Medical Assisting Chapter 9 PowerPoint® to accompany Medical Assisting Chapter 9 Chapter 9 Second Edition Ramutkowski  Booth  Pugh  Thompson  Whicker Chapter 9 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Maintaining Patient Records Objectives 9-1 Explain the purpose of compiling patient medical records. 9-2 Describe the contents of patient record forms. 9-3 Describe how to create and maintain a patient record. 9-4 Identify and describe common approaches to documenting information in medical records.

Maintaining Patient Records Objectives (cont.) 9-5 Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records. 9-6 Discuss tips for performing accurate transcription. 9-7 Explain how to correct a medical record. 9-8 Explain how to update a medical record. 9-9 Identify when and how a medical record may be released.

Maintaining Patient Records  Importance of Patient Records Patient Records Also known as charts containing: Past and present medical conditions Communications between health team members Name & address Insurance coverage Occupation Medical treatment plan Health-care needs Response to care Lab and radiology reports The chart is a legal document, and can play a role in patient and staff education. It may also be used for quality control and research.

Importance of Patient Records Legal Guidelines for Patient Records As a general rule, if information is not documented there’s no proof it was ever done. Charts are used in court. Standards for Records Complete, accurate and well-documented records can serve as convincing evidence that the doctor provided appropriate care. Incomplete, inaccurate, altered or illegible records may imply poor standards.

Importance of Patient Records Patient Education Quality of Treatment Additional Uses of Patient Records Research

Contents of Patient Charts Standard Chart Information Patient Registration Form Date of current visit Demographic data (age, date of birth, SS#, address, telephone number, marital status, etc.) Medical insurance information Emergency contact person Family medical history List of medical problems

Contents of Patient Charts Standard Chart Information (cont.) Past Medical History Illnesses, surgeries, allergies and current medications Family medical history Social history (use of drugs and alcohol, cigarette smoker, etc) Occupational history Statement of current patient complaint recorded in patient’s own words

Contents of Patient Charts Standard Chart Information (cont.) Physical Examination Results Containing results of a general physical exam Results of Laboratory and other Tests Results from lab tests performed on patient Records from other Physicians or Hospitals Include along with these records a copy of the patient consent authorizing release of information

Contents of Patient Charts Standard Chart Information (cont.) Doctor’s Diagnosis and Treatment Plan Lists doctor’s diagnosis, medications prescribed and overall treatment plan Operative Reports, Follow-Up Visits, and Telephone Calls A continuous record of all care provided to the patient while under the doctor’s care Also document calls made to and from the patient

Contents of Patient Charts Standard Chart Information (cont.) Informed Consent Forms Signed consent forms show that the patient understands procedure, outcomes and options Patient may still change their mind even after signing the consent form Hospital Discharge Summary Forms Includes information summarizing the patient’s hospitalization Follow-Up care after discharge is also included and the physician signs it

Contents of Patient Charts Standard Chart Information (cont.) Correspondence With or About the Patient All written correspondences regarding the patient should be included Be sure to record date each was received on the actual form Information Received by Fax Dating and Initialing Request an original copy, if not available make a photocopy of the fax. Be sure to date and place your initials on everything you place in the chart.

Initiating and Maintaining Patient Records Completing Medical History Forms Documenting Test Results Initial Interview Documenting Patient Statements Examination Preparation & Vital Signs

Initiating and Maintaining Patient Records (cont.) Follow-Up Duties Transcribe notes the doctor dictates Post results of laboratory and examinations on summary sheet Record all telephone communication with the client Record all medical or discharge instructions given to the client

Apply Your Knowledge The medical assistant is obtaining the initial information from a patient. The patient informs the medical assistant that he/she has used intravenous drugs for the past 3 years. Which section of the chart will this be recorded in?

Apply Your Knowledge -Answer The medical assistant is obtaining the initial information from a patient. The patient informs the medical assistant that he/she has used intravenous drugs for the past 3 years. Which section of the chart will this be recorded in? This should be recorded in the past medical history section. More specifically under the social history section.

ompleteness onfidentiality onciseness lient’s words larity The Six Cs of Charting C ompleteness Fill out all forms in the patient record completely so others will understand your notations and entries. hronological order Date entries in the order they occur. This shows consistency with accurate documentation. onfidentiality All information in patient record must be kept confidential to protect patient privacy. lient’s words Be sure to record the client’s exact words and do not rephrase their statements. onciseness Be as brief and to the point as possible. Use medical abbreviations to save time. larity Be precise and use accepted medical terminology when describing a patient’s condition.

Types of Medical Records Source-Oriented Medical Records Problem-Oriented Medical Records Also called conventional Information is arranged according to who supplied the data Problems and treatments are described on the same form Presents some difficulty with tracking progress of specific events. (POMR) makes it easier to track specific illnesses Consists of: Data base Problem list Educational, diagnostic and treatment plan Progress notes

SOAP Documentation Incorporated with POMR Utilizes an orderly series of steps for dealing with any medical case Lists the following: Patient symptoms Diagnosis Suggested treatment

SOAP Documentation P A O S lan ssessment bjective data ubjective data Plan of action consists of the treatment plan to correct the illness or problem. Assessment is the impression of the patient’s problem that leads to a diagnosis. P lan Objective data is data observed by the physician during the examination. A ssessment Subjective data is information the patient tells you about their symptoms. O bjective data S ubjective data

Appearance, Timeliness, and Accuracy of Records  Neatness & Legibility Timeliness Use a good quality pen, black ink preferably. Make all writing legible. Never use white out in charts. Accuracy  Record all findings as soon as they are available For late entries, record both original date and current date Record date and time of telephone calls and information discussed Check information carefully Double check accuracy of information Make sure most recent information is recorded Follow correct procedure for correcting errors

Professional Attitude and Tone Maintain a professional tone with your writing by: Recording patient comments in their own words Not recording your personal, subjective comments, judgments, opinions or speculations You may call attention to a problem by attaching a note to the chart but do not make such comments part of the chart.

Computer Records Advantages Security Concerns Can be accessed by more than one person at-a-time Can be used in teleconferences Useful for tickler files Security Concerns Protecting patient confidentiality is a major area of concern

Medical Transcription Transcription means transforming spoken words into written format. Dictated information is part of the medical record and must be kept confidential. Always date and initial each transcription page. Strive for ultimate accuracy and completeness of transcribed information.

Medical Transcription (cont.) Transcribing Recorded Dictation Organize your work area Adjust transcription machine speed, tone and volume as needed Listen initially to entire recording before transcribing and document areas with difficult interpretations Listen to voice tones to determine correct punctuation Never try to guess at meanings Re-read for accuracy and correct spelling and punctuation Physicians should initial all transcribed doctor’s notes

Medical Transcription (cont.) Transcribing Direct Dictation Use a writing pad and good pen that will not smear Use incomplete sentences and phrases to keep up with physicians pace Use abbreviations Ask for clarification immediately if something is unclear Read the dictation back to verify accuracy

Medical Transcription (cont.) Reference Books Medical Terminology Books Transcription Aids Secretarial Books Medical Reference Books

Apply Your Knowledge or O S Label the following items as either (S) “subjective” or (O)“objective”. O S headache or vomiting nausea chest pain respirations = 22 and non-labored skin color

Apply Your Knowledge -Answer Label the following items as either (S) “subjective” or (O)“objective”. headache headache S vomiting vomiting O nausea nausea S chest pain chest pain S skin color skin color O respirations = 22 and non-labored respirations = 22 and non-labored O

Correcting and Updating Patient Records Medical records in legal terms are regarded as “due course” meaning information is to be entered at the time of occurrence and not “conveniently” later. Use care with corrections because it is more difficult to explain a chart that has been altered after something was documented. Date and initial each addition to the medical record.

Release of Records Procedures for Releasing Records Special Cases Obtain a signed and newly dated release form authorizing the transfer of their information, and place in file. Make photocopies of original materials. Copy and send only documents covered in the release authorization. Special Cases Divorce and death Confidentiality Children age 18 in many states are to be treated as adults and their parents do not have the right to see their records without authorization.

Apply Your Knowledge The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another physician’s office. What would you do in this situation?

Apply Your Knowledge -Answer The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another fax number. What would you do in this situation? It is difficult to know the actual originator of a fax transmittal and to verify the signature. The safest solution would be not to release any information ever via fax.

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