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Advance Topics in Hospital Health Information Management
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MRD WORKFLOW START Charts from Unit NEEDED LOANED RECORD RECORDS
Med. Record Request Accomplished Release to Borrower Returned Record Recording/ Indexing Pre-sort Search: Forwarded Records Un-filed MPI Record of Adm. Etc… Assembly Accomplish Trucking System Remove from Trucking System In MPI File? NO Analysis Disease Coding/Indexing YES In File? YES Complete? NO Operation Coding Routing Process YES NO Physician’s Index Search at: Incomplete Processing Etc… Final Disposal Data Collection Statistics Re-check Complete? Permanent File Retrieval system
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CREATION AND COMPILATION
OF THE MEDICAL RECORDS
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CREATION OF THE MEDICAL RECORD
Registration Counter/Admitting Unit/Emergency Room Collection of essential & accurate identification information Reason for admission to the healthcare facility Provisional diagnosis Admitting impression Working diagnosis Symptom
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LINKAGES OF THE ADMITTING UNIT
Medical Records Billing Admitting Unit Ward/ Unit Ambulatory Services
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RECORD CREATION Ward Past medical history Family history
History of present illness Physical examination Plan of treatment Request for diagnostics Physicians continues to record, on daily basis, writing notes on the patient’s progress, medical findings, treatment, test results, and the general condition of the patient.
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RECORD CREATION Nurses record all observations, medications, treatment and other services rendered by them to the patient. Other health professionals record their findings and treatment as required during the patient’s hospitalization. At discharge, the physician write the condition at the end of the progress notes, the prognosis, treatment and whether the patient has to attend for follow-up. In addition the physician accomplish the following: * Discharge Summary * Discharge Diagnosis * Operation performed .
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CREATION OF THE MEDICAL RECORD
ADMITTING UNIT NURSING UNIT PATHOLOGY/ LABORATORY RECOVERY RADIOLOGY/ X-RAY OPERATING ROOM MEDICAL RECORD DEPARTMENT ECG
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FLOW OF DATA COLLECTION
SIMPLISTIC FLOW MODEL DATA DATA REPOSITORY PATIENT ENTERS HEALTHCARE PATIENT MEDICAL RECORD PATIENT CONDITION ASSESSED/ EVALUATED Patient History Physical Examination DIAGNOSTIC ACTIVITIES Transaction & Results
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MEDICAL RECORD PROCESSING (Interdepartmental Systems Flow)
ADMITTING OFFICE PATIENT UNIT/ WARD MEDICAL RECORD DEPARTMENT Reservation Reception Information Identification Social Data Assignment Notification History Examination Diagnosis Treatment Progress Education Evaluation Completion Coding Indexing Analysis Reports Filing Retrieval
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MRD WORKFLOW START Charts from Unit NEEDED LOANED RECORD RECORDS
Med. Record Request Accomplished Release to Borrower Returned Record Recording/ Indexing Pre-sort Search: Forwarded Records Un-filed MPI Record of Adm. Etc… Assembly Accomplish Trucking System Remove from Trucking System In MPI File? NO Analysis Disease Coding/Indexing YES In File? YES Complete? NO Operation Coding Routing Process YES NO Physician’s Index Search at: Incomplete Processing Etc… Final Disposal Data Collection Statistics Re-check Complete? Permanent File Retrieval system
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DOCUMENTATION AND RECORDING
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DOCUMENTATION: Objectives;
THE MEDICAL RECORD SERVICE DOCUMENTATION: Objectives; 1. To serve as database containing all information regarding a patient; 2. To communicate such information to individuals authorized to access it; 3. To be authentic; 4. To be comprehensive; 5. To be available when needed; 6. To be originator-friendly, and 7. To be economical. Methods: 1. Traditional Mechanical 1.1 Handwriting Encode into the system 1.2 Oral 1.3 Typing directly onto typewriter
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DOCUMENTATION GUIDELINES
THE MEDICAL RECORD SERVICE DOCUMENTATION GUIDELINES Documentation should be complete; Documentation should be objective and non- judgmental; Documentation must be legible and written in ink; Entries must be dated and signed; Documentation of volunteers must be reviewed and initiated by a regular hospital staff prior to the filling of the medical records;
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Documentation should be completed shortly after the service was provided;
No form may be removed or destroyed once it is filed in the Medical Records Office; Errors should be corrected in the proper manner.
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GOOD RECORDING AND DOCUMENTATION PRACTICES
THE MEDICAL RECORD SERVICE GOOD RECORDING AND DOCUMENTATION PRACTICES Evidence of timely recording of entries Legibility Authentication of all entries Use of approved abbreviation Avoidance of extraneous remarks Medical Record should contain no unexplained time gaps. e.g. E.R. record Record Skipped spaces (consecutive lines) Correct spelling Ethical
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GUIDELINES FOR GOOD REPORTING AND DOCUMENTATION
FACTUAL = OBJECTIVE ENTRY = WHAT YOU SEE, WHAT YOU WRITE ACCURATE CONFIDENTIAL COMPLETE CURRENT ORGANIZED ETHICAL LEGIBLE CORRECT SPELLING CONSECUTIVE LINES SIGNATURE WHERE AND WHEN TO CHART NEVER DOCUMENT FOR SOMEBODY ELSE CHART AN OMMISSION AS A NEW ENTRY
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STEPS TO EFFECTIVE MEDICAL RECORD DOCUMENTATION
THE MEDICAL RECORD SERVICE STEPS TO EFFECTIVE MEDICAL RECORD DOCUMENTATION 1. A complete history and physical exam including baseline lab values, pap smear,breast examination and rectal examination are required. Provisional diagnosis must be documented. 2. Daily progress notes must reflect findings, assessment and plan of care. Avoid use of such phrases as “status quo”.Progress notes should reflect the acute condition of the patient. 3. Physician orders must reflect treatment of the condition for which the patient was admitted or which develops subsequently. If ancillary tests or medical therapies are ordered which are not consistent with the current diagnosis or condition, they should be justified in the progress notes. 4. Note all abnormal test findings in the progress notes, along with an assessment of the findings’ impact on the patient’s current condition. A[ plan for treatment or follow-up must be included. 5. If antibiotic ordered do not conform with sensitivity results, document the reason for the choice.
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THE MEDICAL RECORD SERVICE
6. If the patient must undergo unplanned surgery,document indications clearly. 7. Nosocomial infections, transfusion reactions or errors, or trauma suffered in the hospital should be completely assessed in the progress notes. 8 Document early efforts to arrange an adequate discharge plan for the patient. 9. The final note should reflect the medical stability of the patient on discharge. Blood pressure and temperature within normal limits, wound status if surgery was performed, and any abnormal ancillary findings should be addressed with a plan for follow-up after discharge. 10 The final summary should be a meaningful recapitulation of the patient’s course of illness, hospital management, discharge plan/instruction and include a plan for follow-up care. At discharge, final diagnosis which relate to the current hospitalization should be included.
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Thank you!
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