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Medical Records Management

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Presentation on theme: "Medical Records Management"— Presentation transcript:

1 Medical Records Management
Chapter 14 Medical Records Management

2 Medical Records Management and the TPMS

3 Ownership of Medical Records
The property of the one creating the record Information belongs to the patient and is protected with privacy and confidentiality Patients are allowed access to their medical records and can ask that certain material be added or excluded from their file

4 Ownership of Medical Records
Providers who involve their patients in their medical record keeping foster trust and respect with their patients

5 The Purpose of Medical Records
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6 The Purpose of Medical Records
Provide a base for managing patient care Provide interoffice and intraoffice communication as necessary Determine any patterns that surface to signal the provider of patient needs

7 The Purpose of Medical Records
Serve as a basis for legal information necessary to protect providers, staff, and patients Provide clinical data for research (See Figure 14-1)

8 Authorization to Release Information
Even release of information required of a subpoena requires notification of the patient Patients must sign a release form if information is to be given to others May be yearly, when accepting insurance coverage, on case-by-case basis Should be very specific in what information is and what information is not to be released

9 The Importance of Accurate Medical Records
Accuracy is essential to patient care Critical to the facility’s smooth functioning Necessary when referring patient to specialists May be needed in litigation

10 Correcting Medical Records
On paper or in a manual medical record Draw single line using red pen through the error Make the correction Write Corr. or Correction above the area corrected Indicate your initials and current date Never obliterate Forensic experts are able to determine when and how corrections were made (Procedures 14-4 and 14-5 in text)

11 Correcting Medical Records
Errors in EMRs Draw a line through the error (using the “tracking” device in the word processing software) The correction is made immediately after the information lined out “Corr.” or “Correction” is indicated with your initials and date correction made EMR software locks out any chart additions after a specified time

12 Correcting Medical Records
If information or a chart has been sent elsewhere, make a copy of the corrected information and send it ASAP

13 Manual or EMRs Americans are to have EHRs by 2014 and e-prescribing of Medicare medications may be mandatory by 2011 Manual Advantages Established and understood Easier to protect confidentiality No worry of computer malfunction

14 Manual or EMRs Manual Disadvantages
Can be used by only one person at a time Easily misplaced or misfiled Great amount of equipment and storage space required More susceptible to error

15 Manual or EMRs Electronic Advantages Multiple users possible
Not easily misplaced or misfiled Data and patterns in data more easily accessed Quickly available in emergencies Office storage space not a problem Legible and organized patient documentation Improved medical management Improved quality of care

16 Manual or EMRs Electronic Disadvantages
Need protection to prevent loss of data and security Expensive to establish and maintain May require on-site assistance Can require up to 12 weeks for staff to prove productive

17 Manual or EMRs Chosen records system must fit the facility and needs of providers Must provide easy retrieval Must be easily understood and grammatically correct

18 Types of Medical Records
Problem-Oriented Medical Records (POMRs) Identifies problems numerically as listed by patients Readily identifies frequency of recurring problems Nearly always use SOAP/SOAPER for progress notes

19 Types of Medical Records
Source-Oriented Medical Records (SOMRs) Groups information chronologically and by source Makes it difficult to quickly assess a patient’s clinical picture

20 Equipment and Supplies
Vertical files Open-shelf lateral files Movable file units File folders Identification labels

21 Equipment and Supplies
Guides and positions Used to separate file folders Single captions and double captions Out-guides

22 Basic Rules for Filing Alphabetizing is key to organizing files and charts Rules facilitate alphabetic process in maintaining files Indexing units

23 Basic Rules for Filing Filing patient charts Filing identical names

24 Steps for Filing Medical Documentation in Patient Files
Inspect Index Code Sort File

25 Filing Techniques and Common Filing Systems
Alphabetic is intrinsic to all methods Color coding used a high percentage of time Numeric is used in very large ambulatory care and hospital systems Subject filing often used for business records

26 Filing Techniques and Common Filing Systems
Color-coding There are many systems Usually have alphabetic base Customized color-coding systems Tab-Alpha Alpha-Z Customized Color-Coded Systems

27 Filing Techniques and Common Filing Systems
Alphabetic filing Numeric filing Straight numeric Terminal digit Middle digit (Procedure 14-1) (Procedure 14-2)

28 Filing Techniques and Common Filing Systems
Numeric filing Components of numeric filing Serially numbered dividers with guides Miscellaneous (general) numeric file section Alphabetic card file Accession record

29 Filing Techniques and Common Filing Systems
Subject filing Choosing a filing system Consider type, purpose, and use of information Take into account number of files or records Recognize need for confidentiality (Procedure 14-3) (HIPAA note in the text)

30 Filing Procedures Cross-referencing
Helps store files for quick and accurate retrieval Especially helpful with foreign names, hyphenated names, and stepfamilies Should be simple Steps for cross-referencing Rules for cross-referencing (See text for list)

31 Filing Procedures Tickler files in manual system or calendar reminders in EMRs A reminder that action needs to be taken Should contain Patient’s name Tickler date when action should be taken Required action Additional relevant information

32 Filing Procedures Release marks Check-out system Provider’s initials
Quality control measure Check-out system Out-sheets or out-guides List of information that should be included on out-sheet

33 Filing Procedures Locating missing files or data
Conduct a systematic search Steps to searching

34 Filing Procedures Filing chart data Types of reports Clinical notes
Correspondence Laboratory reports Miscellaneous (Procedure 14-6)

35 Filing Procedures Retention and purging Record purging Active files
Inactive files Closed files

36 Correspondence Filing procedures for correspondence
Remove paper clips and staple items together Inspect to see if item is ready to be filed On incoming correspondence, be sure letterhead is related to letter

37 Correspondence Filing procedures for correspondence
On outgoing correspondence, look at inside address and reference line On incoming or outgoing correspondence, code indexing units of designated label Create a miscellaneous folder for items that do not have enough in number to warrant individual folder

38 Electronic Medical Records
Mandated and increasing in popularity EMRs create, store, edit, and retrieve patient charts on a computer (Procedure 14-7)

39 Electronic Medical Records
Costs are high, but money is saved in transcription and labor costs, copying expenses, and malpractice insurance costs Purchased as a single computer application or part of a larger practice management system Some clinics purchase a total practice management system in steps EMRs can perform numerous tasks (see the text for List)

40 Electronic Medical Records
EMRs require that the providers and all staff members use the computer for viewing charts, writing prescriptions, creating progress notes, recording laboratory results May very soon respond to voice recognition rather than keyed entries Confidentiality and privacy must be assured when using EMRs

41 Electronic Medical Records
Essential system backup assures availability of charts Confidentiality Medical assistants must always maintain confidentiality Never appropriate to discuss any information outside the clinic unless authorized to do so No discussion of patient information within the facility when not your concern See HIPAA box in text detailing HIPAA compliance

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