Medical Records Management Chapter 14 Medical Records Management

Medical Records Management and the TPMS [FIGURE 14-1]

Purpose of Medical Records Provide base for managing patient care Provide interoffice and intraoffice communication as necessary Determine any patterns that surface to signal provider of patient needs

Purpose of Medical Records Serve as basis for legal information to protect providers, staff, patients Provide clinical data for research

Ownership of Medical Records Property of those who create record Information belongs to patient and is protected with privacy and confidentiality Patients are allowed access to their medical records and can ask certain information be added or excluded from their file

Ownership of Medical Records Providers who include their patients in their medical record keeping foster trust and respect with their patients

Authorization to Release Information Before information released from medical record, patient notified and written approval received Identify reason for release and what information specifically requested Only that information released Does not include release of information to patient’s chosen insurance carrier

Manual or Electronic Medical Records Americans to have EHRs by 2014 Planned projects: transmitting x-rays and laboratory results electronically 2011: Electronic prescribing (e-prescribing) of medications for Medicare

Manual or Electronic Medical Records Advantages Currently established and understood Easier to protect confidentiality No worry of computer malfunction

Manual or Electronic Medical Records Disadvantages Can be used by only one person at a time Easily misplaced or misfiled Equipment and storage space required More susceptible to error

Manual or Electronic Medical Records Advantages Multiple users possible Not easily misplaced or misfiled Errors less likely Patterns and data more easily accessed Quickly available in emergencies Office storage space not required Legible, organized patient documentation Improved medication management Improved quality of care

Manual or Electronic Medical Records Disadvantages Need protection to prevent loss of data Expensive to establish and maintain May require on-site assistance Can require up to 12 weeks for staff to prove productive

Manual or Electronic Medical Records 2009: American Reinvestment and Recovery Act (ARRA) Incentives for physicians and hospitals to make transition to EMR Solo practitioners least likely to use EMRs EMRs grow faster in larger, multi-provider clinics Medical record system must fit facility

The Importance of Accurate Medical Records Accuracy essential to patient care Critical to facility’s smooth functioning Important when referring patient to outside specialists Essential in controlling costs May be needed in medical litigation

The Importance of Accurate Medical Records Creating paper and electronic charts Chart prepared on or before day of patient’s first visit Paper medical records require assembly of appropriate file folders and forms Electronic medical charts prepared in much the same manner except that all information stored electronically (See Procedure 14-1: Establishing a Paper Medical Chart for a New Patient) (See Procedure 14-2: Registering a New Patient Using Medical Office Simulation Software)

The Importance of Accurate Medical Records Correcting medical records Paper medical record Draw single line using red ink pen through error Make correction Write Corr. or Correction above area corrected Indicate your initials and current date Never obliterate Forensic experts able to determine when and how corrections were made (See Procedure 14-3: Correcting a Paper Medical Record)

The Importance of Accurate Medical Records Correcting medical records Errors in EMRs Draw line through error (using “tracking” device in word processing software) Correction made immediately after information lined out “Corr.” or “Correction” indicated with your initials and date correction made EMR software locks out chart additions after specified time (See Procedure 14-4: Updating Patient Registration Information Using Medical Office Simulation Software (MOSS))

The Importance of Accurate Medical Records Correcting medical records If information or chart sent elsewhere, make copy of corrected information and send it as quickly as possible

Types of Medical Records Problem-oriented medical records (POMRs) Vital identification data, immunizations, allergies, medications, problems Identified by a number that corresponds to charting relevant to that problem number Each problem followed with the SOAP(ER) approach for all progress notes

Types of Medical Records Problem-oriented medical records (POMRs) S: Subjective impressions O: Objective clinical evidence A: Assessment or diagnosis P: Plans for further studies, treatment, management E: Education for patient R: Response of patient to education and care given

Types of Medical Records Problem-oriented medical records (POMRs) Internists, family practitioners, pediatricians use POMR system Used in manual medical records as well as EMRs Various formats for POMR manual charts

Types of Medical Records Source-oriented medical records (SOMRs) Groups information according to its source Makes different types of information quickly accessible Many providers use SOAP(ER) method to record their chart notes SOMR does not have problem list Many EMR software packages use POMR or SOMR format

Types of Medical Records Strict chronological arrangement Data filed strictly with most recently charted materials to top of folder Difficult for provider or MA to quickly assess patient’s clinical picture May fit specialty office where patients seen on short-term basis

Equipment and Supplies Vertical files Open-shelf lateral files Movable file units Open-shelf lateral file cabinet >> File folders Identification labels [FIGURE 14-3]

Equipment and Supplies Guides and positions Out guides An out guide indicating name of person who has possession of the file >> [FIGURE 14-6]

Basic Rules for Filing Alphabetizing is key to organizing files and charts Indexing rules developed by Association of Medical Records Administrators (AMRA)

Basic Rules for Filing Indexing units Filing identical names Unit identifies each part of a name Each unit identified according to unit 1 Applied to individual names, organizations, clinics Filing identical names When names identical, address may be used to order files Preferred methods include date of birth or Social Security number

Steps for Filing Medical Documentation in Patient Files Inspect Index Code Sort File

Filing Techniques and Common Filing Systems Color-coding technique used in three major filing systems Patient charts use alphabetic system of color coding Color coding can be used in numeric filing Color coding makes retrieval of files more efficient

Filing Techniques and Common Filing Systems Color coding Tab-Alpha system Alpha-Z system Customized color coding systems Colored File folders by first name Colored File folders by last name Color-coded numbers

Filing Techniques and Common Filing Systems Alphabetic filing Simplest filing methods; strictly maintained by assigning label to each file Numeric filing Organized by number rather than by letter Preserves patient confidentiality Straight numeric Terminal digit Middle digit (See Procedure 14-5: Steps for Manual Filing with an Alphabetic System) (See Procedure 14-6: Steps for Manual Filing with a Numeric System)

Filing Techniques and Common Filing Systems Components of numeric filing Serially numbered dividers with guides Miscellaneous (general) numeric file section Alphabetic card file Accession record

Filing Techniques and Common Filing Systems Subject filing Convenient for locating frequently used services or for filing reference materials for patient needs Choosing a filing system Facility primary objectives with storage of patient files, business records, research files Selecting alphabetic or numeric system Confidentiality of charts HIPAA compliant (See Critical Thinking box)

Filing Procedures Cross-referencing Store files for quick and accurate retrieval Especially helpful with foreign names, hyphenated names, stepfamilies Does not need to be elaborate Steps for cross-referencing (See text for steps and examples)

Filing Procedures Tickler files Reminder that some action needs to be taken at date in future Can be accomplished manually or electronically Should contain the following: Patient name Tickler date when action should be taken Required action Additional relevant information

Filing Procedures Release marks Checkout system Provider’s initials Quality-control measure Checkout system Out sheets or out guides for use when chart removed List of information that should be included on out sheet

Filing Procedures Locating missing files or data Conduct systematic search Steps to searching Check files for proper filing order whenever returning or retrieving file folder When finished with a record, refile it immediately

Filing Procedures Filing chart data Types of reports Clinical notes Correspondence Laboratory reports Miscellaneous

Filing Procedures Retention and purging Record purging Active files Inactive files Closed files (See Table 14-2: Records for Retention)

Correspondence Filing procedures for correspondence Remove paper clips and staple items together Inspect to see if item is ready to be filed On incoming correspondence, be sure letterhead is related to letter

Correspondence Filing procedures for correspondence On outgoing correspondence, look at inside address and reference line On incoming or outgoing correspondence, code indexing units of designated label Create miscellaneous folder for items that do not have enough in number to warrant individual folder

Electronic Medical Records Mandated; one day will replace all paper/manual medical records Fewer errors created Create, store, edit, retrieve patient data Allow more than one person to access chart at same time

Electronic Medical Records Purchased as single computer application or part of larger practice management system EMR capability list Providers use computers to open and view charts and write prescriptions System administrators can identify access and privileges for confidentiality EMR fully recognized as legal document

Archival Storage Providers preserve patient medical records for life of practice Computers help to solve space issues through EMRs Records copied onto optical disks or CDs Should have backup system

Archival Storage Transfer of data EMRs easily emailed in whole or in part Faxing Scanners (optical character recognition)

Archival Storage Confidentiality Major issue in using computer and online devices for storage and transfer of medical information Never discuss information outside clinic Unwise to discuss private information within facility if it is not your concern