1. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. UNIT 4 SEMINAR Hello Students. The seminar will begin shortly.

2. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Questions Do you have any questions about the course? Only the students that have questions should be typing for the next few minutes. Keep in mind that certain questions might require research; thus don’t be offended if I ask you to email the question to me.

3. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. The information in this Seminar was designed for Gerald Burke’s students. Contact your instructor for clarifications if you are not in Gerald Burke’s class. Your instructor might have different course expectations.

4. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. QUESTION 1 Which of the following are not needed when describing a patient’s chief complaint? a. Remedies the patient has tried to relieve symptoms b. Duration of pain c. Time when symptoms were first noticed d. How many family members are healthy

5. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. ANSWER QUESTION 1 D

6. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. QUESTION 2 Continuity of care means: a. an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries b. a formal examination of an organization’s or individual’s accounts c. that which continues smoothly from one provider to another, so that the patient receives the most benefit d. granted or endowed with a particular authority

7. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. ANSWER QUESTION 2 C

8. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. QUESTION 3 Which of the following is not objective information? a. Progress notes b. Family history c. Diagnosis d. Physical examination and findings

9. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. ANSWER QUESTION 3 B

10. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. QUESTION 4 A filing system in which an intermediary source of reference, such as a file card, must be consulted to locate specific files is called a(n) _____ system. a. shelf filing b. indirect filing c. direct filing d. Shingling

11. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. ANSWER QUESTION 4 B

12. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. QUESTION 5 Medical facilities should keep records on minors for how long? a. Indefinitely b. Until the minor is deceased c. For 10 years d. Until the minor reaches the age of majority, plus 3 years

13. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. ANSWER QUESTION 5 D

14. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Career Tip #3 – Read publications that will enhance your career. Why should you read publications that will enhance your career?

15. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Which career related publications do you read?

16. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. WSJ Online Wall Street Journal Online http://online.wsj.com/home-page Look around and save it to your favorites or make it your home page.

17. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. WSJ Online The WSJ Online contains a tremendous amount of career guidance and a wide range of information. Most of the articles are free.

18. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. WSJ Online

19. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. WSJ Online The WSJ Online helps you stay a step or two ahead. Learn about it before it happens. Learn from the mistakes and successes of other professionals and job hunters.

20. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. WSJ Online Learn how to manage your career. – Job search strategy. – Increase salary. – Change careers, switch industries, reinvent yourself, etc. – Stand out from the competition. – Overcome career obstacles. – Deal with difficult peers and managers. – Find out what employers want and need. – Learn about industry trends.

21. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. WSJ Online Learn which organizations are going to hire more employees. Learn which organizations are going to layoff part of their staff.

22. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. WSJ Online WSJ Online’s other features – Education – Personal Finance – Small Business – Real Estate – World News – US News

23. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. WSJ Online – Financial Markets – Technology – Life & Style – Opinion – Health Industry – Economy – Law – Management – Media and Marketing

24. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. WSJ Online Arts & Entertainment Autos Books Fashion Sports Travel And More!

25. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. WSJ Online The WSJ Online provides world-class caliber career guidance. Find out for yourself.

26. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Career Tips Remember Career Tip #1? – Consider signing up with one or more employment agencies that specialize in your chosen profession(s).

27. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. More Employment Agency Strategy Why should you consider registering with employment agencies in different industries?

28. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. More Employment Agency Strategy Why should you contact the agencies and let them know when you are not available for work(due to a current work assignment, etc.)?

29. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. More Employment Agency Strategy Why should you consider giving a gift to the employment agency/recruiter that has been sending you on the best work assignments?

30. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Introduction Medical records management systems are only as good as the ease of retrieval of the data in the files. Organization and adherence to set routines will help to ensure that medical records are accessible when they are needed.

31. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Why Medical Records Are Important Assist the physician in providing the best possible care to the patient Offer legal protection to those who provide care to the patient Provide statistical information that is helpful to researchers Vital for financial reimbursement Can you think of other reasons why medical records are important?

32. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Medical records must be kept confidential and in a secured, locked location.

33. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. An efficient medical record system should: provide for easy retrieval be organized and orderly contain information that is completely legible contain accurate information show information that is easily understood and grammatically correct What are some other attributes of an efficient medical record system?

34. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Types of Records Name some disadvantages of paper-based medical records?

35. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Disadvantages of Paper-Based Medical Records Only one person can use the record at a time, unless multiple people are crowding around the same record. Items can be easily lost or misfiled or can slip out of the record if not securely fastened. The record itself can be misplaced or be in a different area of the facility when needed.

36. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Organization of the Medical Record What are source-oriented records?

37. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Source-Oriented Medical Records Traditional method of keeping patient records. Observations and data are cataloged according to their sources. Forms and progress notes are filed in reverse chronologic order. Separate sections are established for laboratory reports, x-ray films, radiology reports, and so on.

38. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Organization of the Medical Record What are problem-oriented records?

39. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Problem-Oriented Medical Records Divides records into four bases: 1.Database 2.Problem list 3.Treatment plan 4.Progress notes

40. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Problem-Oriented Medical Records Database Includes: – Chief complaint – Present illness – Patient profile – Review of systems – Physical examination – Laboratory reports

41. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Problem-Oriented Medical Records Problem List – Numbered and titled list of every problem the patient has that requires treatment – May include social and demographic troubles as well as medical and/or surgical notes

42. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Problem-Oriented Medical Records Treatment Plan Includes: – Management – Additional workups needed – Therapy Each plan is titled and numbered with respect to the problem.

43. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Problem-Oriented Medical Records Progress Notes – Structured notes are numbered to correspond with each problem number. – Progress notes follow the SOAP approach. What does the acronym SOAP stand for?

44. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. SOAP Approach to Progress Notes SOAP acronym S—Subjective impressions O—Objective clinical evidence A—Assessment or diagnosis P—Plans for further studies, treatment, or management

45. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Obtaining the History There are different ways to obtain a patient’s medical history. What are some of those ways?

46. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Obtaining the History Histories may be obtained by: Patient questionnaire Medical assistant asking the patient questions Physician asking the patient questions Combination of questionnaire and questions

47. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. What is “authentication” as it pertains to medical records?

48. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Authentication For a chart to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written. This is “authentication” and is best done by initialing entries (or the equivalent) made to the medical record.

49. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Progress Notes Have you ever seen or worked with progress notes? Continually added to the medical record. Must list each patient visit and any notations about the visit. Instructions, prescriptions, and telephone calls for advice should be noted in the progress notes. Always initial entries in progress notes.

50. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Corrections and Alterations to Medical Records How do you correct an error in a paper based medical record?

51. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Correcting an Error Three Steps 1.Draw one line through the error. 2.Insert the correction above or immediately after the error. 3.In the margin, write “correction” or “corr” and initial the entry.

52. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Corrections and Alterations to Medical Records Never use correction fluid, erasers, or any other type of obliteration methods. Do not mark through information to obliterate it. Do not hide errors.

53. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Correcting Electronic Records An electronic medical record contains an error. How do you correct the error? Four

54. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. 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. Most of the time you will not have the computer authority to delete or change previous entries on electronic medical records. Why will most health care organizations not permit the deletion or alteration of electronic medical record entries?

55. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Keeping Records Current Records must be methodically kept current. The patient’s health is jeopardized when current, accurate records are not available to the physician. Remember that the physician bases his decisions on the information in the patient medical record. Do not allow paper-based histories and reports to accumulate for a long time before filing them. In your opinion, how long is too long?

56. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Classifications of Records in the Physician’s Office Active files – patients currently receiving treatment Inactive files – patients who have not been seen for about 6 months to a year. Closed files – patients who have died, moved away, or otherwise discontinued treatment

57. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Transfer of Records Follow office policies regarding transferring medical records from active to inactive or closed categories. Files may need to be physically rearranged to accommodate transfers.

58. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Retention and Destruction Most physicians keep medical records for 10 years at a minimum. Some records may warrant longer retention periods. Follow local, state, and federal guidelines for retention and destruction of records. In most cases, keep medical records at least as long as the length of time of the statute of limitations for medical professional liability claims.

59. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Retention and Destruction Medicare and Medicaid patient records must be kept for at least 6 years. Follow office policies for record retention and destruction. How long should you keep records on patients who are deceased?

60. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Keep records on patients who are deceased for at least 2 years.

61. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Releasing Medical Record Information Requests must be made in writing for release of records. Patients must sign an authorization for release of medical records. Patients can revoke previously signed authorizations for release of records. Release only records that are specified on the request.

62. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. SAMPLE

63. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Filing Equipment Various types of equipment are available for storing medical records in today’s medical offices.

64. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. What does your office need to consider before it purchases filing equipment?

65. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Considerations in Choosing Filing Equipment Office space availability Structural considerations Cost of space and equipment Size, type, and volume of records Confidentiality requirements Retrieval speed Fire protection

66. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Color-Coding Almost all medical offices use some sort of color-coding in their filing systems. Numeric color-coding provides a high degree of patient confidentiality. Why is this statement true?

67. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. QUESTIONS?