1. Patient Medical Records

2. Types of Records in an Office
Medical records of the patient’s state of health
Correspondence pertaining to the field of health care
Documents related to the business and financial management of the practice

3. Objectives Components that make up medical records
The SOAP format-the most common format used for recording medical information about patients
The 3 parts of the problem oriented medical record (POMR) format
Transcribe medical data dictated by a physician, apply guidelines for grammar
The preservation of medical records
Who actually owns a patient’s medical record
Standards to be used for quality assurance in maintaining medical records

4. The Medical Record Patient’s medical record=“Patient’s Chart”
The source of info about all aspects of a patient’s health care
Accurate and up-to-date
Proper health care, financial and legal success
The AMA should be familiar with:
Why med. records are regarded as legal documents
The types of reports and information found in a MR
The importance of well-maintained MRs for the practice
The method for making corrections to a MR

5. MR as Legal Documents
A patient’s MR constitutes the legal record of the practice
May have to be produced in court
Uphold the rights of physician if involved in litigation or as a witness
Malpractice cases
Content and quality of MR is pivotal, can be more important than physician’s credentials, personality, or reputation
If data is incomplete, illegible or poorly maintained, an attorney can make the Dr. appear negligible

6. What is a MR? Holds all the data about that patient MRs include:
Chart notes
Chronological order of ongoing patient care and progress, made by physician, nurse, or other professional regarding pertinent points of a given visit or communication with patient
History and physical
Patient’s complete medical history(obtained in an interview on 1st visit), initial results of physical exam
Referral and consultation letters
Copies of letters sent to other physicians referring the patient for exams, tests, etc.
Medical Reports
Lab reports, X-ray reports, etc.
Correspondence
Copies of all correspondence with patient, including letters, faxes, and notes of phone conversations
Clinical Forms
Immunization records and pediatric growth and development records
Medication List
List of the all medications prescribed, including dosage, dispensing instructions, etc.

7. Reasons for Maintaining MRs
MRs are used in the following ways:
Main source of info for coordinating and carrying out patient care among all providers involved with the patient
Evidence of the course of an illness and a record of the treatment being used
A record of the quality of care provided to patients
A tool for ensuring communication and continuity of care from one medical facility to another
The legal record for the practice
The main record to ensure appropriate reimbursement
A source of data for research purposes (lecture, bk, article)

8. Making Corrections
Remember: No part of a record should be altered, removed, deleted, or destroyed
If error or discrepancy occurs, an addendum to the record must be made
How to make a correction:
Use strike-through feature-must be able to read the incorrect material
Enter the word “error” next to the deleted statement
Write your initials and date next to correction
Enter the correct information into the MR

9. The Soap Method of Record Keeping and the POMR Format

10. SOAP Method
The most common system for outlining and structuring chart notes for a MR
Facilitates the creation of uniform and complete notes in a simple format that is easy to read
SOAP-Subjective, Objective, Assessment, Plan

11. SOAP: Subjective
The patient’s description of the problem or complaint, including symptoms troubling the patient, when they began, remedies tried, past medical treatment, etc.
Subjective record includes the following headings:
Chief complaint (CC): Reason for the visit
History of present illness (HPI): Info about symptoms
Past medical history (PMH): list of illnesses and treatments
Family history (FH): facts about family’s health related to you
Social history (SH): Social and marital history (eating, drinking, smoking, occupation, interests, etc.)
Review of systems (ROS): physician’s review of each body ststem with the patient (Ex: respiratory system)

12. SOAP: Objective Physician’s examination of the patient
May be dictated under the heading Physical Exam (PE)
Complete physical exam
Subheadings for a physical exam:
Vital signs (VS)
General: description of the patient might be
HEENT: Head, eyes, ears, nose, throat
Neck
Heart
Etc.

13. SOAP: Assessment
Physician's interpretation of the subjective and objective findings
“Assessment” is used interchangeably with “Diagnosis (Dx)” and “Impression”
Gives a name to the condition from which the patient is suffering
Rule out (R/O): The diagnosis is not likely and further tests must be performed

14. SOAP: Plan Plan-treatment This section lists the following:
Prescribed medications and their exact dosages
Instructions given to the patient
Recommendations for hospitalization or surgery
Any special tests that need to be performed

15. Problem-Oriented Medical Records (POMR)
Another form of record keeping revolves around a list of the patient’s problems
3 essential components:
Database
Complete history of the patient, problem, history, family, social, etc.
Initial plan
Based on the database and initial problems of the patient
Problem list
A running account of the patient’s problems
Referred to a updated at each visit
Used for:
Organizing entries within the problem list
To outline the history and physical for the database section

16. Transcription Guidelines

17. Transcription Guidelines
AMA’s role is to transcribe physicians’ chart notes and other medical documents
Physician may dictate and then give recording to an AMA for transcription

18. Listening Techniques
Dictation equipment: digital media (CD, analog media)
Tone, volume, rate of speed can be regulated for the assistant’s own comfort and rate of transcription
Confidential info-headphones
Foot pedal starts and reverses the machine

19. Office Policy
Every office uses its own format for transcribing chart notes
Include instructions or corrections when transcribing
You may not add anything that is not there

20. Basic Medical Transcription Guidelines
Skill in spelling, punctuation, capitalization
Knowledge of medical terminology, guidelines for medical abbreviations

21. Areas to Know Commas Semicolons Colons Capital letters Hyphens
Abbreviations
Numbers
Symbols
Memos
Grammar
Document formatting

22. Record Retention, Ownership, and Quality Assurance

23. Preservation of Files
Patient MRs need to be preserved-importance to the practice and value as legal document
Kept until possible malpractice suit has passed or for four years after patient has left the practice
Many are kept in an inactive file permanently, however

24. Ownership
American Medical Association Council on Ethical and Judicial Affairs-deals with the ownership of MRs
Notes made by the physician and MRs are physician’s property
Used for physician’s use in treatment of patients
Info inside belongs to the patient-nature of the diagnosis, etc.
Physician cannot use or withhold the info in the recird according to his or her own wishes
Ex: Dr. is ethically obligated to furnish copies of office notes to any physician who is assuming responsibility for care of the patient (with a record release form signed and dated by patient)
Patient’s have the right to control the amount and type of info that is released from the MR
Patient’s alone have the authority to release info to anyone not directly involved with their care-fee may be charged

25. Quality Assurance Best record of the care given a patient
AMAs job is to make certain the info recorded in the MR is accurate and up-to-date
If AMA is unsure of what was dictated, they must flag it for the physician
The AMA should make sure each record contains the following:
Dated notations describing the service received by the patient
Notations regarding q. procedure performed
Accurate notations. An addendum must be made by physician if a discrepancy occurs
Justification for hospitalization
If necessary, a discharge summary regarding hospitalization before the patient arrives for a follow-up visit

26. Key Terms (Define)
Assessment-the physician’s interpretation of the subjective and objective findings
Chief complaint (CC)-reason for the visit or why they are seeking medical advice
Diagnosis (Dx)-what the physician determines is the problem with the patient
Family history (FH)-facts about the health of the patient’s siblings, parents, blood relatives
History of present illness (HPI)-info about the symptoms troublign the patient: when they began, what affects them
Impression objective past medical history (PMH)-listing of any illnesses the patient has had in the past along with the treatments administered or performed
Physical exam (PE)-a complete physical examination where findings for each of the major areas of the body are covered
Plan-treatment for patient as directed by the physician
Problem-oriented medical record (POMR)-see PowerPoint
Review of systems (ROS)-physician’s review of each body system (ex: respiratory system)
Rule out (R/O)-the diagnosis is not likely and that further tests will be performed
SOAP-see PowerPoint
Social history (SH)-info regarding the patient’s eating, drinking, smoking habits, occupation, interests
Subjective-the patient’s description of the problem or complaint

27. Thinking It Through (Answer.)
How does the use of the SOAP format for record keeping minimize a provider’s exposure to legal risk?
Where in the POMR file would you look for information regarding a patient’s family history of intestinal cancer?
A former patient calls asking to retrieve x-rays taken more than five years ago. What do you say?
You are transcribing the physician’s dictation and cannot understand several words. What do you do?