1. Chapter 13: Managing Medical Records
Lesson 1:
Managing Medical Records

2. Lesson Objectives
Lesson Objectives
Upon completion of this lesson, students should be able to …
Define, spell and use key terms.
Discuss problem-oriented medical record (POMR)
Discuss source-oriented medical Record (SOMR)
Describe four components of SOAP charting method.
Document cc, HPI, PMH 2

3. Medical Abbreviationscc
HPI (not PHI!)
PMH
Px or PE Dx Rx Tx fx
f/u
WNL
ROS
Neuro
HEENT
Cor
Lungs GI GU
Skin
Extremities

4. What questions would you ask?
cc What is the reason for your visit?
HPI
Onset When did it start?
Description: sudden, gradual
Course
Circumstance, description surrounding onset, how did it happen, is it getting better or worse?
Duration How long does it last
Frequency How often?
Location Where is it?
Quality
What is it like, color, teture, odor, sharp vs. throbbing, crushing, pressure, burning etc.
Intensity (if pain)/ Severity
Pain level (1-10)
Radiating (if pain)
Aggravating factors
Alleviating factors
Meds
Allergies

5. ROS Review of Systems Done by MD to make sure nothing missed!
Head to toe, ask questions about major illnesses, symptoms
Neuro
HEENT
Neck
Chest
Lungs
Cor GI GU
Skin
Extremities

6. PMH Surgeries and hospitalizations Illnesses: chronic or acute
What and when (include year)
Illnesses: chronic or acute
FH Family History
Mother, father, grandparents, siblings
SH Social History
Marital status, children, living arrangements, alcohol, smoking, caffeine, sexual activity, illicit drugs, habits, sleep, exercise
Occupational!
Nutritional
Type of diet or restrictions
Preventive care
Developmental since birth
Full term, no complications….
Immunizations
Lifestyle MUST INCLUDE SMOKING Hx

7. Ownership of Medical Records
If pt. requests to view own medical record, access must be allowed unless physician determines it may be detrimental
Prior to allowing pt to view their record, MA must first check with physician or office manager for approval
Never leave pt or any one else alone with their record

8. Ownership of X-rays
X-rays property of medical facility that performed X-rays
Physicians able to loan films to referring physicians for further examination but pt must sign release
Films must always be returned to original facility
Sometimes can obtain duplicate copy of film for fee

9. Responsibilities of MA re: MR
7 c’s
Cc in clients own words, concise, complete, clear, chronological, confidential, correct
Be sure information accurate
Ensure that pt records kept up to date,
Chart in real time 9

10. Categories and Reports Found in Medical Record
Demographics
Insurance information
Pt’s past medical records
History and physical
Office notes
Progress notes
Telephone messages
Pathology results
Nursing notes
Medication records
Copies of Prescriptions
Medications
Physician orders
Radiology reports
Laboratory reports
Operative reports
Consultation reports
Pyschiatric notes
ECGs, Spirometry
Miscellaneous
Everything EXCEPT _____

11. Formats for Recording Medical Information
Chronological record
Problem-oriented medical record (POMR)
Source-oriented medical record (SOMR)

12. Chronological Record One of most common types of medical records
Follows pt. over period of time
Most recent on top (reverse chronological)
Each visit consists of new entry by date
This record sometimes make it more difficult to “catch” diagnoses

13. Problem-Oriented Medical Record
Developed by Dr. Lawrence Weed in 1970
Used to identify pt problems and chart by those problems
Functional aspect of this type of charting pt problem list found at front of chart
As new problems and diagnoses identified, noted on problem list, helping health care provider to identify trends

14. Figure 13-2 An example of a medical history sheet to list patient problems.

15. Sections of Problem Oriented Medical Record
Database
Problem list
Treatment plan
Progress notes 15

16. SOAP Charting Method distinct because of four parts of approach “S”
Identifies subjective information gathered from pt – things that pt believes they seeing a physician for, usually chief complaint
“O”
Stands for objective, data gathered during visit – such as vital signs, weight change, fevers, blood work, and other measurable data

17. SOAP Charting
“A”
For assessment, physician’s preliminary (clinical) diagnosis
“P”
Plan of care for this pt
POMR and SOAP methods can be combined in one chart, making for very concise, clear set of information on any pt

19. SOAP
What is wrong with this note?

20. SOAP Note
DOB
Time
O: BP inaccurate
A: obesity
Signature

21. SOMR Source Oriented Medical Record Divided into sections
Orders, labs, progress notes, etc.
Each section chronological
Very common in hospitals and institutions

22. Critical Thinking Question
What types of information should not be included in pt chart, and why?

23. Information that SHOULD NOT be Included in a Pt’s Chart
Your opinions
Internal office problems
Subjective comments
Billing and balance information (separate file)

24. Utilization Review
Review of charts to see if services being used according to best practice and law
Used for
Quality assurance (QA)
Determine Insurance reimbursement

25. How to Correct Error in Medical Record
Do not erase or totally obliterate original error with commercial products such as correcting fluid
Draw single line through error so original entry can still be seen
Initial above single line
Date and write “error”
Once this complete, write in correction 25

26. Correction to Chart
Pt Name DOB

27. An example of a late entry to the medical record.

28. Correcting Errors Made When Documenting in EMR
When documenting in EMR, prior to saving entry, errors may be corrected by deleting as you would with any other type of computer program
However, if error discovered after entry saved, additional entry called addendum will be required
Addendum - addition to original document
When using EMR, entry automatically dated and signed electronically when saved 28

29. Steps for Adding Items to Chart
Item added to pt record as soon as it discovered that item was omitted
Locate last entry in medical record
Using pen with black ink, on next line of record, immediately after last entry, place current date and time
Stat, “Late entry”
Sign entry with your full name and credentials

30. Guidelines for Changing Items in a Pt’s Record
Locate information to be changed
Using pen with black ink, draw one single line through incorrect information,
So that incorrect information not obscured, but can still be read
Place date of correction, your initials, and “error” above incorrect information
Enter correct information

31. Chapter 13: Managing Medical Records Lesson 2: Filing

32. Lesson Objectives
Lesson Objectives
Compare and contrast alphabetic, numeric, and color-coded filing systems.
State effective system used for cross-referencing.
Understand how to find missing file.
Define tickler file. 32

33. Categories of Medical Records
Active records
Inactive records
Closed records 33

34. Active Records
Relate to pts who have been seen within past three years and currently being treated
Each medical practice may have its own policy regarding what constitutes “active” file, but it is usually from three to six years

35. Inactive Records
Relate to pts who have not been seen within past three years or another time period determined by office policy (must keep for 7 years)
Files still maintained by office but generally kept in separate storage file cabinet that may be off-site
Pts have not received formal notification that physician terminated care.
May return when medical problem develops.

36. Closed Records
Records of pts who have actively terminated their contact with physician or have expired
Files can be placed in storage boxes or converted and saved on computer disk
Files referred to as archives, since they no longer needed but must be kept for legal reasons

37. Types of File Storage
Vertical
Lateral
Movable 37

38. Options for Storing Medical Records
Medical office building
Another office or building near to medical office
Business that specializes in archival and retrieval 38

39. Guidelines for Retaining Medical Records
Legal statues to keep records and documents vary by state
Standard set by most states for keeping records 2-7 years after last treatment, or seven years after pt reaches age of majority
AMA recommends keeping records for 10 years
Some worker’s comp (eg. Asbestos) require 30 yrs.
To be absolutely safe, medical records should be retained forever 39

40. Issues Addressed in Medical Record Destruction Policy
Length of time records kept
Where records will be kept
Person responsible for deciding what to keep and what to destroy
Method used for documenting destruction of records
Method of disposal 40

41. Traditional Hard Copy Pt Record
May be placed within separate tabbed folder that remains in filing cabinet
File folders may be color-coded to indicate primary care physician
Each physician may be assigned folder color as well as special indicators
This helps keep files in order in large clinics

42. Divider Guides
Divides files into subsections using letter or by pt number

43. Out Guide
Placed in file when file removed to indicate where file should be returned
Can be used to indicate who removed file and when it was removed
Especially helpful in large office when trying to locate charts
Usually distinctive color, such as red, is used to indicate file missing

44. Figure 13-8 An example of an out guide.

45. Using color coded labels enables medical staff to quickly identify important information

46. Systems Used for Filing
Alphabetic system
Numeric system
Subject filing
Color-coding
Let’s take closer look at each of these! 46

47. Rules for Alphabetic System
Name with only initial first name is filed before full name
Hyphenated names treated as one unit
Apostrophes disregarded
Titles and initials disregarded, but placed in parentheses after name
Married women to be indexed using their legal name. Husband’s name can be cross-referenced. 47

48. Rules for Alphabetic System
Seniority units filed numerically
Numeric seniority terms filed before alphabetic terms 48

49. Numerical Filing or Pt Identification System
Used in hospitals and many larger clinics
Number is assigned to each pt’s medical record
Generally six-digit number divided into three sections of two digits each 49

50. Types of Numerical Filing
Straight numerical filing
Terminal digit filing
Middle digit filing
Unit numbering
Serial numbering 50

52. Numerical Filing Straight Numeric Simplest numerical method
Each record filed sequentially based on assigned number
Numbers used system begin at 01 and continue upward
File space becomes depleted rapidly as new files added to one section requiring constant reshifting of files to make room for new files
Also terminal digit or middle-digit filing

53. Alpha-Z System
System based on 13 colors using white letters on colored background for first one-half of alphabet, and addition of white stripe on colored background for second half of alphabet
Uses file labels to denote pt’s name, and color label with letter of alphabet to indicate index unit

54. Alpha-Z System
Ideal for large practice with many pts having same surnames
Can be adapted to particular office’s needs
In large practices with several physicians, each physician may have color assigned to him or her

55. Methods to Ensure Location of Records is Known
Write down name of removed file on master file sheet
Use out guide to indicate removal of record

56. Guidelines for Locating Missing Files
Look for file with “sound-alike” or “look-alike” name
For color-coded files, look for folder with same color-coding
For files filed numerically, look for transposed numbers.
Look for transposed letters
Look for different spellings 56

57. Guidelines for Locating Missing Files
Look at folders filed before and after missing record
Look in other areas throughout office
For video on locating lost files click here, go to MyHealthProfessionsKit.com, or insert DVD-ROM found in back of your book. 57

58. Tickler Files Reminders for future events Should be reviewed daily
Contents include:
Pt’s names
Telephone numbers
Dates when action or activities should occur
Action to be taken 58

59. Figure 13-11 Tickler file using a file drawer.

60. Questions? Competencies 13-1 Changing Item in Medical Record
13-2 Organizing Pt File
13-3 File Record Alphabetically
Complete Alphabetizing exercise1 by hand, attach
Document comp You are the Pt, you filed your record alphabetically in correct location daily
13-4 File record Numerically
Stack of Charts will be given to sort and list of pt charts to put in sequence, list to sort on paper
Document your assigned case study including chart #
13-5 Locating Missing File
Video Lost File : Pt Karen Adams 60