1. Medical Records Management

2. Medical Records Where should medical records be kept?
How long are the records kept?

3. Points to Remember
Medical 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 Record
What 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 permission
1 year time limit if not otherwise stated
Only requested information may be released
Released 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 sources
Separate 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)?

11. SOAP Notes
What do these stand for? S O A P

12. SOAP Notes S – Subjective – what patient says
O – Objective – what you see/hear
A – Assessment – diagnosis
P – Plan - treatment

13. 6 C’s of Charting Client’s own words Clarity (Clear) Completeness
Conciseness
Chronological order
Confidentiality

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. Charting
How do you correct an error that you made while charting?

16. Correcting a Medical Record
Draw a single line through error
Make correction in chart above error
Write “Corr” or “correction” in the margin
Date and initial
What 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.

18. Equipment & Supplies

19. Equipment & Supplies
Outguides

20. Basic Rules for Filing
Which of these names is filled first in alphabetical order? Patricia A. McColm Patricia H. McColm
Indexing 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 Filing
Rule 2: Initial used as a legal name is filed as a name Example: Eliot, T. S. Elliott T. S.

23. Basic Rules for Filing
Rule 3: Foreign prefixes or abbreviations become one unit with the last name
Example:
Lisa M. Del Vecchio Delvecchio Lisa M
Jill A. St. John Stjohn Jill A

24. Basic Rules for Filing
Rule 4 – Hyphenated names are considered one unit
George M. Andrews-Scott becomes
Andrews-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 color
Each folder given a color-coded label
Only full-cut folders are used

26. Tickler File
What is it?
How does a computer do this?

27. Project 3 – Week 7 There are two essays: There is a filing exercise.
Download documents from DocSharing
Make two cover sheets – one for Part I and one for Part II essay
1 – 2 pages in length (300 words)
Must have a reference citation in both
There is a filing exercise.
Look for the announcement entitled Unit 7: Project 3 Information!