadvantages of EHRs.DisadvantagesCostlyRetraining needed for entire staffMay need to hire an IT staff memberDowntime of systemAdvantagesOverall, more efficient and less labor-intensive medical records managementFewer lost medical recordsDecreased repeated or duplicated medical testsReduced transcription costsReadability/legibility of charts, resulting in increased patient safetyMore access to charts after hoursEasier to access patient education materialsImproved billingMore efficient transfer of recordsDecreased physical space and cost for storageOverall, the benefits outweigh the disadvantages.Electronic Medical RecordsExtensive information, including practice guidelines and the best practices for EHR problems, can be found on the American Health Information Management Association (AHIMA) Web site.Additional Advantages of Computerizing RecordsIn a setting in which several terminals in a network are connected to a main computer, computerizing medical records presents several advantages.A physician can call up the record on his or her own or another computer monitor whenever the record is needed, review or update the file, and save it to the central computer again.Computerized records can also be used in teleconferences, where people in different locations can look at the same record on their individual computer screens at the same time.Records can also be sent by modem to the physician’s home computer so that the physician will have a patient’s records on hand for calls after hours.Computer access to patient records is also helpful for health-care providers with satellite offices in different cities or different parts of a city.Another advantage of electronic medical records is the ability to "tickle" an account to alert staff members about patients who are due for yearly checkups or who require follow-up care.Some facilities, including physician offices, have begun to use electronically scanned images of patients’ thumbprints and license photos to keep track of records and identify patients prior to providing care as another security measure ensuring that each patient receives the correct treatment.Both systems save time, help maintain the security of patient records, ensure compliance with correct patient/correct treatment, and avoid some forms of identity theft and fraud.Safety ConcernsWhen medical records are kept electronically, it is essential that the facility have policies in place to ensure security and confidentiality of records.In addition, electronic files must be backed up on a regular basis to avoid accidental loss of data.Whether you are documenting by hand or electronically, accuracy is always important.Careful key entry is essential to maintain accurate electronic files.Protecting the confidentiality of patient records in computer files is the greatest concern about electronic health records.
16 Checkpoint LO 15.6Explain the advantages and disadvantages of the electronic health record.Learning Outcome:15.6 Compare the paper medical record to the electronic health record.Instructor: Divide the class into two groups, and assign each group either advantages or disadvantages. After a few minutes, ask each group’s spokesperson to share the group’s answers with the class.
17 Correcting and Updating Patient Records Using Care with CorrectionsUpdating Patient RecordsLearning Outcome:15.7 Explain and demonstrate the process used to correct errors in the medical record.All information in the record should be entered at the time of patient contact or visit and not days, weeks, or months later.Information corrected or added some time after a patient’s visit or other visit can be regarded as “convenient” and may damage a doctor’s position in a lawsuit.Untimely submissions can also jeopardize patient care.Using Care with CorrectionsIf changes to the medical record are not done correctly, the record can become a legal problem for the physician and the practice.A physician may be able to more easily explain poor or incomplete documentation than to explain a chart where the original documentation appears to have been altered.Always be extremely careful to follow the appropriate procedures for correcting patient records.The best defense is to correct the mistake immediately or as soon as possible after the original entry was made.To correct any mistake in a medical record, carefully draw a single line through the error, making sure that the original entry is still legible.Write or type the corrected information above or below the original entry or even in the margin, as close as possible to the original entry.If there is not enough room near the error to make the full correction, make a notation near the error as to where in the chart the correction may be found.When making the correction, note the date and reason for the correction and initial the completed correction.If at all possible, have another staff member witness the correction and also initial it as a witness.Updating Patient RecordsAll additions to a patient’s record should be done so that there can be no interpretation of deception on the physician’s part.In a note accompanying the material, the physician should explain why the information is being added to the record.Each item added to the record must be dated and initialed. The electronic record usually does dates and times automatically and credits the person whose password is used.This reinforces the standard of never allowing anyone else to use your password. As the administrative medical assistant, you may be asked to act as a third-party witness to these additions to paper records.In the case of electronic records, once a note is written and approved, there is often the option for the writer to sign and then lock the record so that further additions cannot be made.Should the provider decide later that something was omitted or requires an update, the provider will add an addendum to the record instead of adding the information directly to the previous entry.
18 Checkpoint LO 15.7Why is it important that any correction to the medical record does not cover up or mask the original documentation?Learning Outcome:15.7 Explain and demonstrate the process used to correct errors in the medical field.Instructor: Divide the class into three or four groups, and give them a few minutes to discuss this checkpoint. Then ask each group’s spokesperson to share the group’s answers with the class.
19 Release of Records Procedures for Releasing Records Special Cases ConfidentialityAuditing Medical RecordsInternal AuditsExternal AuditsLearning Outcome:15.8 Outline the procedure used to correctly and legally release patient medical information.All physical medical records, including x-rays, test results, and medical notes created by the physician, are considered the property of the practice; however, the information contained within the physical record belongs to the patient and is regarded as confidential.Even though the practice owns the records, no one can see the information within them or obtain information from them without the patient’s written consent.However, the law may require the physician to release them, as in the case of a patient with a contagious disease or when the records are subpoenaed by a court.Under no circumstances should you release patient information to insurance companies over the telephone.This information should be released in writing after the patient has signed a written release statement.Under HIPAA, release of information over the telephone may be problematic.Additionally, any request to release medical records should be approved by the physician.Procedures for Releasing RecordsPhysicians often receive requests for copies of a patient’s records.Follow these steps for releasing medical information:Obtain a signed and newly dated release from the patient authorizing the transfer of specific information—that is, giving information to another party outside the physician’s office. Verbal consent in person or over the telephone is not considered a valid release. The release form should be filed in the patient’s record.Make photocopies of the original material. Copy and send only those portions of the record covered by the release and usually only records originating from your facility. Unless the patient specifically requests that you do so, you should not release records that were obtained from other sources, such as consultations or tests done in a hospital. Do not send original documents. If for any reason you cannot make copies, send the originals and tell the recipient that they must be returned. (If you are sending them by the U.S. Postal Service or another mail delivery system, be sure to request a signature and return receipt so that you have documentation showing that the documents were received). Follow up with the recipient until the originals have been returned and are placed in the patient’s files. Often, the recipient is also asked to sign a statement of responsibility for the original records until they are returned to the office. Document in the chart who has possession of the original documents, the date the recipient received the originals, and the date they are returned.Call the recipient to confirm that all materials were received. Avoid faxing confidential records unless they can be sent to a secure, password-protected fax machine so that only the intended recipient can obtain the information. Otherwise, there is no way to know who will see documents sent by fax.Special CasesIt may not always be immediately clear who has the right to sign a release-of-records form.When you are in doubt regarding who is authorized to sign, always ask your supervisor before releasing confidential medical records.ConfidentialityWhen children reach age 18, most states consider them adults with the right to privacy.Some states extend this right to privacy to emancipated minors who are under the age of 18 and living on their own or are married, a parent, or in the armed services.The main legal and ethical principle to keep in mind is that you must protect each patient’s right to privacy at all times.Auditing Medical RecordsThe auditing of medical records is a great quality assurance tool.To audit a record means to examine and review a random group of patient records.There are two types of audits: internal and external.The frequency of these internal audits varies.Internal AuditsInternal audits can be done by the medical staff.Audits should be done before billing is submitted (prospective) and after billing is submitted (retrospective).The audit schedule should be determined by the medical office.External AuditsExternal audits are done by government entities.Over the past few years, government audits have increased in order to recover possible overpayments.External auditors may want to investigate the medical records further by interviewing the staff, patient, and all physicians who participated in the care of the patient.If there is anything that is fraudulent in the billing that is discovered, the physician may have to refund monies or could be penalized.
20 Checkpoint LO 15.8What is the difference between an internal audit and an external audit?Learning Outcome:15.8 Outline the procedure used to correctly and legally release patient medical information.Instructor: Divide the class into two groups, and assign each group either the internal or external audit. After a few minutes, ask the spokesperson for each group to share the group’s answer with the class.
21 SummaryLO Medical records are legal documents that give a complete, concise, chronological history of a patient’s medical history, treatment plan, and treatment outcome. Additionally, they act as a communication tool between care providers. Regardless of the type of record, the patient chart provides physicians and other medical care providers with all the important information, observations, and opinions that have been recorded about a patient.
22 Summary (continued)LO SOMR stands for source-oriented medical records. All items within the patient medical record are filed according to the location from which they originated. POMR stands for problem-oriented medical records. Items filed in these medical records are filed under the problem (number) to which they relate. SOAP format of documentation is used with POMR records and stands for subjective, objective, assessment, and plan. CHEDDAR format of documentation takes the SOAP format to the next level and stands for chief complaint, history, exam, detailed problem/complaint, drugs and dosages, assessment, and return information (if applicable).
23 Summary (continued)LO Documents commonly found in the paper medical record include patient registration; medical history and physical examination forms; laboratory, x-ray, and other results; records from other physicians, hospitals, and other providers; physician diagnosis and treatment plans; operative and other hospital reports; and consent forms for any information that has been released to or received from other providers.LO The initial interview provides the base information for a new patient coming to the medical practice. It introduces the practice to the patient and the patient to the practice. Prior to, or during, the initial interview, the patient will complete the medical history form, which is the basis of the patient medical record.
24 Summary (continued)LO The 6 Cs of medical charting are client’s words, clarity, completeness, conciseness, chronological order, and confidentiality.LO The federal government recommends that all health records become electronic by The electronic health record has many advantages over the paper health record, such as simultaneous access from more than one site and low risk of record loss. A dual system of paper and electronic records will continue for several years since conversion will not occur for all existing records.
25 Summary (continued)LO The proper way to make corrections in a medical record is to draw a single line through the error so that the original entry is still legible. Make the correction as close as possible to the original entry, noting the reason for the correction; date and initial the correction.LO In order to release any medical record, express written permission from the patient must be received. Unless it is impossible to do so, copies should be made and the originals should remain in the office. If originals must be released, verification that the records have been received and by whom should be noted in the chart. Follow-up should take place until the original records are returned to the office.