Maintaining Patient Records Chapter 9 Maintaining Patient Records PowerPoint® presentation to accompany: Medical Assisting Third Edition Booth, Whicker, Wyman, Pugh, Thompson

Learning Outcomes 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.

Learning Outcomes (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.

Introduction Medical records document the evaluation and treatment of patients Critical to patient care Sectioned to describe various aspects of patient information and care Legal documents Medical assistant has a major role in documenting in and maintaining patient records

Importance of Patient Records  The patient’s chart Past and present medical conditions Communication tool for health-care team Plan to provide for continuity of care Documentation for billing and coding Patient education and research Legal document admissible in court

Importance of Patient Records (cont.)  Information included in patient record Name and address Insurance coverage and person responsible for payment Occupation Medical history Current complaint Health-care needs Medical treatment plan Response to care Lab and radiology reports

Patient Records: Legal Guidelines Proof of event or procedure No documentation No proof Care is considered not done Legal document Must document complete information about patient care Document if patient is noncompliant

Patient Records: Standards for Records Complete, accurate, and well-documented records are evidence of appropriate care Incomplete, inaccurate, altered, or illegible records may imply poor standards Everyone who documents in the patient record has a responsibility to the patient and employing physician

Patient Records (cont.) Additional Uses of Patient Records Quality of Treatment Patient Education Peer review JCAHO review Health-care analysis and policy decisions Research Test results Health issues Treatment instructions Source of data

Apply Your Knowledge Good Job! What is the purpose of documentation in a patient’s medical record? ANSWER: Documentation in the medical record provides evidence of appropriate care. If a procedure is not documented, it is considered not done. Good Job!

Patient Charts: Standard Chart Information Patient Registration Form Date Patient demographic information Age, DOB Address SSN Insurance / financial information Emergency contact

Patient Charts: Standard Chart Information (cont.) Past medical history Illnesses, surgeries, allergies, and current medications Family medical history Social history (diet, exercise, smoking, use of drugs and alcohol) Occupational history Current patient complaint recorded in patient’s own words

Patient Charts: Standard Chart Information (cont.) Physical examination results Results of laboratory and other tests Records from other physicians or hospitals Include a copy of the patient consent authorizing release of information

Patient Charts: Standard Chart Information (cont.) Doctor’s diagnosis and treatment plan Treatment options and final treatment list Instructions to patient Medication prescribed Comments or impressions Operative reports, follow-up visits, and telephone calls These are part of the continuous patient record Document calls made to and from the patient

Patient Charts: Standard Chart Information (cont.) Informed consent forms Verify that the patient understands procedures, outcomes, and options Patient may withdraw consent at any time Hospital discharge summary forms Information summarizing the patient’s hospitalization Instructions for follow-up care Physician signature

Patient Charts: Standard Chart Information (cont.) Correspondence with or about the patient All written correspondence regarding the patient Record date item was received on the actual form Information received by fax Request an original copy; if not available, make a photocopy of the fax Dating and initialing Be sure to date and place your initials on everything you place in the chart

Apply Your Knowledge Correct! What section of the patient record contains information about smoking, alcohol use, and occupation? ANSWER: Information about smoking, alcohol use, and occupation is part of the patient’s past medical history. Correct!

Initiating and Maintaining Patient Records Completing medical history forms Documenting test results Initial Interview Examination, preparation, and vital signs Documenting patient statements Maintain patient privacy during interview

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

Right! Apply Your Knowledge In addition to transcribing notes the doctor dictates and posting lab results, what are two other follow-up tasks the medical assistant might be required to perform as part of follow-up to a patient appointment? ANSWER: The medical assistant may have to record telephone calls with the patient, as well as medical or discharge instructions given to the patient. Right!

The Six Cs of Charting C Client’s words – Clarity – Completeness – C onciseness – Chronological order – confidentiality – Do not interpret patient’s words Precise descriptions / medical terminology Fill out forms completely To the point / approved abbreviations Legal issues Follow HIPAA guidelines

Apply Your Knowledge Great! What are the six Cs of charting? ANSWER: The six C’s of charting are Client’s words Conciseness Clarity Chronological order Completeness Confidentiality Great!

Types of Medical Records Source-Oriented Medical Records Problem-Oriented Medical Records Conventional approach Information is arranged according to who supplied the data Problems and treatments are on the same form Difficult to track progress of specific events POMR records make it easier to track specific illnesses Information included Database Problem list Educational, diagnostic, and treatment plans Progress notes

Medical Records: SOAP Documentation Orderly series of steps for dealing with any medical case Lists the following Patient symptoms Diagnosis Suggested treatment SOAP

SOAP Documentation P A O S lan ssessment bjective data ubjective data The treatment plan to correct the illness or problem The impression of the patient’s problem that leads to diagnosis P lan What the physician observes during the examination A ssessment Information the patient tells you O bjective data S ubjective data

GOOD! Apply Your Knowledge What type of documentation provides an orderly series of steps for dealing with any medical case, and what are the components of this type of documentation? ANSWER: SOAP documentation provides an orderly series of steps for dealing with any medical case. The components are S – Subjective data A - Assessment O – Objective date P - Plan GOOD!

Apply Your Knowledge S O Good Job! Label the following items as either (S) “subjective” or (O) “objective.” ____ headache ____ pulse 72 ____ vomited x 3 ____ nausea ____ skin color ____ respirations 16, labored ____ chest pain ____ poor appetite S O ANSWER:

Appearance, Timeliness, and Accuracy of Records Neatness and legibility Use a good-quality pen Blue ink is preferred (differentiates original from copy) Highlight critical items such as allergies Handwriting must be legible Make corrections properly

Appearance, Timeliness, and Accuracy of Records (cont.) 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 Retrieve file quickly in event of an emergency

Appearance, Timeliness, and Accuracy of Records (cont.) Check information carefully Never guess or assume Double-check accuracy findings and instructions Make sure most recent information is recorded

Appearance, Timeliness, and Accuracy of Records (cont.) Professional attitude and tone Record patient comments in his or her own words Do not record your personal or subjective comments, judgments, opinions, or speculations You may call attention to problems or observations by attaching a note to the chart, but do not make such comments part of medical record.

Appearance, Timeliness, and Accuracy of Records (cont.) Computer records Accuracy is also important with electronic records Advantages Can be accessed by more than one person at a time Can be used in teleconferences Useful for tickler files Security concerns Protect patient confidentiality

Apply Your Knowledge Very Good! What is important to remember when you are documenting in the medical records? ANSWER: It is important that medical records be neat and legible, timely, accurate, and maintain a professional tone. Very Good!

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

Medical Transcription (cont.) Transcribing direct dictation Use a writing pad and pen that will not smear Use incomplete sentences and phrases to keep up with physician’s pace Use abbreviations Ask for clarification immediately if something is unclear Read the dictation back to verify accuracy Enter notes into patient record, date, and initial

Medical Transcription (cont.) reference books Medical terminology books Transcription Aids Secretarial books Medical reference books

Apply Your Knowledge Excellent! When taking direct dictation, when should you clarify information if you do not understand something? ANSWER: You should immediately clarify information that you do not understand when taking direct dictation. Excellent!

Correcting and Updating Patient Records Medical records are created in “due course” Legal term meaning information is to be entered at the time of occurrence Information corrected or added after patient’s visit is regarded as “convenient” Use care with corrections It is more difficult to explain a chart that has been altered after something was documented

Correcting Patient Records When mistakes happen, correct them immediately Draw a line through the original information It must remain legible Insert correct information above or below original line or in margin Document why correction was made Date, time, and initial correction Have a witness, if possible eror m/d/yyyy 00:00pm misspelled JHC /chj error

Updating Patient Records Additions to record should not appear deceptive Document why late entry is made Date and initial added items May have a third party witness addition Addition made to record because patient called back with additional information. Mm/dd/yyyy – JHC / chj

Apply Your Knowledge Super Job! What is the appropriate way to correct an error in a patient’s medical record? ANSWER: To correct an error in a patient’s medical record: Draw a line through the original information It must remain legible Insert correct information above or below original line or in margin Document why correction was made Date, time, and initial correction

Release of Information to HMO Insurance Company Release of Records Records are property of physician Contain confidential patient health information Must have patient’s written consent to release Exceptions: cases of contagious disease or court order Release of Information to HMO Insurance Company I authorize Dr. J. Jones to release my healthcare information to the above-named insurance company. Christopher Hansen mm/dd/yyyy Patient Signature Date

Release of Records (cont.) Procedures for releasing records Obtain a signed and newly dated release form authorizing the transfer of information, and place it in the patient’s record Make photocopies of original materials Copy and send only documents covered in the release authorization Call to confirm receipt of materials

Release of Records (cont.) Special cases Divorce Legal guardian of children (may be one or both parents) Death Next of kin Legally authorized representative If unsure, ask supervisor Confidentiality 18-year-olds Considered adults in most states Must have written consent to release their records Legal and ethical principle: Protect patient’s right to privacy at all times.

Nice Job! 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? ANSWER: 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 based on a fax request and release of information form. Nice Job!

In Summary Medical assistants must properly prepare and maintain patient records There are several methods for documentation, but regardless of method, records must be complete, legible, current, accurate, and professional Properly maintain, correct, update, and release patient medical records

End of Chapter 9 Organization is the power of the day; without it, nothing is accomplished. ~ Sophia Palmer From A Daybook for Nurses: Making a Difference Each Day