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

2. Lesson Objectives
Lesson Objectives
Upon completion of this lesson, students should be able to …
Define and spell the terms to learn for this chapter.
Discuss the problem-oriented medical record.
Describe the four components of the SOAP charting method. 2

3. Categories and Reports Found in a Medical Record
Patient’s past medical records
History and physical
Insurance information
Office notes
Progress notes
Telephone messages
Pathology results
Nursing notes
Medications
Physician orders
Radiology reports
Laboratory reports
Operative reports
Consultation reports
ECGs
Miscellaneous

4. Formats for Recording Medical Information
Chronological record
Problem-oriented medical record
Source-oriented medical record

5. Chronological Record Follows the patient over a period of time
Each visit consists of a new entry by date rather than by symptom or diagnosis
One of the most common types of medical records
This record sometimes make it more difficult to “catch” diagnoses

6. Problem-Oriented Medical Record
Developed by Dr. Lawrence Weed in 1970
Used to identify patient problems and chart by those problems
The functional aspect of this type of charting is the patient problem list found at the front of the chart
As new problems and diagnoses are identified, they are noted on the problem list, helping the health care provider to identify trends

7. Problem-Oriented Medical Record
Helps health care providers who do not already know a specific patient obtain a “snapshot” regarding previous visits and problems at a glance

8. Sections of the Problem Oriented Medical Record
Database
Problem list
Treatment plan
Progress notes 8

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

10. SOAP Charting
“A”
Is for assessment, the physician’s preliminary diagnosis
“P”
Indicates the section of the chart discussing the plan of care for this patient
The POMR and SOAP methods can be combined in one chart, making for a very concise, clear set of information on any patient

11. Source Oriented Medical Record
Common method utilized in medical clinics
Patient information is placed in the medical record in reverse chronological order and organized in different sections
Each office determines which sections are to be used and in what order they are to appear in the medical chart
The sections commonly used include history and physical, insurance, progress notes, medications, laboratory, and consultations

12. Source Oriented Medical Record
The most recent information is seen first in each section of the medical record
This method makes it complicated to identify and locate past medical problems, treatments, and results
Progress notes are included with each patient encounter whether it is an office visit, telephone call, or written communication

13. Critical Thinking Question
What types of information should not be included in the patient chart, and why?

14. Information that SHOULD NOT be Included in a Patient’s Chart
Your opinions
Internal office problems
Subjective comments

15. Contents that SHOULD BE Included in the Medical Record
Factual (objective) statements
Everything that is done during a patient’s medical visit, ordered over the telephone, or discussed with a patient over the telephone or
Legible writing in black ink

16. How to Correct an Error in the Medical Record
Do not erase or totally obliterate the original error with commercial products such as correcting fluid
Draw a single line through the error so the original entry can still be seen
Initial above the single line
Date and write “error”
Once this is complete, write in the correction 16

17. Correcting Errors Made When Documenting in an EMR
When documenting in an EMR, prior to saving the entry, errors may be corrected by deleting as you would with any other type of computer program
However, if an error is discovered after the entry is saved, an additional entry called an addendum will be required
An addendum is an addition to the original document 17

18. Correcting Errors Made When Documenting in an EMR
In this case, the addendum should be titled “correction”
When using an EMR, the entry will be automatically dated and signed electronically when saved 18

19. Steps for Adding Items to a Patient’s Chart
An item is added to a patient record as soon as it is discovered that the item was omitted
Locate the last entry in the medical record
Using a pen with black ink, on the next line of the record, immediately after the last entry, place the current date
On the same line, after the date, place the statement, “Late entry”

20. Steps for Adding Items to a Patient’s Chart
Note the date on which the information to be added was gathered
Enter the information that was originally omitted
Sign the entry with your full name and credentials

21. Guidelines for Changing Items in a Patient’s Record
Locate the incorrect information
Using a pen with black ink, draw one single line through the incorrect information, so that the incorrect information is not obscured, but can still be read
Never erase entries in a medical record
Never use correction fluid in a medical record

22. Guidelines for Changing Items in a Patient’s Record
Never mark through information so that it cannot be read
Place the date of the correction, your initials, and “error” above the incorrect information
Enter the correct information

23. Responsibilities of the MA
Document information clearly in the medical record
Be sure that information added to the medical record is accurate
Ensure that patient records are kept up to date
Make files as easily accessible as possible 23

24. Contents of Medical Records
Patient registration form
Family and medical history form
Form to chart physical examination results
Results of all tests performed on the patient
Records from referring physicians or hospital visits
Informed consent forms
Diagnosis and treatment plan
Patient correspondence

25. Contents of Medical Records
Consultation report
Operative report
Pathology report
Radiology report
Discharge summary
Emergency room report
Psychiatric note
Special procedure report

26. Questions? 26