Guide to Medical Billing CHAPTER Third Edition Clinical Records and Medical Documentation 3

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Reasons for Keeping Accurate Medical Records Essential to running a good medical practice Essential for treating patient conditions properly Essential for efficient billing

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Contents of a Patient’s Chart (1 of 3) Acknowledgment of receipt of HIPAA Privacy Practices Notice Patient Information Form Examination/treatment forms Pathology/laboratory/X-ray reports Operative reports Discharge summaries Billing forms for previous visits

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Contents of a Patient’s Chart (2 of 3) Consent form Signature on file Forms related to financial arrangements Correspondence log Letters to/from provider History and Physical Form Progress notes

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Contents of a Patient’s Chart (3 of 3) Medication Flow Sheet Test results Consultation reports

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Specialty Charts Pediatric charts Charts for emergency patients Radiology records

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Filing Guidelines (1 of 2) Name of patient should not appear on outside of chart. When possible, patient charts should be placed in locked room Charts should be identified with a number rather than with patient’s name.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Filing Guidelines (2 of 2) When creating a new chart, label the chart as soon as it is put together.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Alphabetical Filing Means filing charts alphabetically by the first letter of last name. If last name is hyphenated then the name should be filed under the first part of the last name. Color-coded tabs may be used for alphabetical filing.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Rules for Medical Charting (1 of 4) Document only in your area of responsibility. Never use correction fluid. Use standard abbreviations and terms. Do not write in the margins. Never alter information on a chart. Never write information in a chart that the patient should not see.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Rules for Medical Charting (2 of 4) Document anything the patient says in quotation marks. Take the time to document noncompliance. Be specific when documenting. If something is in the chart that could be a potential problem, alert the physician.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Rules for Medical Charting (3 of 4) Document in ink. Document changes made to a patient’s appointment. When documenting a patient’s appointment, include reason for the appointment.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Rules for Medical Charting (4 of 4) Make detailed notes of follow-up calls. Update patient’s medical history at each visit.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler SOAP Notes SOAP = Subjective, Objective, Assessment, and Plan Standardizes medical evaluation entries made in clinical records Should be organized in a manner that allows current patient documentation to be found quickly

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler POMR Charting POMR = problem-oriented medical record Method used to track a patient’s medical progress Minimizes possibility of providers overlooking previous issues

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Retention of Records (1 of 2) All records should be kept as long as needed or for period required by state laws Microfiche or microfilm used for records of patients who are no longer seen. Federal regulations mandate records on Medicare and Medicaid patients be retained for at least 10 years after treatment.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Retention of Records (2 of 2) For tax purposes, records should be kept for at least 7 years after the tax return is filed.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Advantages of Electronic Records Easy access to patient record Ability to provide better care due to easier access Improved communication among health care professionals

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Disadvantages of Electronic Records Legality of storage More difficult to determine when changes to the record occurred Need to obtain state-required signature/initials of person making the notation, as well as the date Issue of vulnerability Viruses and hard-drive issues

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Transferring Records (1 of 2) Obtain written permission from the patient. Do not send original record or file. Make copy of all information to be transferred. Mark envelope containing records “Personal and Confidential”.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Transferring Records (2 of 2) Send information via a courier, registered mail, or with return receipt requested. Black out or cover unauthorized information.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Common Medical Forms Patient Information Sheet Release of Information Form Assignment of Benefits Form Patient History Form Insurance Coverage Form