Medical Records Management

Medical Records Where should medical records be kept? How long are the records kept?

Points to Remember Medical records must be kept confidential and in a secured, locked location. The record should never leave the medical facility in which it originated, except for legal reasons.

Medical Record What is placed into the patient’s medical record?

Ownership of the Medical Record Who owns the medical record?

Ownership of the Medical Record Patients own the content and have a right of access to the information in the record.

Authorization to Release Information Patient must give written permission 1 year time limit if not otherwise stated Only requested information may be released Released information never includes insurance or financial information

Organization of the Medical Record What are Source-Oriented Medical Records (SOMR)?

Source-Oriented Medical Records (SOMR) Traditional method of keeping patient records. Information filed according to their sources Separate sections for laboratory reports, x-ray films, radiology reports, and so on. Forms and progress notes are filed in reverse chronologic order (newest on top).

Organization of the Medical Record What are Problem-Oriented Medical Records (POMR)?

SOAP Notes What do these stand for? S O A P

SOAP Notes S – Subjective – what patient says O – Objective – what you see/hear A – Assessment – diagnosis P – Plan - treatment

6 C’s of Charting Client’s own words Clarity (Clear) Completeness Conciseness Chronological order Confidentiality

Charting Can you chart for someone else? Why are we conscious of using correct medical terminology when charting? Why do we use correct grammar and punctuation?

Charting How do you correct an error that you made while charting?

Correcting a Medical Record Draw a single line through error Make correction in chart above error Write “Corr” or “correction” in the margin Date and initial What is done for electronic records?

Correcting Electronic Records If an error is made while typing, simply backspace and correct the error. If the error is discovered later, make an additional entry with corrected information. Do not delete or change previous entries on electronic records.

Equipment & Supplies

Equipment & Supplies Outguides

Basic Rules for Filing Which of these names is filled first in alphabetical order? Patricia A. McColm Patricia H. McColm Indexing Units a chosen according to the filing system to be used.

Basic Rules for Patient Filing Rule 1: Last name, first name, middle name Example: 1 2 3 Obama Barack Hussein

Basic Rules for Filing Rule 2: Initial used as a legal name is filed as a name Example: 1 2 3 Eliot, T. S. Elliott T. S.

Basic Rules for Filing Rule 3: Foreign prefixes or abbreviations become one unit with the last name Example: 1 2 3 Lisa M. Del Vecchio Delvecchio Lisa M Jill A. St. John Stjohn Jill A

Basic Rules for Filing Rule 4 – Hyphenated names are considered one unit George M. Andrews-Scott becomes 1 2 3 Andrews-Scott George M

3 Major Filing Methods Alphabetic – What is it? Numeric – What is it? Subject – What is it? Color Coding (used in all 3 major systems) Each letter is assigned a different color Each folder given a color-coded label Only full-cut folders are used

Tickler File What is it? How does a computer do this?

Project 3 – Week 7 There are two essays: There is a filing exercise. Download documents from DocSharing Make two cover sheets – one for Part I and one for Part II essay 1 – 2 pages in length (300 words) Must have a reference citation in both There is a filing exercise. Look for the announcement entitled Unit 7: Project 3 Information!