Managing Medical Records Lesson 1: 13 Managing Medical Records Lesson 1:

Lesson Objectives Lesson Objectives Upon completion of this lesson, students should be able to … Define and spell the terms to learn for this chapter. Discuss the problem-oriented medical record. Describe the four components of the SOAP charting method. 2

Categories and Reports Found in a Medical Record Patient’s past medical records History and physical Insurance information Office notes Progress notes Telephone messages Pathology results Nursing notes Medications Physician orders Radiology reports Laboratory reports Operative reports Consultation reports ECGs Miscellaneous

Formats for Recording Medical Information Chronological record Problem-oriented medical record Source-oriented medical record

Chronological Record Follows the patient over a period of time Each visit consists of a new entry by date rather than by symptom or diagnosis One of the most common types of medical records This record sometimes make it more difficult to “catch” diagnoses

Problem-Oriented Medical Record Developed by Dr. Lawrence Weed in 1970 Used to identify patient problems and chart by those problems The functional aspect of this type of charting is the patient problem list found at the front of the chart As new problems and diagnoses are identified, they are noted on the problem list, helping the health care provider to identify trends

Problem-Oriented Medical Record Helps health care providers who do not already know a specific patient obtain a “snapshot” regarding previous visits and problems at a glance

Sections of the Problem Oriented Medical Record Database Problem list Treatment plan Progress notes 8

SOAP Charting Method is distinct because of the four parts of the approach “S” Identifies the subjective information gathered from the patient – the things that the patient believes they are seeing a physician for, usually the chief complaint “O” Stands for objective, the data gathered during the visit – such as vital signs, weight change, fevers, blood work, and other measurable data

SOAP Charting “A” Is for assessment, the physician’s preliminary diagnosis “P” Indicates the section of the chart discussing the plan of care for this patient The POMR and SOAP methods can be combined in one chart, making for a very concise, clear set of information on any patient

Source Oriented Medical Record Common method utilized in medical clinics Patient information is placed in the medical record in reverse chronological order and organized in different sections Each office determines which sections are to be used and in what order they are to appear in the medical chart The sections commonly used include history and physical, insurance, progress notes, medications, laboratory, and consultations

Source Oriented Medical Record The most recent information is seen first in each section of the medical record This method makes it complicated to identify and locate past medical problems, treatments, and results Progress notes are included with each patient encounter whether it is an office visit, telephone call, or written communication

Critical Thinking Question What types of information should not be included in the patient chart, and why?

Information that SHOULD NOT be Included in a Patient’s Chart Your opinions Internal office problems Subjective comments

Contents that SHOULD BE Included in the Medical Record Factual (objective) statements Everything that is done during a patient’s medical visit, ordered over the telephone, or discussed with a patient over the telephone or e-mail Legible writing in black ink

How to Correct an Error in the Medical Record Do not erase or totally obliterate the original error with commercial products such as correcting fluid Draw a single line through the error so the original entry can still be seen Initial above the single line Date and write “error” Once this is complete, write in the correction 16

Correcting Errors Made When Documenting in an EMR When documenting in an EMR, prior to saving the entry, errors may be corrected by deleting as you would with any other type of computer program However, if an error is discovered after the entry is saved, an additional entry called an addendum will be required An addendum is an addition to the original document 17

Correcting Errors Made When Documenting in an EMR In this case, the addendum should be titled “correction” When using an EMR, the entry will be automatically dated and signed electronically when saved 18

Steps for Adding Items to a Patient’s Chart An item is added to a patient record as soon as it is discovered that the item was omitted Locate the last entry in the medical record Using a pen with black ink, on the next line of the record, immediately after the last entry, place the current date On the same line, after the date, place the statement, “Late entry”

Steps for Adding Items to a Patient’s Chart Note the date on which the information to be added was gathered Enter the information that was originally omitted Sign the entry with your full name and credentials

Guidelines for Changing Items in a Patient’s Record Locate the incorrect information Using a pen with black ink, draw one single line through the incorrect information, so that the incorrect information is not obscured, but can still be read Never erase entries in a medical record Never use correction fluid in a medical record

Guidelines for Changing Items in a Patient’s Record Never mark through information so that it cannot be read Place the date of the correction, your initials, and “error” above the incorrect information Enter the correct information

Responsibilities of the MA Document information clearly in the medical record Be sure that information added to the medical record is accurate Ensure that patient records are kept up to date Make files as easily accessible as possible 23

Contents of Medical Records Patient registration form Family and medical history form Form to chart physical examination results Results of all tests performed on the patient Records from referring physicians or hospital visits Informed consent forms Diagnosis and treatment plan Patient correspondence

Contents of Medical Records Consultation report Operative report Pathology report Radiology report Discharge summary Emergency room report Psychiatric note Special procedure report

Questions? 26