1. Medical Assisting Chapter 9
PowerPoint® to accompany
Medical Assisting Chapter 9
Chapter 9
Second Edition
Ramutkowski  Booth  Pugh  Thompson  Whicker
Chapter 9
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

2. Maintaining Patient Records
Objectives
9-1 Explain the purpose of compiling patient medical records.
9-2 Describe the contents of patient record forms.
9-3 Describe how to create and maintain a patient record.
9-4 Identify and describe common approaches to documenting information in medical records.

3. Maintaining Patient Records
Objectives (cont.)
9-5 Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records.
9-6 Discuss tips for performing accurate transcription.
9-7 Explain how to correct a medical record.
9-8 Explain how to update a medical record.
9-9 Identify when and how a medical record may be released.

4. Maintaining Patient Records
Importance of Patient Records
Patient Records
Also known as charts
containing:
Past and present medical conditions
Communications between health team members
Name & address
Insurance coverage
Occupation
Medical treatment plan
Health-care needs
Response to care
Lab and radiology reports
The chart is a legal document, and can play a role in patient and staff education. It may also be used for quality control and research.

5. Importance of Patient Records
Legal Guidelines for
Patient Records
As a general rule, if information is not documented there’s no proof it was ever done.
Charts are used in court.
Standards for Records
Complete, accurate and well-documented records can serve as convincing evidence that the doctor provided appropriate care.
Incomplete, inaccurate, altered or illegible records may imply poor standards.

6. Importance of Patient Records
Patient Education
Quality of Treatment
Additional Uses of
Patient Records
Research

7. Contents of Patient Charts Standard Chart Information
Patient Registration Form
Date of current visit
Demographic data (age, date of birth, SS#, address, telephone number, marital status, etc.)
Medical insurance information
Emergency contact person
Family medical history
List of medical problems

8. Contents of Patient Charts Standard Chart Information (cont.)
Past Medical History
Illnesses, surgeries, allergies and current medications
Family medical history
Social history (use of drugs and alcohol, cigarette smoker, etc)
Occupational history
Statement of current patient complaint recorded in patient’s own words

9. Contents of Patient Charts Standard Chart Information (cont.)
Physical Examination Results
Containing results of a general physical exam
Results of Laboratory and other Tests
Results from lab tests performed on patient
Records from other Physicians or Hospitals
Include along with these records a copy of the patient consent authorizing release of information

10. Contents of Patient Charts Standard Chart Information (cont.)
Doctor’s Diagnosis and Treatment Plan
Lists doctor’s diagnosis, medications prescribed and overall treatment plan
Operative Reports, Follow-Up Visits, and Telephone Calls
A continuous record of all care provided to the patient while under the doctor’s care
Also document calls made to and from the patient

11. Contents of Patient Charts Standard Chart Information (cont.)
Informed Consent Forms
Signed consent forms show that the patient understands procedure, outcomes and options
Patient may still change their mind even after signing the consent form
Hospital Discharge Summary Forms
Includes information summarizing the patient’s hospitalization
Follow-Up care after discharge is also included and the physician signs it

12. Contents of Patient Charts Standard Chart Information (cont.)
Correspondence With or About the Patient
All written correspondences regarding the patient should be included
Be sure to record date each was received on the actual form
Information Received by Fax
Dating and Initialing
Request an original copy, if not available make a photocopy of the fax.
Be sure to date and place your initials on everything you place in the chart.

13. Initiating and Maintaining Patient Records
Completing Medical
History Forms
Documenting Test
Results
Initial
Interview
Documenting Patient
Statements
Examination Preparation & Vital Signs

14. Initiating and Maintaining Patient Records (cont.)
Follow-Up Duties
Transcribe notes the doctor dictates
Post results of laboratory and examinations on summary sheet
Record all telephone communication with the client
Record all medical or discharge instructions given to the client

15. Apply Your Knowledge
The medical assistant is obtaining the initial information from a patient. The patient informs the medical assistant that he/she has used intravenous drugs for the past 3 years. Which section of the chart will this be recorded in?

16. Apply Your Knowledge -Answer
The medical assistant is obtaining the initial information from a patient. The patient informs the medical assistant that he/she has used intravenous drugs for the past 3 years. Which section of the chart will this be recorded in?
This should be recorded in the past medical history section. More specifically under the social history section.

17. ompleteness onfidentiality onciseness lient’s words larity
The Six Cs of Charting C
ompleteness
Fill out all forms in the patient record completely so others will understand your notations and entries.
hronological order
Date entries in the order they occur. This shows consistency with accurate documentation.
onfidentiality
All information in patient record must be kept confidential to protect patient privacy.
lient’s words
Be sure to record the client’s exact words and do not rephrase their statements.
onciseness
Be as brief and to the point as possible. Use medical abbreviations to save time.
larity
Be precise and use accepted medical terminology when describing a patient’s condition.

18. Types of Medical Records
Source-Oriented Medical Records
Problem-Oriented Medical Records
Also called conventional
Information is arranged according to who supplied the data
Problems and treatments are described on the same form
Presents some difficulty with tracking progress of specific events.
(POMR) makes it easier to track specific illnesses
Consists of:
Data base
Problem list
Educational, diagnostic and treatment plan
Progress notes

19. SOAP Documentation Incorporated with POMR
Utilizes an orderly series of steps for dealing with any medical case
Lists the following:
Patient symptoms
Diagnosis
Suggested treatment

20. SOAP Documentation P A O S lan ssessment bjective data ubjective data
Plan of action consists of the treatment plan to correct the illness or problem.
Assessment is the impression of the patient’s problem that leads to a diagnosis. P
lan
Objective data is data observed by the physician during the examination. A
ssessment
Subjective data is information the patient tells you about their symptoms. O
bjective data S
ubjective data

21. Appearance, Timeliness, and Accuracy of Records
Neatness & Legibility
Timeliness
Use a good quality pen, black ink preferably.
Make all writing legible.
Never use white out in charts.
Accuracy 
Record all findings as soon as they are available
For late entries, record both original date and current date
Record date and time of telephone calls and information discussed
Check information carefully
Double check accuracy of information
Make sure most recent information is recorded
Follow correct procedure for correcting errors

22. Professional Attitude and Tone
Maintain a professional tone with your writing by:
Recording patient comments in their own words
Not recording your personal, subjective comments, judgments, opinions or speculations
You may call attention to a problem by attaching a note to the chart but do not make such comments part of the chart.

23. Computer Records Advantages Security Concerns
Can be accessed by more than one person at-a-time
Can be used in teleconferences
Useful for tickler files
Security Concerns
Protecting patient confidentiality is a major area of concern

24. Medical Transcription
Transcription means transforming spoken words into written format.
Dictated information is part of the medical record and must be kept confidential.
Always date and initial each transcription page.
Strive for ultimate accuracy and completeness of transcribed information.

25. Medical Transcription (cont.)
Transcribing Recorded Dictation
Organize your work area
Adjust transcription machine speed, tone and volume as needed
Listen initially to entire recording before transcribing and document areas with difficult interpretations
Listen to voice tones to determine correct punctuation
Never try to guess at meanings
Re-read for accuracy and correct spelling and punctuation
Physicians should initial all transcribed doctor’s notes

26. Medical Transcription (cont.)
Transcribing Direct Dictation
Use a writing pad and good pen that will not smear
Use incomplete sentences and phrases to keep up with physicians pace
Use abbreviations
Ask for clarification immediately if something is unclear
Read the dictation back to verify accuracy

27. Medical Transcription (cont.)
Reference Books
Medical
Terminology Books
Transcription
Aids
Secretarial
Books
Medical Reference
Books

28. Apply Your Knowledge or O S
Label the following items as either (S) “subjective” or (O)“objective”. O S
headache or
vomiting
nausea
chest pain
respirations = 22 and non-labored
skin color

29. Apply Your Knowledge -Answer
Label the following items as either (S) “subjective” or (O)“objective”.
headache
headache S
vomiting
vomiting O
nausea
nausea S
chest pain
chest pain S
skin color
skin color O
respirations = 22 and non-labored
respirations = 22 and non-labored O

30. Correcting and Updating Patient Records
Medical records in legal terms are regarded as “due course” meaning information is to be entered at the time of occurrence and not “conveniently” later.
Use care with corrections because it is more difficult to explain a chart that has been altered after something was documented.
Date and initial each addition to the medical record.

31. Release of Records Procedures for Releasing Records Special Cases
Obtain a signed and newly dated release form authorizing the transfer of their information, and place in file.
Make photocopies of original materials.
Copy and send only documents covered in the release authorization.
Special Cases
Divorce and death
Confidentiality
Children age 18 in many states are to be treated as adults and their parents do not have the right to see their records without authorization.

32. 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?

33. Apply Your Knowledge -Answer
The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another fax number. What would you do in this situation?
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 ever via fax.

34. End of Chapter
End of Chapter