The Patient’s Health Record / Chart

Standards HS-AHI-5. Students will outline the evolution of a client’s medical record and analyze the purpose, utilization, ownership, and the value of data contents. d) Determine who has responsibility for completing each portion of the health record and differentiate between quantitative and qualitative analysis.

Purpose of the Patient’s Chart Communication between doctor & hospital staff Planning patient care Educational purposes Research

A Legal Document Protects: – Patient – Physician – Staff – Health care facility Health Information Services: – Analyzes & checks chart for completeness – Maintains in an acceptable manner – Statute of limitations, litigation

Documentation The act of recording information in a patient’s medical record. Use the patient’s words when documenting information from the patient. Make copies of any reports the patient may have brought during the visit. Record vital signs, height, and weight accurately Interview the patient

Staying Legal Make all entries in ink, usually blue ink All entries must be legible & accurate Entries must never be obliterated or erased All entries must include date & time & indication of the person that made the entry May be indicated with the initials Only use approved abbreviations Use proper guidelines when releasing information

The Information (I) Is privileged – only the patient has the right to review chart at anytime. Must give written permission if released to another person or agency. Release of information - third party payer – Identify those accessing chart

The Information (II) Record belongs to health care facility Information belongs to patient The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L ) [HIPAA] was enacted by the US Congress in 1996.

Be on the Look-Out for: Name alert - 2 or more patients with same last name, also Jr. & Sr. Split or thinned chart Correct sequence is used when creating a chart System for tracking charts when removed from facility. Keep the charts according to agency policy: – chronological, reverse chronological

Be on the Look-Out for (cont.): File diagnostic reports after review --Doctors will initial page after review to indicate it has been reviewed and is ready to be filed promptly. Keep charts re-filed quickly so it can be located quickly. Review charts frequently for new orders and that old orders have been completed.

Monitoring the Chart There are various types of audits/ “monitoring systems” – qualitative, quantitative, and self monitoring, including manual and automated methods. –Qualitative looks at the quality of documentation assessing adherence to clinical practice guidelines, evaluating consistency in charting, and adherence to regulations, standards and interpretations. –Quantitative looks at the quantity of documentation assessing adherence to clinical practice guidelines, evaluating consistency in charting, and adherence to regulations, standards and interpretations.