MEDICAL RECORDS MANAGEMENT.  Dr. owns the medical record  TRADITIONAL MEDICAL RECORD- Addresses all problems all at once.  PROBLEM ORIENTED RECORD-

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Presentation transcript:

MEDICAL RECORDS MANAGEMENT

 Dr. owns the medical record  TRADITIONAL MEDICAL RECORD- Addresses all problems all at once.  PROBLEM ORIENTED RECORD- Categorizes each problem separately and gives detailed pan for each problem/diagnosis.  Any? So far

Color-coded labels Out-guides Can anyone tell me what an out-guide is?

 The patient's medical record is a legal document that must accurately reflect the care provided to the patient.  This is why we stress accurate notation of any interactions with a patient--taking telephone messages from patients, setting appointments for patients, checking patients in, and so on.

 SOAP stands for the following: Subjective impressions – pt gives info  Objective clinical evidence – what you observe  Assessment or diagnosis – DR.  Plan for further studies, treatment, or management- DR.

 CONDITIONING- Remove all pins, paper clips, tape etc.  RELEASING- A mark is placed somewhere on the chart to indicate the chart is ready to file.  INDEXING- Deciding where to place a paper in the file.  CODING- When there is more than once place to file a piece of paper, the original is coded for the main location and then cross-reference a sheet to show where the 2 nd paper is filed.  SORTING- Arranging papers in filing sequence.

 Any corrections made in a medical record must be visible, so any information that has been incorrectly documented cannot be erased or obliterated, and correction fluid may never be used to fix a mistake.  Who can tell me the proper way of correcting an error in a chart?

 Active means the Pt. has been seen in the past 3 years.  Inactive not seen after 3 years and files get put onto film.  Files usually kept for 10 years.  Charts are to never go home with the Dr. or leave the office.  Legally, charts can leave-If the original documents are subpoenaed, the record should be copied and the copy should be maintained in the medical office until the original is returned

 HIPAA" is an acronym for the Health Insurance Portability & Accountability Act of 1996  Improved efficiency in healthcare delivery by standardizing electronic data interchange, and  Protection of confidentiality and security of health data through setting and enforcing standards  er.htm

 Who is affected?  Virtually all healthcare organizations – including all healthcare providers, health plans, public health authorities, healthcare clearinghouses, and self-ensured employers – as well as life insurers, information systems vendors, various service organizations, and universities.

 HIPAA calls for severe civil and criminal penalties for non-compliance, including:  – fines up to $25K for multiple violations of the same standard in a calendar year  – fines up to $250K and/or imprisonment up to 10 years for knowing misuse of individually identifiable health information

 Personal opinions on HIPAA?  What steps must be taken to insure the confidentiality requirements required by HIPAA has been followed prior to releasing information in the medical record?