MO 260 SEMINAR 4 MEDICAL RECORDS!.

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Presentation transcript:

MO 260 SEMINAR 4 MEDICAL RECORDS!

Medical Records What a mess!

Medical Records It is a joke!

MEDICAL RECORDS MANAGEMENT Filing Medical Records Prevents loss of continuity of medical care (Care that continues smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care) Allows for time management Filed alphabetically Filed numerically Must be filed accurately for good Pt care

Dr. owns the medical record pt info IN record. The additions to medical records should be placed under the appropriate tab in the medical record in reverse chronological order, as soon as appropriate after arrival. Ways of assisting with the purging outdated medical records include: Color-coded year indicators When choosing the forms for a new medical record, the medical assistant will use the forms that are indicated in the office policy/procedure manual for use.

Supplies That Assist with Proper Filing of Medical Records What are the supplies?

Roller shelves

Medical Records Privacy When are medical records created? They are created when we visit a health professional such as doctor, nurse, dentist, chiropractor, specialist. HIPAA law provided medical record privacy. What medical information is not covered by HIPAA? http://www.privacyrights.org/print/fs/fs8-med.htm http://www.youtube.com/watch?v=7Poj-MB_MBA

LEGAL DOCUMENT The patient's medical record is a legal document that must accurately reflect the care provided to the patient. This is why we stress accurate notation of any interactions with a patient--taking telephone messages from patients, setting appointments for patients, checking patients in, and so on. http://www.facs.org/ahp/proliab/nisonson0500.pdf

SOAP NOTES IN RECORDS SOAP stands for the following: Subjective impressions – pt gives info Objective clinical evidence – what you observe Assessment or diagnosis – DR. Plan for further studies, treatment, or management- DR. http://www.ehow.com/how_4842610_write-soap.html

CORRECTIONS Any corrections made in a medical record must be visible, so any information that has been incorrectly documented cannot be erased or obliterated, and correction fluid may never be used to fix a mistake. Who can tell me the proper way of correcting an error in a chart?

ACTIVE AND INACTIVE CHARTS Active means the Pt. has been seen in the past 3 years. Inactive not seen after 3 years and files get put onto film. Files usually kept for 10 years. Charts are to never go home with the Dr. or leave the office. Legally, charts can leave-If the original documents are subpoenaed, the record should be copied and the copy should be maintained in the medical office until the original is returned

ELECTRONIC HEALTH RECORDS The Electronic Health Record (EHR) is a electronic record of patient health information generated by one or more encounters in any care delivery setting. The Electronic Health Record (EHR) is a electronic record of patient health information generated by one or more encounters in any care delivery setting.

Electronic Health Record Excerpt from a 1966 film on use of computers in healthcare, this segment from Akron general hospital predicts great things for computers. http://www.youtube.com/watch?v=t-aiKlIc6uk

Electronic Health Records Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. http://www.youtube.com/watch?v=2-bytJuQxW0

Personal Health Record A PHR is an electronic repository where a patient can store his/her health data privately and securely and can share this data with healthcare providers and others at the patient’s discretion

Electronic Health Record EHR systems can reduce medical errors. Save paper More secure EHR systems are believed to increase physician efficiency and reduce costs, as well as promote standardization of care. http://www.youtube.com/watch?v=5p1EcOFueEc

Electronic Health Record Improved billing accuracy Although billing is now largely accomplished electronically in the United States, these claims often require additional documentation from a patient's medical record. This is a tedious task when records are in an electronic format not compatible with the billing program, or when the records are in paper format. An integrated electronic medical record / billing system, therefore, both expedites and makes billing more accurate.