Presentation on theme: "Maintaining Patient Records"— Presentation transcript:
1 Maintaining Patient Records 9Maintaining Patient Records
2 IntroductionMedical records document the evaluation and treatment of patientsCritical to patient careSectioned to describe various aspects of patient information and careLegal documentsMedical assistant has a major role in documenting in and maintaining patient recordsLearning Outcome:9.1 Explain the purpose of compiling patient medical records.Parts of a medical recordPersonal information or dataPhysical and mental conditionMedical historyMedical careMedical future if patient is referred to other physicians
3 Importance of Patient Records The patient’s chartPast and present medical conditionsCommunication tool for health-care teamPlan to provide for continuity of careDocumentation for billing and codingPatient education and researchLegal document admissible in courtLearning Outcomes:9.1 Explain the purpose of compiling patient medical records.9.2 Describe the contents of patient record forms.Chart should be consistently updated whenever patient has contact with office.
4 Importance of Patient Records (cont.) Information included in patient recordName and addressInsurance coverage and person responsible for paymentOccupationMedical historyCurrent complaintHealth-care needsMedical treatment planResponse to careLab and radiology reportsLearning Outcomes:9.1 Explain the purpose of compiling patient medical records.9.2 Describe the contents of patient record forms.
5 Legal Guidelines for Patient Records Proof of event or procedureNo documentation – no proof that care was doneLegal documentMust document complete information about patient careDocument if patient is noncompliantLearning Outcomes:9.1 Explain the purpose of compiling patient medical records.9.2 Describe the contents of patient record forms.Medical records must be kept for 7 yearsPediatric records: 7 years from age of majorityMany legal experts recommend 10 years instead of 7Noncompliant: Patient who does not follow the medical advice he or she has been given.
6 Standards for RecordsComplete, accurate, and well-documented records are evidence of appropriate careIncomplete, inaccurate, altered, or illegible records may imply a poor standard of careEveryone who documents in the patient record has a responsibility to the patient and employing physicianLearning Outcome:9.1 Explain the purpose of compiling patient medical records.9.5 Discuss the needs for neatness, timeliness, accuracy, and professional tone in patient records.
7 Patient Records Additional Uses of Patient Records Quality of TreatmentPatient EducationPeer reviewTJC reviewHealth-care analysis and policy decisionsResearchTest resultsHealth issuesTreatment instructionsLearning Outcomes:9.1 Explain the purpose of compiling patient medical records.9.2 Describe the contents of patient record forms.Source of data
8 Apply Your Knowledge Good Job! What is the purpose of documentation in a patient’s medical record?ANSWER: Documentation in the medical record provides evidence of appropriate care. If a procedure is not documented, it is considered not done.Good Job!
9 Standard Chart Information Patient Registration FormDatePatient demographic informationAge, DOBAddressSSNInsurance/financial informationEmergency contactLearning Outcome:9.2 Describe the contents of patient record forms.The completed patient registration form is the basis of each patient’s financial record, which is created and filed separately from the medical record.
10 Standard Chart Information (cont.) Patient medical historyIllnesses, surgeries, allergies, and current medicationsFamily medical historySocial history (diet, exercise, smoking, use of drugs and alcohol)Occupational historyCurrent patient complaint recorded in patient’s own wordsLearning Outcome:9.2 Describe the contents of patient record forms.Medicare and managed care plans now require the patient’s complaint to be entered into the medical record.The patient medical history forms the basis for each patient’s medical record.
11 Standard Chart Information (cont.) Physical examination resultsResults of laboratory and other testsRecords from other physicians or hospitalsInclude a copy of the patient consent authorizing release of informationLearning Outcome:9.2 Describe the contents of patient record forms.
12 Standard Chart Information (cont.) Doctor’s diagnosis and treatment planTreatment options and final treatment listInstructions to patientMedication prescribedComments or impressionsOperative reports, follow-up visits, and telephone callsThese are part of the continuous patient recordDocument calls made to and from the patientLearning Outcome:9.2 Describe the contents of patient record forms.Continuation of the medical record lasts as long as the patient is under the doctor’s care.
13 Standard Chart Information (cont.) Informed consent formsVerify that the patient understands procedures, outcomes, and optionsPatient may withdraw consent at any timeHospital discharge summary formsInformation summarizing the patient’s hospitalizationInstructions for follow-up carePhysician signatureLearning Outcome:9.2 Describe the contents of patient record forms.
14 Standard Chart Information (cont.) Correspondence with or about the patientAll written correspondence regarding the patientRecord date item was received on the actual formInformation received by fax – request an original copyDate and initial everything you place in the chartLearning Outcome:9.2 Describe the contents of patient record forms.
15 Apply Your Knowledge Correct! What section of the patient record contains information about smoking, alcohol use, and occupation?ANSWER: Information about smoking, alcohol use, and occupation is part of the patient’s past medical history.Correct!
16 Initiating and Maintaining Patient Records Completing medicalhistory formsDocumenting test resultsInitialInterviewExamination, preparation, and vital signsDocumenting patient statementsLearning Outcome:9.3 Describe how to create and maintain a patient record.Documenting patient statementsRecord any signs, symptoms, or other information in the patient’s own wordsRecord information in specific detailsConduct interview in private roomDo not include your opinionExam prepRecord vital signsRecord medications patient is currently takingRecord responses to treatmentAsk patient, “Is there anything else you would like the doctor to know?”Maintain patient privacyduring interview
17 Initiating and Maintaining Patient Records (cont.) Follow-upTranscribe notes the doctor dictatesPost results of laboratory tests and examinationsRecord all telephone communication with the clientRecord all medical or discharge instructions given to the clientLearning Outcome:9.3 Describe how to create and maintain a patient record.Documentation of telephone communicationDateContent of conversation (document the call even if no one answers)Your initials
18 Right! Apply Your Knowledge In addition to transcribing notes the doctor dictates and posting lab results, what are two other follow-up tasks the medical assistant might be required to perform as part of follow-up to a patient appointment?ANSWER: The medical assistant may have to record telephone calls with the patient, as well as medical or discharge instructions given to the patient.Right!
19 The Six Cs of Charting C Client’s words – Clarity – Completeness – C onciseness –Chronological order –confidentiality –Do not interpret patient’s wordsPrecise descriptions/medical terminologyFill out forms completelyTo the point/approved abbreviationsLearning Outcomes:9.3 Describe how to create and maintain a patient record.9.4 Identify and describe common approaches to documenting information in medical records.Legal issuesFollow HIPAA guidelines
20 Apply Your Knowledge Great! What are the six Cs of charting? ANSWER: The six C’s of charting areClient’s words ConcisenessClarity Chronological orderCompleteness ConfidentialityGreat!
21 Types of Medical Records Source-Oriented Medical RecordsProblem-Oriented Medical RecordsConventional approachInformation is arranged according to who supplied the dataProblems and treatments are on the same formDifficult to track progress of specific eventsPOMR records make it easier to track specific illnessesInformation includedDatabaseProblem listEducational, diagnostic, and treatment plansProgress notesLearning Outcome:9.4 Identify and describe common approaches to documenting information in medical records.POMR sectionsDatabase:Record of patient’s history and information from initial patient interviewFindings and results from physical examinationsTests, x-rays, and other proceduresProblem list:Each problem is given its own number and is datedProblem is identified by number throughout recordEducational, diagnostic, and treatment planDiagnostic workups, treatments, and instructions for the patientProgress notesPatient’s condition, complaints, problems, treatment, and responses to care.Arranged in chronological orderSigns: Objective, external factors that can be seen or felt by the physician or measured by an instrument.Symptoms: Subjective, internal conditions felt by the patient.
22 Types of Medical Records (cont.) SOAP documentationOrderly series of steps for dealing with any medical caseLists the followingPatient symptomsDiagnosisSuggested treatmentSOAPLearning Outcome:9.4 Identify and describe common approaches to documenting information in medical records.
23 SOAP Documentation P A O S lan ssessment bjective data ubjective data The treatment plan to correct the illness or problemThe impression of the patient’s problem that leads to diagnosisPlanWhat the physician observes during the examinationAssessmentInformation the patient tells youObjective dataLearning Outcome:9.4 Identify and describe common approaches to documenting information in medical records.SOAP notes can be used with both conventional and POMR charts.Use only approved medical abbreviations.Subjective data
24 CHEDDAR Format Expands on SOAP format C Chief complaint, presenting problems, subjective statementsHHistory: social and physical historyEExaminationLearning Outcome:9.4 Identify and describe common approaches to documenting information in medical records.DDetails of problem and complaintsDDrugs and dosageAAssessment of diagnostic process and diagnosisRReturn visit information or referral
25 Apply Your KnowledgeLabel the following items as either (S) “subjective” or (O) “objective.”____ headache ____ pulse 72____ vomited x 3 ____ nausea____ skin color ____ respirations 16, labored____ chest pain ____ poor appetiteSOOSOOSS
26 GOOD! Apply Your Knowledge What type of documentation expands on the SOAP format?ANSWER: CHEDDAR format of documentation.GOOD!
27 Appearance, Timeliness, and Accuracy of Records Neatness and legibilityUse a good-quality penBlue ink is preferred (differentiates original from copy)Highlight critical items such as allergiesHandwriting must be legibleMake corrections properlyLearning Outcome:9.5 Discuss the needs for neatness, timeliness, accuracy, and professional tone in patient records.
28 Appearance, Timeliness, and Accuracy of Records (cont.) Record all findings as soon as they are availableFor late entries, record both original date and current dateRecord date and time of telephone calls and information discussedRetrieve file quickly in event of an emergencyLearning Outcome:9.5 Discuss the needs for neatness, timeliness, accuracy, and professional tone in patient records.Medical records must be readily available when a doctor or other health-care professional needs them.
29 Appearance, Timeliness, and Accuracy of Records (cont.) Check information carefullyNever guess or assumeDouble-check accuracy findings and instructionsMake sure most recent information is recordedLearning Outcome:9.5 Discuss the needs for neatness, timeliness, accuracy, and professional tone in patient records.
30 Appearance, Timeliness, and Accuracy of Records (cont.) Professional attitude and toneRecord patient comments in his or her own wordsDo not record your personal or subjective comments, judgments, opinions, or speculationsLearning Outcome:9.5 Discuss the needs for neatness, timeliness, accuracy, and professional tone in patient records.You may call attention to problems or observations by attaching a note to the chart, but do not make such comments part of medical record.
31 Electronic Health Records Essential to quality of health care and patient safetyAdvantagesFewer lost recordsReduced transcription costsReadability/legibilityChart access after hoursEasier access to patient education materialsImproved billingDisadvantagesCostlyRetraining of staffIT staff may be neededPossible damage to software and systemLearning Outcome:9.10 Discuss the advantages and disadvantages of the electronic medical record, also known as the electronic health record.Medical records software vendorsMedicware.comAllscripts (merged with Misys Computer Systems)Powermed.comMedicalcharting.comBefore choosing an EHR system, compare available softwareIs the product licensed?What does each license actually provide?What technical support is available, and when?Is there a cost for technical support? How much?How is text imported into the system?Which image formats will the system support?What printers will the system support?What if you need to replace the system?Is everything in writing?
32 Electronic Health Records (cont.) Advantages of computer recordsCan be accessed by more than one person at a timeCan be used in teleconferencesUseful for tickler filesSecurity concerns – protect patient confidentialityLearning Outcome:9.10 Discuss the advantages and disadvantages of the electronic medical record, also known as the electronic health record.Security concernsRecords must be backed up on a regular basis to avoid data lossPolicies must be in place to protect security and confidentiality
33 Apply Your Knowledge Very Good! What is important to remember when you are documenting in the medical records?ANSWER: It is important that medical records be neat and legible, timely, accurate, and maintain a professional tone.Very Good!
34 Medical Transcription Transcription means transforming spoken words into written formatDictated information is part of the medical record and must be kept confidentialDate and initial each transcription pageStrive for ultimate accuracy and completeness of transcribed informationLearning Outcome:9.6 Discuss tips for performing accurate transcription.Abbreviations in transcribed documents: “When in doubt, spell it out.”
35 Medical Transcription (cont.) Transcribing direct dictationUse a writing pad and pen that will not smearUse incomplete sentences and phrases to keep up with physician’s paceUse abbreviations accuratelyAsk for clarification immediately if something is unclearRead the dictation back to verify accuracyEnter notes into patient record, date, and initialLearning Outcome:9.6 Discuss tips for performing accurate transcription.
36 Medical Transcription (cont.) reference booksMedicalterminology booksTranscriptionAidsLearning Outcome:9.6 Discuss tips for performing accurate transcription.SecretarialbooksMedical referencebooks
37 Apply Your Knowledge Excellent! When taking direct dictation, when should you clarify information if you do not understand something?ANSWER: You should immediately clarify information that you do not understand when taking direct dictation.Excellent!
38 Correcting and Updating Patient Records Medical records are created in “due course”Legal term meaning information is to be entered at the time of occurrenceInformation corrected or added after patient’s visit is regarded as “convenient”Make corrections as soon as possible after the original entry was madeLearning Outcomes:9.7 Explain how to correct a medical record.9.8 Explain how to update a medical record.“Convenient” entries can damage a physician’s position in a lawsuit.
39 Correcting Patient Records When mistakes happen, correct them immediatelyDraw a line through the original informationIt must remain legibleInsert correct information above or below original line or in marginDocument why correction was madeDate, time, and initial correctionHave a witness, if possibleerorm/d/yyyy 00:00pm misspelled JHC/chjLearning Outcome:9.7 Explain how to correct a medical record.If changes are not made correctly, the medical record can become a legal problem for the physician.error
40 Updating Patient Records Additions to record should not appear deceptiveDocument why late entry is madeDate and initial added itemsMay have a third party witness additionLearning Outcome:9.8 Explain how to update a medical record.Follow the detailed guidelines in your organization for late entries to a patient’s chart.Addition made to record because patient called back with additional information.Mm/dd/yyyy – JHC/ chj
41 Apply Your Knowledge Super Job! What is the appropriate way to correct an error in a patient’s medical record?ANSWER: To correct an error in a patient’s medical record:Draw a line through the original informationIt must remain legibleInsert correct information above or below original line or in marginDocument why correction was madeDate, time, and initial correctionSuper Job!
42 Release of Information to HMO Insurance Company Release of RecordsRecords are property of the practiceContain confidential patient health informationMust have patient’s written consent to releaseExceptions: cases of contagious disease or court orderRelease of Information to HMO Insurance CompanyI authorize Dr. J. Jones to release my health-care information to the above-named insurance company.Christopher Hansen mm/dd/yyyy Patient Signature DateLearning Outcome:9.9 Identify when and how a medical record may be released.Releasing information to insurance companiesUnder no circumstances should you release patient information to insurance companies over the telephone.Release the information in writing after the patient has signed a written release statement.All requests to release medical records should be approved by the physician.
43 Release of Records (cont.) Procedures for releasing recordsObtain a signed and newly dated release form authorizing the transfer of information, and place it in the patient’s recordMake photocopies of original materialsCopy and send only documents covered in the release authorizationCall to confirm receipt of materialsLearning Outcome:9.9 Identify when and how a medical record may be released.Transfer: Giving information to another party outside the physician’s office.Verbal consent in person or over the telephone is not considered a valid release.Do not send originals unlessRequired by a court of lawOriginals cannot be copied (x-rays)When sending originals, require their return and follow up with recipient until they are returned.
44 Release of Records (cont.) Special casesDivorce – legal guardian of children (may be one or both parents)Death – next of kin or legally authorized representativeIf unsure, ask supervisorConfidentiality18-year-olds are considered adults in most statesLegal and ethical principle: Protect patient’s right to privacy at all times.Learning Outcome:9.9 Identify when and how a medical record may be released.Confidentiality and adulthoodWhen a person reaches the age of legal adulthood in your state, no one, including the person’s parents, may see their medical records without their consent.In some states, the right to privacy is extended to emancipated minors (living on their own, married, or in the armed services).
45 Nice Job! Apply Your Knowledge The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another physician’s office. What would you do in this situation?ANSWER: It is difficult to know the actual originator of a fax transmittal and to verify the signature. The safest solution would be not to release any information based on a fax request and release of information form. Request the original form.Nice Job!
46 In Summary9.1 Patients’ records should be compiled because they serve as legal documents, and may be used in medical malpractice cases and lawsuits.9.2 The content of a patient record consists of standard chart information; information received by fax; dating and initialing of patients’ charts.
47 In Summary (cont.) Include Maintain the charts properly 9.3 To create and maintain patient records formsIncludeRegistration formMedical historyExam results, lab and other testsRecords from other physicians and hospitalsDiagnosis and treatment plansOperative reports, consent forms, discharge summariesCorrespondence with or about patients.Maintain the charts properlyDocumenting detailed notes about the contact with the patient, patient responses and progress, and treatment outcomes.
48 In Summary (cont.)9.4 The most common approaches in documenting information into medical records is through Conventional or Source Oriented records, Problem-Oriented Medical Records (POMR), SOAP, and CHEDDAR.9.5 Neatness, legibility, accuracy, and professional tone are musts in maintaining medical records.
49 In Summary (cont.) 9.6 When performing accurate transcription: Use incomplete sentences or phrases to keep up with the physician’s paceUse abbreviations whenever possibleIf physician speaks fast, ask him or her to speak slower and more clearlyRead dictation back to physician for clarityEnter notes into patient record.
50 In Summary (cont.)9.7 When correcting medical records, make sure you correct as soon as possible. Use appropriate procedure to make corrections.9.8 Each item that is added to the patient record as an update should be dated and initialed. If the information is extremely important, get a third party to witness and initial and date as well.
51 In Summary (cont.)9.9 Medical records can only be released with patient’s written consent or subpoena by the courts. Consent form must be on file.9.10 The advantages of the electronic medical record outweigh the disadvantages. Evaluate software before purchasing. Maintain sensitivity to patient needs.
52 End of Chapter 9Organization is the power of the day; without it, nothing is accomplished.~ Sophia PalmerFrom A Daybook for Nurses: Making a Difference Each Day
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