1. Maintaining Patient Records
Chapter 9
Maintaining Patient Records
PowerPoint® presentation to accompany:
Medical Assisting
Third Edition
Booth, Whicker, Wyman, Pugh, Thompson

2. Learning Outcomes
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. Learning Outcomes (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. Introduction
Medical records document the evaluation and treatment of patients
Critical to patient care
Sectioned to describe various aspects of patient information and care
Legal documents
Medical assistant has a major role in documenting in and maintaining patient records

5. Importance of Patient Records
The patient’s chart
Past and present medical conditions
Communication tool for health-care team
Plan to provide for continuity of care
Documentation for billing and coding
Patient education and research
Legal document admissible in court

6. Importance of Patient Records (cont.)
Information included in patient record
Name and address
Insurance coverage and person responsible for payment
Occupation
Medical history
Current complaint
Health-care needs
Medical treatment plan
Response to care
Lab and radiology reports

7. Patient Records: Legal Guidelines
Proof of event or procedure
No documentation
No proof
Care is considered not done
Legal document
Must document complete information about patient care
Document if patient is noncompliant

8. Patient Records: Standards for Records
Complete, accurate, and well-documented records are evidence of appropriate care
Incomplete, inaccurate, altered, or illegible records may imply poor standards
Everyone who documents in the patient record has a responsibility to the patient and employing physician

9. Patient Records (cont.)
Additional Uses of
Patient Records
Quality of Treatment
Patient Education
Peer review
JCAHO review
Health-care analysis and policy decisions
Research
Test results
Health issues
Treatment instructions
Source of data

10. 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!

11. Patient Charts: Standard Chart Information
Patient Registration Form
Date
Patient demographic information
Age, DOB
Address
SSN
Insurance / financial information
Emergency contact

12. Patient Charts: Standard Chart Information (cont.)
Past medical history
Illnesses, surgeries, allergies, and current medications
Family medical history
Social history (diet, exercise, smoking, use of drugs and alcohol)
Occupational history
Current patient complaint recorded in patient’s own words

13. Patient Charts: Standard Chart Information (cont.)
Physical examination results
Results of laboratory and other tests
Records from other physicians or hospitals
Include a copy of the patient consent authorizing release of information

14. Patient Charts: Standard Chart Information (cont.)
Doctor’s diagnosis and treatment plan
Treatment options and final treatment list
Instructions to patient
Medication prescribed
Comments or impressions
Operative reports, follow-up visits, and telephone calls
These are part of the continuous patient record
Document calls made to and from the patient

15. Patient Charts: Standard Chart Information (cont.)
Informed consent forms
Verify that the patient understands procedures, outcomes, and options
Patient may withdraw consent at any time
Hospital discharge summary forms
Information summarizing the patient’s hospitalization
Instructions for follow-up care
Physician signature

16. Patient Charts: Standard Chart Information (cont.)
Correspondence with or about the patient
All written correspondence regarding the patient
Record date item was received on the actual form
Information received by fax
Request an original copy; if not available, make a photocopy of the fax
Dating and initialing
Be sure to date and place your initials on everything you place in the chart

17. 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!

18. Initiating and Maintaining Patient Records
Completing medical
history forms
Documenting test results
Initial
Interview
Examination, preparation, and vital signs
Documenting patient statements
Maintain patient privacy
during interview

19. Initiating and Maintaining Patient Records (cont.)
Follow-up
Transcribe notes the doctor dictates
Post results of laboratory tests and examinations
Record all telephone communication with the client
Record all medical or discharge instructions given to the client

20. 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!

21. The Six Cs of Charting C Client’s words – Clarity – Completeness – C
onciseness –
Chronological order –
confidentiality –
Do not interpret patient’s words
Precise descriptions / medical terminology
Fill out forms completely
To the point / approved abbreviations
Legal issues
Follow HIPAA guidelines

22. Apply Your Knowledge Great! What are the six Cs of charting?
ANSWER: The six C’s of charting are
Client’s words Conciseness
Clarity Chronological order
Completeness Confidentiality
Great!

23. Types of Medical Records
Source-Oriented Medical Records
Problem-Oriented Medical Records
Conventional approach
Information is arranged according to who supplied the data
Problems and treatments are on the same form
Difficult to track progress of specific events
POMR records make it easier to track specific illnesses
Information included
Database
Problem list
Educational, diagnostic, and treatment plans
Progress notes

24. Medical Records: SOAP Documentation
Orderly series of steps for dealing with any medical case
Lists the following
Patient symptoms
Diagnosis
Suggested treatment
SOAP

25. SOAP Documentation P A O S lan ssessment bjective data ubjective data
The treatment plan to correct the illness or problem
The impression of the patient’s problem that leads to diagnosis P
lan
What the physician observes during the examination A
ssessment
Information the patient tells you O
bjective data S
ubjective data

26. GOOD! Apply Your Knowledge
What type of documentation provides an orderly series of steps for dealing with any medical case, and what are the components of this type of documentation?
ANSWER: SOAP documentation provides an orderly series of steps for dealing with any medical case. The components are
S – Subjective data A - Assessment
O – Objective date P - Plan
GOOD!

27. Apply Your Knowledge S O Good Job!
Label 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 appetite S O
ANSWER:

28. Appearance, Timeliness, and Accuracy of Records
Neatness and legibility
Use a good-quality pen
Blue ink is preferred (differentiates original from copy)
Highlight critical items such as allergies
Handwriting must be legible
Make corrections properly

29. Appearance, Timeliness, and Accuracy of Records (cont.)
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
Retrieve file quickly in event of an emergency

30. Appearance, Timeliness, and Accuracy of Records (cont.)
Check information carefully
Never guess or assume
Double-check accuracy findings and instructions
Make sure most recent information is recorded

31. Appearance, Timeliness, and Accuracy of Records (cont.)
Professional attitude and tone
Record patient comments in his or her own words
Do not record your personal or subjective comments, judgments, opinions, or speculations
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.

32. Appearance, Timeliness, and Accuracy of Records (cont.)
Computer records
Accuracy is also important with electronic records
Advantages
Can be accessed by more than one person at a time
Can be used in teleconferences
Useful for tickler files
Security concerns
Protect patient 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 format
Dictated information is part of the medical record and must be kept confidential
Date and initial each transcription page
Strive for ultimate accuracy and completeness of transcribed information

35. Medical Transcription (cont.)
Transcribing direct dictation
Use a writing pad and pen that will not smear
Use incomplete sentences and phrases to keep up with physician’s pace
Use abbreviations
Ask for clarification immediately if something is unclear
Read the dictation back to verify accuracy
Enter notes into patient record, date, and initial

36. Medical Transcription (cont.)
reference books
Medical
terminology books
Transcription
Aids
Secretarial
books
Medical reference
books

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 occurrence
Information corrected or added after patient’s visit is regarded as “convenient”
Use care with corrections
It is more difficult to explain a chart that has been altered after something was documented

39. Correcting Patient Records
When mistakes happen, correct them immediately
Draw a line through the original information
It must remain legible
Insert correct information above or below original line or in margin
Document why correction was made
Date, time, and initial correction
Have a witness, if possible
eror
m/d/yyyy 00:00pm misspelled JHC
/chj
error

40. Updating Patient Records
Additions to record should not appear deceptive
Document why late entry is made
Date and initial added items
May have a third party witness addition
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 information
It must remain legible
Insert correct information above or below original line or in margin
Document why correction was made
Date, time, and initial correction

42. Release of Information to HMO Insurance Company
Release of Records
Records are property of physician
Contain confidential patient health information
Must have patient’s written consent to release
Exceptions: cases of contagious disease or court order
Release of Information to HMO Insurance Company
I authorize Dr. J. Jones to release my healthcare information to the above-named insurance company.
Christopher Hansen mm/dd/yyyy Patient Signature Date

43. Release of Records (cont.)
Procedures for releasing records
Obtain a signed and newly dated release form authorizing the transfer of information, and place it in the patient’s record
Make photocopies of original materials
Copy and send only documents covered in the release authorization
Call to confirm receipt of materials

44. Release of Records (cont.)
Special cases
Divorce
Legal guardian of children (may be one or both parents)
Death
Next of kin
Legally authorized representative
If unsure, ask supervisor
Confidentiality
18-year-olds
Considered adults in most states
Must have written consent to release their records
Legal and ethical principle: Protect patient’s right to privacy at all times.

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.
Nice Job!

46. In Summary
Medical assistants must properly prepare and maintain patient records
There are several methods for documentation, but regardless of method, records must be complete, legible, current, accurate, and professional
Properly maintain, correct, update, and release patient medical records

47. End of Chapter 9
Organization is the power of the day; without it, nothing is accomplished.
~ Sophia Palmer
From A Daybook for Nurses: Making a Difference Each Day