2 Medical Records Where should medical records be kept? How long are the records kept?
3 Points to RememberMedical records must be kept confidential and in a secured, locked location.The record should never leave the medical facility in which it originated, except for legal reasons.
4 Medical RecordWhat is placed into the patient’s medical record?
5 Ownership of the Medical Record Who owns the medical record?
6 Ownership of the Medical Record Patients own the content and have a right of access to the information in the record.
7 Authorization to Release Information Patient must give written permission1 year time limit if not otherwise statedOnly requested information may be releasedReleased information never includes insurance or financial information
8 Organization of the Medical Record What are Source-Oriented Medical Records (SOMR)?
9 Source-Oriented Medical Records (SOMR) Traditional method of keeping patient records.Information filed according to their sourcesSeparate sections for laboratory reports, x-ray films, radiology reports, and so on.Forms and progress notes are filed in reverse chronologic order (newest on top).
10 Organization of the Medical Record What are Problem-Oriented Medical Records (POMR)?
12 SOAP Notes S – Subjective – what patient says O – Objective – what you see/hearA – Assessment – diagnosisP – Plan - treatment
13 6 C’s of Charting Client’s own words Clarity (Clear) Completeness ConcisenessChronological orderConfidentiality
14 Charting Can you chart for someone else? Why are we conscious of using correct medical terminology when charting?Why do we use correct grammar and punctuation?
15 ChartingHow do you correct an error that you made while charting?
16 Correcting a Medical Record Draw a single line through errorMake correction in chart above errorWrite “Corr” or “correction” in the marginDate and initialWhat is done for electronic records?
17 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 with corrected information.Do not delete or change previous entries on electronic records.
20 Basic Rules for FilingWhich of these names is filled first in alphabetical order? Patricia A. McColm Patricia H. McColmIndexing Units a chosen according to the filing system to be used.
21 Basic Rules for Patient Filing Rule 1: Last name, first name, middle name Example: Obama Barack Hussein
22 Basic Rules for FilingRule 2: Initial used as a legal name is filed as a name Example: Eliot, T. S. Elliott T. S.
23 Basic Rules for FilingRule 3: Foreign prefixes or abbreviations become one unit with the last nameExample:Lisa M. Del Vecchio Delvecchio Lisa MJill A. St. John Stjohn Jill A
24 Basic Rules for FilingRule 4 – Hyphenated names are considered one unitGeorge M. Andrews-Scott becomesAndrews-Scott George M
25 3 Major Filing Methods Alphabetic – What is it? Numeric – What is it? Subject – What is it?Color Coding (used in all 3 major systems)Each letter is assigned a different colorEach folder given a color-coded labelOnly full-cut folders are used
26 Tickler FileWhat is it?How does a computer do this?
27 Project 3 Part 1 – Due in Unit 6 Part 2 – Due in Unit 7 There are two parts to this project.Part 1 – Due in Unit 6Medical Records Essay – 40 pointsFiling – 15 pointsPart 2 – Due in Unit 7HIPAA Essay – 40 points
28 Project 3Download the following from the Unit 6 folder of Doc Sharing:Medical Records Filing TemplateRubric for Project 3Please be sure to view the instructions for Project 3 in the PowerPoint presentation located in the Unit 6 folder of Doc Sharing.
29 Project 3 – Part 1: EssayUse the template! Download the template and rubric from the Unit 6 folder in Doc Sharing.When you answer each question on the template,Use APA formatting (double space, size 12 TimesNew Roman font)Add a reference citationWrite a minimum of 300 words total for all threequestions.Do not use contractions (I’ve, can’t).Please use spell check and make corrections before you submit!
30 Project 3 – Part 1: EssayAnswer the following questions in essay form (minimum 300 words total):1. Why do medical records exist? (Explain fourreasons. See Chapter 14, page 251 of your text.)2. Discuss the advantages and disadvantages ofestablishing and maintaining electronic healthrecords (EHRs). (See Chapter 14, page 252 of yourtext.)3. Discuss and explain the five basic filing steps.Include why each is important (conditioning,releasing, indexing, etc.). These are in Chapter 14,pages 271 and 272 of your text.
31 Project 3 – Part 1: Filing Download and use the template! List the namesin alphabetical filing orderlast name, first name, middle name/initialDo not change the spelling of the names.
32 Project 3 – Part 2: HIPAA Essay Answer the following question in essay form (minimum 300 words):Question:Explain how HIPAA Privacy Rules benefits the healthcare industry, patient, and physician.This essay is due by midnight Tuesday of Unit 7.
33 Project 3 – Part 2: HIPAA Essay When you answer this question,Use APA formatting (double space, size 12 TimesNew Roman font).Add at least two reference citations. (Your textand the HIPAA website)Write a minimum of 300 words.Do not use contractions (I’ve, can’t).Include a title page.Add a reference page.Please use spell check and make corrections before you submit!
34 Project 3 – Part 2: HIPAA Essay You will need to follow the link provided in the course:See Chapter 16 of your text for more information.Please be sure to state how HIPAA benefits all three of these:The health care industryThe patientThe physician