1. Medical Records and Documentation11
Medical Records and Documentation

2. Learning Outcomes (cont.)
11.1 Explain the importance of patient medical records.
11.2 Identify the documents that comprise a patient medical record.
11.3 Compare SOMR, POMR, SOAP, and CHEDDAR medical record formats.
11.4 Identify the six Cs of charting, giving an example of each.

3. Learning Outcomes (cont.)
11.5 Describe the need for neatness, timeliness, accuracy, and professional tone in patient records.
11.6 Illustrate the correct procedure for correcting and updating a medical record.
11.7 Describe the steps in responding to a written request for release of medical records.

4. Introduction Medical assistants role regarding patient health records
Documentation
Maintenance
Medical records – critical to patient care
Evaluation
Management
Treatment
Learning Outcome: Explain the importance of patient medical records.
A medical assistant plays a major role in documenting in and maintaining patient health (or medical) records. These records detail the evaluation, management, and treatment given to the patient. Patient records are critical to the patient’s care.
Parts of a medical record
Personal information or data
Physical and mental condition
Medical history
Medical care
Medical future if patient is referred to other physicians

5. The Importance of Medical Records
Past medical history and present condition
Communication tool for healthcare team
Legal documentation
Patient and staff education
Quality control and research
Documentation for billing and coding
Learning Outcomes: Identify the documents that comprise a patient medical record.
Medical record
Information about a patient’s medical history and present condition.
Used as a communication tool and legal document
Used for patient and staff education and quality control and research
Provides a “map” or plan to follow for the continuity of patient care
Is a supporting documentation for billing and coding purposes

6. Importance of Patient Records (cont.)
General information
Contact information
Occupation
Medical history
Current complaint
Healthcare needs
Treatment plan or services provided
Radiology and laboratory reports
Response to care
Learning Outcomes: Explain the importance of patient medical records.

7. Legal Guidelines for Patient Records
Support a malpractice claim
Support defense for a malpractice claim
Back up financial records
Documentation
Medical care, evaluation and instructions
Noncompliant patient
Learning Outcomes: Explain the importance of patient medical records.
As a general rule, if information is not documented, no one can prove that an event or procedure took place.
Medical records are used to:
Support a patient’s claim of malpractice against a doctor
Support the doctor in defense against a claim
Back up the information within the financial record
Documentation – the process of recording information in the medical record.
All medical care, evaluation, and instruction the physician gives to the patient
Must be clear, accurate, legible, dated, and per HIPAA guidelines, written in blue ink
Noncompliant patient – noncompliant is the medical term used to describe a patient who does not follow the medical advice he or she receives.

8. Standards for Records Evidence of appropriate care
Complete
Accurate
Everyone who documents in the patient record has a responsibility to the patient and physician
Learning Outcome: Explain the importance of patient medical records.
Records that are complete, accurate, and well documented are convincing evidence that a doctor provided appropriate care.
If an employee of the practice charts inappropriately or inaccurately in a patient’s medical record, the physician will also be held responsible for that action. The physician is responsible for all records, both medical and financial.
Under respondeat superior, if anyone in the practice charts inappropriately or inaccurately in a patient’s medical record, the physician will also be held responsible for that action.
As the medical assistant, you are responsible to the patient and the physician for both the medical and administrative procedures you perform and the accurate recording of those procedures.

9. Additional Uses of Patient Records
Patient Education
Quality of Treatment
Research
Test results
Health issues
Treatment instructions
Peer review
TJC review
Health-care analysis and policy decisions
Source of data
Learning Outcomes: Explain the importance of patient medical records.
Patient records serve as ongoing references about individual patients’ medical care.
Patient Education
How test results have changed or how the patient’s general health has improved or worsened.
Emphasize the importance of following treatment instructions.
Educate the healthcare staff about unusual medical conditions, patient progress, or treatment plan results.
Quality of Care
Evaluate the quality of care and treatment a facility or specific physician provides.
Review medical records to monitor whether the care provided and the fees charged meet accepted standards.
Provide statistics for healthcare analysis and future healthcare plans and policy decisions.
Research
Carefully kept records are valuable sources of data about patient responses, behavior, symptoms, side effects, and outcomes of new drugs or treatments
Information in charts may spur researchers to begin a study

10. Apply Your Knowledge Good Job!
What is the purpose of documentation in a patient’s medical record?
ANSWER: Documentation in the medical record provides evidence of appropriate care. If a procedure is not documented, it is considered not done.
Learning Outcomes: Explain the importance of patient medical records.
Good Job!

11. Contents of Patient Medical Records
Patient Registration Form
Date
Patient demographic information
Age, DOB
Address, phone number
SSN
Insurance/financial information
Emergency contact
Learning Outcome: Identify the documents that comprise a patient medical record.
Each new patient who comes to the office will require a medical record which must contain certain standard information.
The first document a new patient completes is the registration form which covers demographic information.
Patient Registration Form – information requested is fairly uniform and includes:
Date of visit
Patient’s legal name and physical address and mailing address if different
Phone numbers including area code. address may also be requested, but written permission must be received prior to ing the patient.
Patient’s date of birth, sex, marital status, and Social Security number
Medical insurance information, employer name/address, and patient occupation
Emergency contact name, relationship, and phone number
Primary care physician (if specialty office) and referral source
The completed registration form (with front and back copies of the patient’s insurance card) is the base document for each patient’s financial record.
Refer to CONNECT to see a video about Registering a New Patient.

12. Contents of Patient Medical Records (cont.)
Patient medical history
Past medical history
Family medical history
Social and occupational history
History of present illness (chief complaint)
Learning Outcome: Identify the documents that comprise a patient medical record.
The patient medical history contains:
Past medical history – including illnesses, surgeries, known allergies, and current medications, family medical history, and social and occupational history (including diet, exercise, smoking, and use of alcohol or drugs).
History of present illness or HPI – description the history of the condition or complaint that is the reason for the visit. This is the patient’s chief complaint, and it should be recorded in the medical records using the patient’s own words.
The medical history serves as the base document for the patient’s medical record. Because of this, it should contain as much information about the patient’s medical history as possible.

13. Contents of Patient Medical Records (cont.)
Physical examination results
Review of systems
Form ensures consistency
Results of laboratory and other tests
Documents from Other Sources
Learning Outcome: Identify the documents that comprise a patient medical record.
Physical Examination Form
Review of systems – identify any signs or symptoms the patient may be experiencing that may reveal information about an illness or condition.
The use of a physical examination form ensures consistency in the examination format and minimizes the risk of “forgotten documentation.”
Results of Laboratory and Other Tests
Findings from tests performed in the office and those received from outside sources.
Documents from Other Sources
Incoming records from other sources
A copy of the patient’s written request authorizing the release of these records to your office from its original source

14. Contents of Patient Medical Records (cont.)
Doctor’s diagnosis and treatment plan
Treatment options and plan
Instructions
Medication prescribed
Comments or impressions
Operative reports, follow-up visits, and telephone calls
Learning Outcome: Identify the documents that comprise a patient medical record.
Diagnosis and Treatment Plan
The treatment plan may include treatment options, the final treatment plan, instructions to the patient, and any medications prescribed.
Include any specific comments or impressions regarding the patient and his care.
All of this information is recorded for every patient visit in documents known as progress notes.
Operative Reports, Follow-Up Visits, and Telephone Calls
Continuation of the medical record lasts as long as the patient is under the doctor’s care.
All procedures, surgeries, follow-up care, notes, phone calls, and all other patient contacts should be recorded in the patient medical record.
Phone calls and between visit contacts may be inserted in the record in chronological order, or a separate log of telephone contacts may be kept separately in the patient record.

15. Contents of Patient Medical Records (cont.)
Hospital discharge summary forms
Consent forms
Verify that the patient understands procedures, outcomes, and options
Patient may withdraw consent at any time
Learning Outcome: Identify the documents that comprise a patient medical record.
Hospital Discharge Summaries
Summary of hospitalization including the reason the patient entered the hospital; tests, procedures, and operations performed in the hospital; medications administered to the patient; and the disposition (outcome) of the case.
Consent Forms
Signed informed consents must be obtained when any procedure is being performed on a patient.
The patient must understand
The treatment offered and the possible outcomes or side effects of the treatment
The possible outcome if the patient receives no treatment
Alternative treatments and possible risks.
Once the patient signs the consent form, he may withdraw consent at any time prior to the treatment being carried out.

16. Contents of Patient Medical Records (cont.)
Correspondence with or about the patient
Information received by fax – request an original copy
Date and initial everything you place in the chart
Learning Outcome: Identify the documents that comprise a patient medical record.
Correspondence with or About the Patient .
All written correspondence from the patient or from other providers, laboratories, or independent healthcare agencies must be kept in the patient’s medical record.
Mark or stamp each item with the date received the document.
Dating and Initialing. You must date and initial each item you place in the patient's medical record.
Refer to CONNECT to see a video about Initiating a Paper-Based Patient Medical Record.

17. Maintaining Confidentiality
The right to notice of privacy practices.
The right to limit or request restriction on their PHI and its use and disclosure.
The right to confidential communications.
Learning Outcome: Identify the documents that comprise a patient medical record.
Patients have the following specific patient rights regarding their PHI (protected health information) and their medical records:
The right to notice of privacy practices.
The practice must give patients a copy of the laws that protect them concerning their PHI.
Patients must receive a written notice of privacy practices on their first visit to a healthcare provider.
The signed form stating they have received this information must be filed in the patient’s medical record.
2. The right to limit or request restriction on their PHI and its use and disclosure.
Patients can limit how their medical information is used, and how much information is shared.
The “Need to Know” general rule permits that only the amount of patient information should be released to meet the current needs of the patient.
3. The right to confidential communications. Patients can request to receive PHI in a manner other than during a medical appointment.

18. Maintaining Confidentiality (cont.)
4. The right to inspect and obtain a copy of their PHI. 5. The right to request an amendment to their PHI. 6. The right to know if their PHI has been disclosed and why.
Learning Outcome: Identify the documents that comprise a patient medical record.
4. The right to inspect and obtain a copy of their PHI.
Follow the protocols established in your office for medical record copying.
It is acceptable to act on a request within 30 days of the request, and to charge a reasonable fee for copying supplies and labor.
5. The right to request an amendment to their PHI.
Healthcare providers have the right to require that a request to amend a record be made in writing.
The request may be denied if the healthcare provider receiving the request is not the original recorder of the PHI, or if the PHI is believed to be accurate and complete.
All requests for amendment and response must be carefully documented and filed in the medical chart.
6. The right to know if their PHI has been disclosed and why. Providers are required to keep a written record of every disclosure made of a patient’s PHI.

19. Apply Your Knowledge Correct!
What section of the patient record contains information about smoking, alcohol use, and occupation?
ANSWER: Information about smoking, alcohol use, and occupation is part of the patient’s past medical history.
Learning Outcome: Identify the documents that comprise a patient medical record.
Correct!

20. Types of Medical Records
Source-Oriented Medical Records
Information is arranged according to who supplied the data
Problems and treatments are on the same form
Difficult to track progress of specific events
Learning Outcome: Define SOMR, POMR, SOAP, and CHEDDAR and compare the differences between the two types of medical record formats used in most medical offices.
The most common methods are the source-oriented (conventional) and problem-oriented medical records.
SOMR – patient information is arranged according to who supplied the data.
These records describe all problems and treatments on the same form in simple chronological order.
Advantage: easy to initiate and maintain
Disadvantages:
Difficulty in tracking the progress of a specific ailment
If the patient has a recurrence of a problem, the first episode and the second one will be filed in separate locations; causing more searching to locate the related “past medical history.”

21. Types of Medical Records (cont.)
Problem-Oriented Medical Records
Data Base
Problem List
Each problem numbered
Sign vs. symptom
An Educational, Diagnostic, and Treatment Plan per each problem
Progress Notes
Learning Outcome: Define SOMR, POMR, SOAP, and CHEDDAR and compare the differences between the two types of medical record formats used in most medical offices.
POMR stands for the problem-oriented medical record system of filing information within a paper medical record..
Database – past medical history; information from the initial interview with the patient; all findings and results from the physical examinations; and tests, X-rays, and other procedure results.
Problem List – each condition or diagnosis is given its own number which is used throughout the record.
Signs – objective, or external, factors that can be seen or felt or measured by an instrument.
Symptoms – subjective, or internal conditions felt by the patient but are not necessarily apparent to physical examination. Together, signs and symptoms help clarify a patient’s problem and can help lead to a diagnosis.
Progress Notes
Progress notes are entered for each problem listed in the initial record.
Includes the patient’s condition, complaints, problems, treatment, and responses to care.

22. Types of Medical Records (cont.)
SOAP documentation
Orderly series of steps for dealing with any medical case
Lists the following
Patient symptoms
Diagnosis
Suggested treatment
SOAP
Learning Outcome: Define SOMR, POMR, SOAP, and CHEDDAR and compare the differences between the two types of medical record formats used in most medical offices.
SOAP format for documentation can still be used with either SOMR or POMR charts

23. SOAP Documentation S O A P ubjective data bjective data ssessment lan
Information the patient tells you O
bjective data
What the physician observes during the examination A
ssessment
Learning Outcome: Define SOMR, POMR, SOAP, and CHEDDAR and compare the differences between the two types of medical record formats used in most medical offices.
S: Subjective data come from the patient; the patient describes his or her signs and symptoms and supplies any other opinions or comments about the current problem
O: Objective data come from the physician, examinations, and test results.
A: Assessment is the diagnosis or impression of a patient’s problem. .
P: Plan of action includes treatment options, chosen treatment, medications, tests, consultations, patient education, and follow-up.
SOAP format allows each type of data to be located within each documented note easily, instead of searching the entire entry.
Use only approved medical abbreviations. Check the policies and procedures manual to see if your office has specific abbreviations that are not to be used in the patient medical records. Refer to Table 11-1 Common abbreviations used in medical records.
The impression of the patient’s problem that leads to diagnosis P
lan
The treatment plan to correct the illness or problem

24. CHEDDAR Format Expands on SOAP format C H D
Chief complaint, presenting problems, subjective statements
History – social and physical history H
Learning Outcome: Define SOMR, POMR, SOAP, and CHEDDAR and compare the differences between the two types of medical record formats used in most medical offices.
Breaks the SOAP format into smaller components:
C: Chief complaint, presenting problems, subjective statements.
H: History; past medical, family, and social histories as well as the history of presenting problem (HPI) and any other contributing information.
E: Examination, including extent of body systems examined.
Examination D

25. CHEDDAR Format Expands on SOAP format D A R Drugs and dosage
Assessment of diagnostic process and diagnosis A
Learning Outcome: Define SOMR, POMR, SOAP, and CHEDDAR and compare the differences between the two types of medical record formats used in most medical offices.
Breaks the SOAP format into smaller components:
D: Drugs and dosage—for example, a list of current medications including dosage and frequency. A: Assessment of the diagnostic process and the impression (diagnosis) made by the physician. R: Return visit information or referral, if applicable.
Return visit information or referral R

26. Apply Your Knowledge Excellent!
Label the following items as either (S) “subjective” or (O) “objective.”
____ headache ____ pulse 72
____ vomited x 3 ____ nausea
____ skin color ____ respirations 16, labored
____ chest pain ____ poor appetite S O O S O O
Learning Outcome: Define SOMR, POMR, SOAP, and CHEDDAR and compare the differences between the two types of medical record formats used in most medical offices. S S
Excellent!

27. Documenting and the Six Cs of Charting
Updating medical forms
Documenting test results
Examination Preparation and Vital Signs
Learning Outcomes: 11.4 Identify the 6 Cs of charting, giving an example of each.
Updating Medical Forms
Patient registration and medical history forms may need updating at times.
The new information may simply be written by hand as near as possible to the original location or a note is made to see the “updated” registration sheet.
Documenting Test Results
X-ray reports, lab test results, or letters from specialists must be inserted in the medical record.
Follow the office policy in placing these items in the same location in each medical record with the most current on top.
You may also be required to record the results on a separate test summary sheet in the chart.
Examination Preparation and Vital Signs
Record vital signs, any medication(s) the patient is currently taking, and any responses to treatment in the medical record.
If the patient makes any additional comments, document these as well and remember to use the patient’s own words

28. Follow-Up Transcribe notes the doctor dictates
Post results of laboratory tests and examinations
Record telephone communication with the client
Record all instructions and education
Learning Outcomes: 11.4 Identify the 6 Cs of charting, giving an example of each.
You will then maintain the patient record by performing some or all of the following duties:
Transcribe notes the doctor dictates about the patient’s progress, follow-up visits, procedures, current status, and other necessary information if a transcription service is not used.
Post laboratory or examination results in the medical record or on the summary sheet.
Record telephone calls from the patient and calls that the doctor or other office staff members make to the patient.
You must initial the entry. Even if the doctor did not reach the patient, the call should be recorded and dated.
State whether the doctor got an answer, left a message on an answering machine or with a person, and so on.
Record any medical instructions or discharge instructions given to the patient.
At the physician’s request, counsel or educate the patient regarding the treatment regimen or home care procedures the patient must follow.
All information must be entered into the record, dated, and initialed.

29. The Six Cs of Charting C Client’s words Clarity Completeness C
onciseness
Chronological order
confidentiality
Learning Outcomes: 11.4 Identify the 6 Cs of charting, giving an example of each.
To maintain accurate patient records, always keep these six Cs in mind when filling out and maintaining charts:
Client’s words – record the patient’s exact words rather than your interpretation of them.
Clarity – use precise descriptions and accepted medical terminology when describing a patient’s condition.
Completeness – completely fill out all the forms used in the patient record. Provide complete information that is readily understandable to others whenever you make any notation in the patient chart.
Conciseness – while striving for clarity, also be concise, or brief and to the point.
Chronological order – all entries in patient records must be dated to show the order in which they are made. This factor is critical, not only for documenting patient care but also in case there is a legal question about the type and date of medical services.

30. Apply Your Knowledge What are the six Cs of charting?
ANSWER: The six C’s of charting are
Client’s words Conciseness
Clarity Chronological order
Completeness Confidentiality
Learning Outcomes: 11.4 Identify the 6 Cs of charting, giving an example of each.

31. Right! Apply Your Knowledge
In addition to transcribing notes the doctor dictates and posting lab results, what are two other follow-up tasks the medical assistant might be required to perform as part of follow-up to a patient appointment?
Learning Outcomes: 11.4 Identify the 6 Cs of charting, giving an example of each.
ANSWER: The medical assistant may have to record telephone calls with the patient, as well as medical or discharge instructions given to the patient.
Right!

32. Appearance, Timeliness, and Accuracy of Records
Neatness and legibility
Medical transcription
Handwritten notes
Blue ink
Highlight specific items such as allergies
Make corrections properly
Learning Outcome: Describe the need for neatness, timeliness, accuracy, and professional tone in patient records.
Complete medical records will do no one any good if they cannot be understood.
Neatness and Legibility – a medical record is useless if it is difficult (or impossible) to read.
Medical Transcription.
Transforms the spoken notes into accurate written form
Transcribed notes are entered into the patient medical record. Always date and initial all transcription pages.
With voice recognition software, transcription is done automatically by the computer. These notes still need to be proofread carefully.
Transcribed material must still meet the six Cs of charting.
Handwritten Notes
Use a good-quality pen that will not smudge or smear.
HIPAA requires that all original documents be maintained in the patient’s medical record. Blue ink is recommended to avoid confusing an original written in black ink with a copy. Blue ink is also more difficult to match.
Use highlighting pens to call attention to specific items like allergies.
Make sure all handwriting is legible.
Make any corrections by following Procedure 11-2, Correcting Medical Records.

33. Timeliness Record all findings as soon as they are available
For late entries, record both original date and current date
Record date and time of telephone calls and information discussed
Retrieve file quickly in event of an emergency
Learning Outcome: Describe the need for neatness, timeliness, accuracy, and professional tone in patient records.
Medical records must be readily available when a doctor or other health-care professional needs them.
Record all exam and test results as soon as they are available.
If you forget to enter a result into the record when it is received, record both the original date of receipt and the date the report was entered into the record.
To document telephone calls, record the date and time of the call, who initiated it, the information discussed, and any conclusions or results.
Establish a procedure for retrieving a file quickly in case of emergency.

34. Accuracy Check information carefully Never guess or assume
Double-check accuracy findings and instructions
Make sure most recent information is recorded
Learning Outcome: Describe the need for neatness, timeliness, accuracy, and professional tone in patient records
Make an accuracy check of all data entered within the medical record a priority. To ensure accurate data, follow these guidelines.
Never guess at or assume knowledge of names, procedures, medications, findings, or any other information about which there is some question.
Always check all the information carefully.
Double-check the accuracy of findings and instructions recorded in the chart.
Make sure the latest information has been entered into the chart in the appropriate location so that the physician has an accurate picture of the patient’s current condition.

35. Professional Attitude and Tone
Record patient comments
Do not record personal or subjective comments, judgments, opinions, or speculations
Learning Outcome: Describe the need for neatness, timeliness, accuracy, and professional tone in patient records
Whenever possible, record information from the patient using his own words, particularly when recording the chief complaint .
You may call attention to problems or observations by attaching a note to the chart, but do not make such comments part of medical record.

36. Apply Your Knowledge Very Good!
What is important to remember when you are documenting in the medical records?
ANSWER: It is important that medical records be neat and legible, timely, accurate, and maintain a professional tone.
Very Good!

37. Correcting and Updating Medical Records
Medical records are created in “due course”
Information is entered at the time of occurrence
Untimely submissions may be regarded as “convenient”
Learning Outcomes: Illustrate the correct procedure for correcting and updating a medical record.
Medical records are regarded as having been created in “due course.”
All information in the medical record should be entered at the time of a patient’s visit.
Information corrected or added some time after a patient’s visit can be regarded as “convenient” and may damage the physician’s position in a lawsuit and can also jeopardize a patient’s care.

38. Using Care with Corrections
Correct mistakes immediately
Draw a line through the original information
Insert correct information
Document why correction was made
Date, time, and initial correction
Have a witness, if possible
Learning Outcome: Illustrate the correct procedure for correcting and updating a medical record.
If changes are not made correctly, the medical record can become a legal problem for the physician. Always be extremely careful to follow the appropriate procedures for correcting patient records.
The best defense is to correct the mistake immediately or as soon as possible after the original entry was made.
Refer to Procedure 11-2, Correcting Medical Records.
Refer to CONNECT to see a video about Correcting the Patient Medical Record .
eror
m/d/yyyy 00:00pm misspelled JHC
/chj
error

39. Updating Patient Records
Additions should not appear deceptive
Document why late entry is made
Date and initial added items
May have a third party witness addition
Learning Outcome: Illustrate the correct procedure for correcting and updating a medical record.
All additions to a patient’s record should be done so there can be no interpretation of deception on the physician’s part.
A note should accompany the material explaining why the information is being added to the record. Each item added to the record must be dated and initialed.
Follow guidelines of your organization for late entries to a patient’s chart.
Refer to Procedure 11-3 Entering (Adding) Information into a Paper Medical Record
Addition made to record because patient called back with additional information.
Mm/dd/yyyy – JHC
/ chj

40. Apply Your Knowledge Super Job!
What is the appropriate way to correct an error in a patient’s medical record?
ANSWER: To correct an error in a patient’s medical record:
Draw a line through the original information
It must remain legible
Insert correct information above or below original line or in margin
Document why correction was made
Date, time, and initial correction
Learning Outcome: Illustrate the correct procedure for correcting and updating a medical record.
Super Job!

41. Responding to Release of Records Request
Records are property of the practice
Contain confidential PHI which belongs to the patient
Must have patient’s written consent to release
Release of Information to HMO Insurance Company
I authorize Dr. J. Jones to release my health-care information to the above-named insurance company.
Christopher Hansen mm/dd/yyyy Patient Signature Date
Learning Outcome: Describe the steps in responding to a written request for release of medical records.
Even though the practice owns the records, no one can see the information within them or obtain information from them without the patient’s written consent.
Releasing information to insurance companies
Under no circumstances should you release patient information to insurance companies over the telephone.
Release the information in writing after the patient has signed a written release statement.
All requests to release medical records should be approved by the physician.
Under HIPAA, release of information over the telephone will likely be problematic.

42. Procedures for Releasing Records
New authorization to transfer records
Verbal consent is not valid
File in medical record
Copy original materials – only information requested
Call to confirm receipt of materials
Learning Outcome: Describe the steps in responding to a written request for release of medical records.
Follow these steps for releasing medical information.
Obtain a signed and newly dated release from the patient authorizing the transfer of specific information. Verbal consent in person or over the telephone is not considered a valid authorization. The signed and dated authorization should be filed in the patient’s medical record.
Make photocopies of the requested original material. Copy and send only those portions of the record covered by the release and usually only records originating from your facility.
Do not send originals unless
Required by a court of law
Originals cannot be copied (x-rays)
Call the recipient to confirm that all materials were received.

43. Procedures for Releasing Records (cont.)
Special cases
Not always clear who can authorize release
If unsure, ask your supervisor
Confidentiality
18 years old
Emancipated minor
Mature minor
Legal and ethical principle: Protect the patient’s right to privacy at all times.
Learning Outcome: Describe the steps in responding to a written request for release of medical records.
Special Cases
It may not always be clear who has the right to sign the authorization to release medical records form
When a divorced couple has shared custody, either one can sign a release form authorizing transfer of medical records.
If a patient dies, the patient’s next of kin or legally authorized representative, such as the executor of the estate, may see the records or authorize their release to a third party
When you are in doubt regarding who is authorized to sign, always ask your supervisor before releasing confidential, protected health information.
Confidentiality and adulthood
Most states consider 18 year olds adults with the right to privacy.
Some states extend the right to privacy to emancipated minors who are under the age of 18 and living on their own, or are married, a parent, or in the armed services.
“Mature minors” – treatment cannot be discussed with parents without permission.
Refer to CONNECT to see a video about PHI Authorization to Release Health Information.

44. Auditing Medical Records
Examination and review
Completeness
Accuracy
Types
Internal
External
Learning Outcome: Describe the steps in responding to a written request for release of medical records.
To audit a record means to examine and review a group of patient records for completeness and accuracy. Audits are done on medical records to determine their ability to back up the charges sent to health insurance carriers. Audits verify that the medical documentation meets required minimum standards.
There are two types of audits:
Internal Audits
The medical staff can perform internal audits on randomly chosen records.
Review of their ability to back up the charges sent to health insurance carriers .
If an office finds many charts are “failing” the internal audits, medical staff needs training and internal audits should be performed more frequently until the records meet the required standards.
External Audits
Performed by government entities, managed care organizations, and private insurance carriers .
External auditors may want to interview the staff members, patients, and all physicians who participated in the patient’s care.
Frequently done to see if medical record documentation backs up billing.

45. Nice Job! Apply Your Knowledge
The medical assistant receives phone call authorizing transfer of medical record information for a client to another physician’s office. What would you do in this situation?
ANSWER: Never release information based on telephone authorization. You cannot be sure who the caller is. Tell them you need a written and signed release of information.
Learning Outcome: Describe the steps in responding to a written request for release of medical records.
Nice Job!

46. In Summary
11.1 Medical records are legal documents that give a complete, concise, chronological history of a patient’s past medical history, current medical issues, treatment plan, and treatment outcome.
Additionally, they act as a communication tool between care providers.
The patient medical record provides physicians and other healthcare providers with all the important information, observations, and opinions that have been recorded about a patient.

47. In Summary
11.2 The records that comprise the patient medical record include, but are not limited to the following:
patient registration form
medical history form
physical exam form
laboratory and other test results
records from physicians or hospitals,
physician diagnosis and treatment plan
operative reports
hospital discharge summaries
follow-up notes
records of telephone calls
signed informed consents
correspondence with or about the patient

48. In Summary (cont.)
11.3 SOMR files documents in the medical record in strict chronological order. POMR files the same documents according to numbered problems found on the patient problem list. SOAP notes organize medical record documentation according to subjective, objective, assessment and plan. The CHEDDAR format breaks down this information even further into chief complaint, history, exam, details, drugs, assessment, and return visit plan.

49. In Summary (cont.)
11.4 The six Cs of charting are client’s words, clarity, completeness, conciseness, chronological order, and confidentiality.
11.5 Neatness, legibility, accuracy, and professional tone are musts in maintaining medical records.
Remember that patient medical records are legal documents.
Personal thoughts and observations should never be a permanent part of the patient medical record.
11.5 Neatness, legibility, accuracy, and professional tone are musts in maintaining medical records.
Remember that patient medical records are legal documents. They must be kept up-to-date and should be easy to read.
Make sure you project a professional tone when recording information. Always check for accuracy and never guess at information.
Personal thoughts and observations should never be a permanent part of the patient medical record.

50. In Summary (cont.)
11.6 The proper way to make corrections in a medical record is to draw a single line through the error so that the original entry is still legible.
Any additions to a medical record should also be made as soon as the need for the addition is noted, and the reason for the addition or change should also be clearly documented.
In order to release any confidential medical information, express written permission from the patient must be received. Only release records that are expressly requested and authorized by the patient.
11.6 The proper way to make corrections in a medical record is to draw a single line through the error so that the original entry is still legible. Make the correction as close as possible to the original entry, noting the reason for the correction and initial the correction.
Any additions to a medical record should also be made as soon as the need for the addition is noted, and the reason for the addition or change should also be clearly documented.
11.7 In order to release any confidential medical information, express written permission from the patient must be received. Unless it is impossible to do so, copies should be made and the originals should remain in the office.
If originals must be released, a statement of responsibility should be signed by the receiver, and should be noted in the patient’s chart.
Follow-up should take place until the original records are returned to the office and returned to the patient’s record. Only release records that are expressly requested and authorized by the patient.
Refer to CONNECT for an exercise about Updating a Patient’s Chart

51. End of Chapter 11
Organization is the power of the day; without it, nothing is accomplished.
~ Sophia Palmer
From A Daybook for Nurses: Making a Difference Each Day