The Medical Record, Documentation, and Filing Chapter 13 The Medical Record, Documentation, and Filing
Beginning the Patient’s Record Patient’s personal information Demographic information Marital status, children, and living arrangements Social habits Occupation information Medical history and family history Medications Testing performed
Purpose of Medical Records Maintains and documents the course of patient care Provider’s evaluation Prescribed treatment Responses to treatment
Purpose of Medical Records Provides for a continuity of care Eliminates incompatible therapies, duplication of efforts, or unnecessary expenses Provides legal protection Maximizes reimbursement Helps conduct research
HIPAA and the Medical Record HIPAA Privacy Rule HIPAA Security Rule Ensures confidentiality of patient’s medical record Protects against use or disclosure of information without the patient’s consent All employees must comply with HIPAA
EMR, EHR, and PHR EMR Electronic medical record Electronic record of health-related information for an individual that is created, gathered, managed, and consulted by licensed clinicians and staff that is maintained through a single organization
EMR, EHR, and PHR EHR Electronic health record Aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization Often used interchangeably with “EMR”
EMR, EHR, and PHR PHR Personal health record Collection of medical records compiled and maintained by the individual
Advantages of EHRs Searchable databases Results can be transmitted to different providers and departments immediately Legible prescriptions sent to pharmacy immediately Reminder systems for routine maintenance and testing
Advantages of EHRs Encourages coordination of care between providers and departments Plug-ins for voice recognition software to decrease transcribing needs Automatic CPT/ICD code assignment Photo upload capabilities to ensure correct patient is selected
Parts of the Medical Record Administrative data Financial and insurance information Correspondence Referrals Past medical records Clinical data Progress notes Diagnostic information Lab information Medications
Parts of the Medical Record
Information in the Record Subjective Provided by the patient Routine information about the patient Chief complaint Objective Provided by the provider and health care team Vital signs Exam findings Diagnostic tests
Administrative, Financial, and Insurance Information Demographics HIPAA Notice of Privacy Practices Insurance information
Correspondence and Referrals All correspondence received by the medical office Referral or follow-up letters from specialists In an EHR, these are scanned and uploaded into the patient record
Past Medical History Records from previous providers or facilities Release of information form Ensures continuity of care
Progress Notes Arranged chronologically Most recent note on top Each entry is timed, dated, and signed Medical office or provider will indicate preferred format for progress notes
Diagnostic and Lab Information Imaging information X-rays, MRIs, and many others Lab reports Critical values should be highlighted and presented to the provider for review
Medications Medications administered in the office Prescriptions Complete documentation Prescriptions
Charting in the Patient Record Problem-oriented medical record (POMR) SOAP Subjective, objective, assessment, plan HPIP History, physical exam, impression, plan CHEDDAR Chief complain, history, examination, details, drugs/dosages, assessment, return visit
Filing Medical Records Step One: Inspect Step Two: Index Step Three: Code Step Four: Sort Step Five: Store
Filing Systems Alphabetic Numeric Subject Geographic Chonologic