1. The Paper Medical Record
Chapter 14
Chapter 14
The Paper Medical Record

2. Introduction
Medical records management systems are only as good as the ease of retrieval of the data in the files.
Organization and adherence to set routines will help to ensure that medical records are accessible when they are needed.
Talk about the students’ own medical records. Discuss the contents of the records and what might be found inside the physical record.

3. This chapter will examine:
Reasons for keeping accurate records
Ownership of records
Differences among types of records
Differences among types of information
Making corrections in the record
Filing procedures and systems
Forms found in medical records
Assign the chapter and ancillaries to the student if not already assigned.

4. Why Medical Records Are Important
Assist the physician in providing the best possible care to the patient
Offer legal protection to those who provide care to the patient
Provide statistical information that is helpful to researchers
Vital for financial reimbursement
Discuss why documentation is critical to quality patient care. Talk about whether it is better to have too little or too much information in the patient’s record.

5. Ownership of the Medical Record
The maker, who initiated and developed the record, owns the physical medical record.
The maker can be a physician or a medical facility.
Patients have a right of access to the information in the record.
Discuss the reasons why the medical record is owned by the physician and not the patient. Talk about whether there are any situations in which the patient should not be allowed access to the medical record.

6. 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.
Discuss why the patient records should not leave the medical facility. Talk about what to do if the physician habitually takes records from the office. Explain how a medical assistant can discourage the physician from doing so.

7. Creating an Efficient Medical Record System
The system should:
provide for easy retrieval
be organized and orderly
contain information that is completely legible
contain accurate information
show information that is easily understood and grammatically correct
Explain what is meant by ease of retrieval. Talk about the reasons that legible handwriting is so important. Discuss the reasons that a medical record might be referred to many years after the patient has visited the office. Discuss whether patient confidentiality applies to deceased patients.

8. Types of Records Paper-based medical records
Computer-based medical records
Discuss the types of records that students have encountered in medical facilities. Talk about whether they prefer a paper-based or computer-based personal medical record.

9. Disadvantages of Paper-Based Medical Records
Only one person can use the record at a time, unless multiple people are crowding around the same record.
Items can be easily lost or misfiled or can slip out of the record if not securely fastened.
The record itself can be misplaced or be in a different area of the facility when needed.
Talk about the reasons why staff members would need to access the medical record at the same time. Discuss ways to look for information that has probably been misfiled.

10. Advantages of Computer-Based Medical Records
More than one person can use the record at a time.
Information can be accessed in a variety of physical locations.
Records can often be accessed from another city or state.
Complete information is often available in emergency situations.
Discuss whether the advantages of computer-based medical records outweigh the disadvantages for a physician’s office.

11. Organization of the Medical Record
Source-oriented records
Problem-oriented records
Choose a medical condition and discuss how it might be charted using a source-oriented organizational method. Choose a different medical condition and talk about its charting in a problem-oriented organizational method.

12. Source-Oriented Medical Records
Traditional method of keeping patient records
Observations and data are cataloged according to their sources
Forms and progress notes are filed in reverse chronological order
Separate sections are established for laboratory reports, x-ray films, radiology reports, etc.
Discuss the source in a source-oriented medical record. Who or what is the source? Talk about why reverse chronological order is best for medical records.

13. Problem-Oriented Medical Records
Courtesy Bibbero Systems, Petaluma, Calif.
Divides records into four bases:
Database
Problem list
Treatment plan
Progress notes
Discuss the advantages of using a problem-oriented medical record. Talk about which method might be more comprehensive or provide better documentation of the patients’ encounters.

14. Database Includes: Chief complaint Present illness Patient profile
Review of systems
Physical examination
Laboratory reports
Explain each part of the database and provide examples of how each might be charted in the medical record.

15. Problem List
Numbered and titled list of every problem the patient has that requires treatment
May include social and demographic troubles as well as medical and/or surgical notes
Talk about situations that might be considered social or demographic issues that relate to the patient. Choose several problems that a patient might have and demonstrate the way that they might be charted using the problem list.

16. Treatment Plan Includes: Management Additional workups needed Therapy
Each plan is titled and numbered with respect to the problem.
Explain why a treatment plan is necessary and must be included in the medical record. Talk about ways to express the need for compliance to the patient. Discuss why patients might not comply with instructions from the physician.

17. Progress Notes
Structured notes are numbered to correspond with each problem number.
Progress notes follow the SOAP approach.
Discuss the SOAP approach and provide examples to the students. Assign a project wherein the SOAP approach to charting is used. Talk about the advantages of using a SOAP approach compared to other methods.

18. SOAP Approach to Progress Notes
SOAP acronym
S—Subjective impressions
O—Objective clinical evidence
A—Assessment or diagnosis
P—Plans for further studies, treatment, or management
Optional E—Evaluation or education
R—Response
Talk about each element of the SOAP method of charting. Discuss the usefulness of the additional “E” and “R” designations.

19. CHEDDAR C—Chief complaint H—History E—Examination
D—Details (of problem and complaints)
D—Drugs and dosages
A—Assessment
R—Return visit
Discuss the CHEDDAR approach and provide examples to the students. Assign a project in which the CHEDDAR approach to charting is used. Talk about the advantages of using a CHEDDAR approach compared to other methods.

20. Contents of the Complete Case History Subjective Information
Patient’s full name
Parents’ names, if a child
Sex
Date of birth
Marital status
Spouse’s name
Number of children
Social Security number
Driver’s license number
Home address and phone
address
Occupation and employer
Business address and phone
Healthcare insurance information
Spouse’s employment information
Source of referral
Talk about each entity and why it is an important component in the medical record.

21. Personal and Medical History
Often obtained by patient questionnaire
Provides information about any past illnesses or surgical operations
Explains injuries or physical defects
Information about the patient’s daily health habits
Information about allergies, advance directives, living wills, and so on
Discuss the advantages and disadvantages of obtaining a patient history by questionnaire or by interview. Talk about which method the students believe is more effective and discuss the reasons for their choices.

22. Patient’s Family History
Physical condition of members of the patient’s family
Past illnesses and diseases family members may have experienced
Record of causes of family members’ deaths
Talk about the reasons that the family history is important to the patient’s medical record. Discuss why deaths play a role in the patient’s current health issues.

23. Patient Information Form
Provide various patient information forms for scrutiny in class. Talk about what makes one type of patient information form better or worse than another. Discuss when the patient information form might be given to an established patient to fill out.

24. Patient’s Social History
Information about the patient’s lifestyle
Alcohol, tobacco, and drug use history
Marital information
Psychological information
Emotional information, if pertinent
Talk about the reasons that the patient’s social history is important to his or her current health issues. Discuss how psychological and emotional situations affect the patient’s physical health.

25. Patient’s Chief Complaint
Nature and duration of pain, if any
Time when the patient first noticed symptoms
Patient’s opinion as to the possible causes of the difficulties
Remedies that the patient may have applied or tried
Whether the patient has had the same or similar condition in the past
Past medical treatment for the same condition
Discuss ways of getting information out of patients about their chief complaint. How might the medical assistant obtain more information from a patient who provides minimal feedback?

26. Pain Scale
“How bad is your pain on a scale of 1 to 10, with “1” being like a mosquito bite and “10” being the worst pain you have ever experienced?”
Discuss pain symptoms that patients might have and practice rating them on the pain scale. Talk about why the pain scale is effective in treating patients.

27. Objective Information
Objective findings, often called signs, are gained from the physician’s examination of the patient.
Discuss examples of signs that can be observed when examining a patient. Talk about whether the medical assistant should note signs in the medical record.

28. Objective Information
Physical examination and findings
Laboratory and radiology reports
Diagnosis
Treatment prescribed
Progress notes
Condition at the time of termination of treatment
Discuss the reason that the physician should note the patient’s condition at the time of the termination of treatment. Talk about whether the physician is obligated to “cure” all patients. Discuss liability issues when physicians make an incorrect diagnosis.

29. Diagnosis Provisional Differential Final
Define the various types of diagnoses.

30. Obtaining the History Histories may be obtained by:
Patient questionnaire
Medical assistant asking the patient questions
Physician asking the patient questions
Combination of questionnaire and questions
Talk about the advantages of giving patients history forms prior to their first visit to the physician’s office.

31. Medical Assistant’s Role When Taking the Patient History
Take the history in a physical location that ensures patient confidentiality.
Ask open-ended questions.
Obtain details of the patient’s condition and symptoms.
Keep all information about the patient confidential.
Practice asking each other open-ended questions. Discuss whether an examination room is a secure physical location for taking patient histories. Talk about the damage that might occur if patients can hear what is said in adjoining rooms.

32. Authentication
For a chart to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written.
This is “authentication” and is best done by initialing entries made to the medical record.
Talk about the reasons that physicians may not authenticate records as they are made or dictated.

33. Making Additions to the Record
Place the most recent information on top.
Physicians should read and initial reports before they are filed.
Some offices direct only abnormal reports to the physician.
Follow the office policy as to which method is used in that particular office.
Talk about the advantages and disadvantages of directing only abnormal reports to the physician. Discuss whether this could be considered practicing medicine without a license.

34. Laboratory Reports
Often on different colors of paper for easy reference.
May need to be attached to standard-sized paper.
Reports may be shingled, if necessary.
Define shingling and explain why it is helpful when filing reports into the medical record.

35. Courtesy Bibbero Systems, Petaluma, Calif.
Laboratory Reports
Demonstrate the way that reports are shingled in the medical record.
Courtesy Bibbero Systems, Petaluma, Calif.

36. Radiology Reports Usually typed on standard-sized stationery.
Place in reverse chronological order, with the most recent report on top.
Medical records often have a separate section for laboratory and radiology reports.
Talk about the various forms of radiology reports. Discuss the ownership of reports that come to the office from other facilities. Talk about whether copies of such records should be provided to the patient (if requested) or whether the patient should be directed to the original facility for copies of reports.

37. Progress Notes Continually added to the medical record.
Must list each patient visit and any notations about the visit.
Instructions, prescriptions, and telephone calls for advice should be noted in the progress notes.
Always initial entries in progress notes.
Talk about the type of information that the medical assistant would add to the progress notes. Discuss why the medical assistant should or should not document his or her opinion as to the patient’s wellness or illness.

38. Making Corrections and Alterations to Medical Records
First, verify the correct procedure as detailed in the policy and procedure manual.
Never use correction fluid, erasers, or any other type of obliteration methods.
Do not mark through information to obliterate it.
Do not hide errors.
If errors could affect the health and well-being of the patient, bring it to the physician’s attention immediately.
Talk about the reasons that errors cannot be obliterated. Discuss the problems that can arise when errors are not documented in the right way.

39. Correcting an Error Three Steps Draw one line through the error.
Insert the correction above or immediately after the error.
In the margin, write “correction” or “corr” and initial the entry, if indicated by the office policy and procedure manual.
Provide practice examples for students to use in correcting errors in a medical record. Discuss the ramifications of incorrect documentation.

40. 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 (addendum) with corrected information.
Do not delete or change previous entries on electronic records.
Talk about why an addendum might be the best way to correct the electronic medical record.

41. Keeping Records Current
Records must be methodically kept current.
Do not allow histories and reports to accumulate for long before filing them.
The patient’s health is jeopardized when current, accurate records are not available to the physician.
Remember that the physician bases his or her decisions on the information in the patient’s medical record.
Talk about the reasons that the patient’s health is at risk because of unfiled reports. Discuss how often filing should be done in the facility.

42. Prescriptions
Some prescription pads are printed on NCR paper, which automatically makes a copy for the medical record.
All prescriptions must be noted in the medical record, including refills called in to the patient’s pharmacy.
Talk about why a patient might want to steal a prescription pad. Discuss ways to prevent the theft of prescription pads.

43. Classifications of Records in the Physician’s Office
Active files
patients currently receiving treatment
Inactive files
patients who have not been seen for about 6 months to a year.
Closed files
patients who have died, moved away, or otherwise discontinued treatment
Explain how a physician might determine the difference between active, inactive, and closed files. Talk about the reasons that a file might be closed or might be reactivated.

44. Transfer of Records
Follow office policies regarding transferring medical records from active to inactive or closed categories.
This process is called “purging.”
Files may need to be physically rearranged to accommodate transfers.
Discuss how often files should be purged in the medical office. Talk about options when space runs out for files in the office.

45. Retention and Destruction
Most physicians keep medical records for 10 years at a minimum.
Some records may warrant longer retention periods.
Records for minor patients should be kept for at least 3 years after he or she reaches legal age.
Use year stickers on patient files.
Talk about the ways to determine whether individual states have regulations about records retention. How might the student find information about such regulations?

46. Retention and Destruction
Follow local, state, and federal guidelines for retention and destruction of records.
HIPAA does not specify medical record retention requirements.
In most cases, keep medical records at least as long as the length of time of the statute of limitations for medical professional liability claims.
Talk about why HIPAA does not specify medical record retention requirements. Discuss reasonable policies for record retention in a medical office in the student’s specific state of residence.

47. Retention and Destruction
Medicare and Medicaid patient records must be kept for at least 6 years.
Keep records on patients who are deceased for at least 2 years.
Follow office policies for record retention and destruction.
Talk about why medical records must be kept on patients who are deceased. Explain why Medicare and Medicaid have a 6-year record retention regulation. What might be the significance of a 6-year period?

48. Releasing Medical Record Information
Requests must be made in writing for release of records.
Patients must sign an authorization for release of medical records.
Patients can revoke previously signed authorizations for release of records.
Release only records that are specified on the request.
Talk about why phone requests for the release of medical records should not be honored. Discuss the reasons for releasing only the records specified on the request.

49. Releasing Medical Record Information
Discuss the form pictured and allow students to practice filling out a copy of the form.
Courtesy Bibbero Systems, Petaluma, Calif.

50. Filing Equipment
Various types of equipment are available for storing medical records in today’s medical offices.
Talk about the advantages and disadvantages of the various types of filing equipment.

51. Considerations in Choosing Filing Equipment
Office space availability
Structural considerations
Cost of space and equipment
Size, type, and volume of records
Confidentiality requirements
Retrieval speed
Fire protection
Discuss how the medical assistant might research filing equipment prior to recommending purchase to the physician. Talk about why the people who will use equipment should be consulted prior to the purchase.

52. Types of Filing Systems
Drawer files
Shelf files
Rotary circular files
Lateral files
Compactable files
Automated files
Card files
Allow the students to express their opinions on the efficiency of each filing system. Research examples on the Internet and compare costs in class.

53. Courtesy Bibbero Systems, Petaluma, Calif.
Filing Supplies
Divider guides
OUTguides
OUTfolders
Files and folders
Labels
Talk about the difference between OUTguides and OUTfolders. Explain how software programs such as Microsoft Word can help the medical assistant to make labels for patient files.
Courtesy Bibbero Systems, Petaluma, Calif.

54. Filing Procedures Conditioning Releasing Indexing and coding Sorting
Storing and filing
Define and explain each filing procedure listed.

55. Indexing Rules
Last name first, then first name, then middle name or initial.
Initials precede names beginning with the same letter.
Hyphenated names are treated as one unit.
Apostrophes are disregarded.
Allow the students to index the names of all classmates into one document. Talk about the issues concerned with various names and how they made the decision to place the names in the order that they chose.

56. Indexing Rules
Index each part of foreign names if confused as to first and last names.
Names with prefixes are filed in regular alphabetic order.
Abbreviated parts of a name are indexed as written.
Talk about how the medical assistant might determine which is a patient’s first or last name.

57. Indexing Rules Name of a married woman is indexed by legal name.
Titles may be used as the last filing unit if needed to distinguish from another identical name.
Terms of seniority are indexed only to distinguish from an identical name.
Talk about why titles might be an important filing unit at the physician’s office.

58. Filing Methods Alphabetic Numeric Alphanumeric Subject
Discuss the advantages and disadvantages of each filing method. Talk about which are the most and least efficient. Discuss the types of files that might necessitate each filing method.

59. Color-Coding
Almost all medical offices use some sort of color-coding in their filing systems.
Numeric color-coding provides a high degree of patient confidentiality.
Talk about why a color-coding system is helpful and adds to the efficiency of the office. Discuss why it is easy to see a file that is misfiled when using a color-coded system.

60. Courtesy Bibbero Systems, Petaluma, Calif.
Color-Coding
Discuss the photo and review the ease of finding a file that is out of place.
Courtesy Bibbero Systems, Petaluma, Calif.

61. Transitory or Temporary Files
Transitory or temporary files are used for materials having no permanent value.
Materials in these files are kept there temporarily, usually until the document is dealt with and is no longer needed.
Useful when seeing patients from another geographic area who are not expected to return to the office.
Talk about situations in which a transitory or temporary file might be used for a patient. Discuss whether it is acceptable to store several transitory patient records in one file.

62. Summary of Scenario
All duties performed in the practice are learning opportunities.
Ask for additional responsibilities.
Always be ready to assist a co-worker.
Earn the trust of patients.
Talk about the scenario. Explain why filing is a critical duty and why the medical assistant should not downplay its importance or delay its execution. Discuss why the medical assistant must always admit and report errors.

63. Closing Comments Advances in medical records occur rapidly.
Be willing to learn.
Adapt to changes.
Keep a positive attitude.
Assign additional projects and review for testing. Perform all procedures detailed within the chapter.