MEDICAL RECORDS MANAGEMENT

Why Medical Records Are Important  Medical Records exist for four reasons  Physician exams the patient and enters findings into the medical record  Legal protection, excellent proof certain procedures were performed.  Provide statistical information for research  Vital for financial reimbursement

Medical Terminology is Important!  Spelling and pronouncing medical terms correctly adds credibility to the medical assistant.  Knowing the definition provides confidence in communication with patients and coworkers.

 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

 Alphabetic  Alphanumeric  Numeric NUMERIC alphabetic

 It is a record in digital format that is capable of being shared within across different health care settings, by being embedded in network- connected enterprise- wide information system.

 Such records may included a whole range of data in comprehensive or summary form, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, billing information. demographicsimmunization

 Dr’s have hand held devises or lap tops. Chart right there it goes into the system. They can pull up your chart on hand held or at front desk computer!

HIPAA – Health Insurance Portability and Accountability Act  HIPAA describes the framework for the use and disclosure of health information for treatment, payment, or health care operations at all "covered entities." The covered entities include hospitals, clinics, physician offices, pharmacies, long-term care, home care, or research facilities. Outside laboratories or companies contracted for specific purposes (e.g., to measure serum concentration of drugs, prepare IV admixtures, or compound drug formulations) are also covered by the regulation, since they would normally require patient data to satisfactorily complete their tasks. However, when such outside entity (referred as "business associate" in HIPAA) is utilized, the primary covered entity must have a contract to protect the health information of patients. The outside entity must follow the policies and procedures of the covered entity and return or destroy any protected information at the end of the relationship. An inappropriate use of patient information by the outside entity, for instance, to directly market their services, is prohibited.  American Journal of Pharmaceutical Education, Summer 2002 by Nahata, Milap American Journal of Pharmaceutical EducationSummer 2002Nahata, Milap

 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

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