Chapter 9 Medical Records

Objectives Review the learning and performance objectives for this chapter By the end of this chapter, demonstrate the procedures in the textbook and the job skills in the workbook

Heart of the Health Care Professional Service Consider the medical record as a diary put in your care and have a high regard for it.

Patients’ Medical Records Aid in diagnosis and treatment Provide documentation of care Verify medical necessity Assist in research Substantiate billing codes Comply with laws Defend the physician

Patients’ Medical Records Prepare and compile a medical record for a new patient File folder Labels Forms Procedure 9-1(See page 265)

Medical Record Systems Paper-based record system Costly to manage, move, and store Paper records are vulnerable Convert paper to electronic records Digitize using a scanner

Medical Record Systems Electronic medical record system Faster More secure Centralized access Less chance for error “Mouse Calls”

Medical Record Systems Medical record organizational systems Problem-oriented medical record system Flow sheets Track specific data Cross referencing

Medical Record Systems

Medical Record Systems Medical record organizational systems Source-oriented record system Most common Organized by sections Integrated record system All records in chronologic order Disregards problem or source

Record Keeping Record keeping Physician hand enters data Physician dictates Physician keys data Medical assistant enters data

Record Keeping Record keepers Oversee system and clerks Documentation requirements Coding Internal audits Authorization requests Obtain outside records

Record Keeping Documenters Attending physician Consulting physician Ordering physician Referring physician Treating physician

Record Keeping Authentication of documents Each document must be signed Indicates document complete/correct Manual signatures Handwritten Electronic signatures Facsimile of actual signature Digital code or encryption

Record Keeping Documentation format SOAP format Subjective Objective Assessment Plan

Record Keeping

Record Keeping Documentation format CHEDDAR format Chief complaint History of present illness Examination Details Drugs and dosages Assessment Return or referral

Record Keeping Documentation guidelines Patient name and current date Complete encounter information Legible Accurate Chronologic order

Record Keeping Documentation guidelines Enter in a timely fashion Objective Specific Reason for encounter Assessment and diagnosis Plan of care Date and identity of observer

Record Keeping Documentation guidelines Standard, approved abbreviations Allergies and adverse reactions Immunizations and injections Patient’s problem list Significant illnesses Medical conditions

Record Keeping Documentation guidelines Rationale for ordering tests Reason for treatment deviation Past and present diagnoses accessible Identify risk factors Past medical history

Record Keeping Documentation guidelines Smoking habits Alcohol and/or substance abuse Patient’s current medical condition Telephone conversations Progress and response

Record Keeping Documentation guidelines Support codes with documentation Lab, X-ray, and EKG results Legible Document/photocopy prescriptions Names of all staff assisting

Record Keeping Documentation guidelines Any drug samples given Patient education and instructions Each entry must be signed Standard technique for corrections See Figure 9-6

Record Keeping Documentation guidelines Medicare documentation guidelines No formal requirement Claims processors may use in audit May affect reimbursement

Record Keeping Documentation terminology Accurate words and phrases Normal Negative Noncontributory Within normal limits Acute versus chronic

Record Keeping Documentation terminology Acronyms and abbreviations Use standard abbreviations Do not invent new abbreviations Illustrations Keep in chart Legible Dated and signed

Record Keeping Documentation terminology Digital images Measurements Photographs Graphics Measurements Use metrics Lesions: Site, size, number Burns: Type, depth, site, percentage

Correcting a Medical Record Correct a medical record Never erase Never use correction fluid Addendum Maintain original entry Figure 9-5 Procedure 9-2

Elements of a Medical Record These video clips preview the administrative and clinical parts of a medical record. Parts of the medical record: Admin. data Parts of the medical record: Clinical data

Elements of a Medical Record Patient information form Registration Demographics Insurance

Elements of a Medical Record Patient medical history Chief Complaint (CC) Subjective: patient’s own words Describes the symptom or problem History of Present Illness (HPI) Detailed account of history of illness or injury

Elements of a Medical Record Patient medical history Past, Family, and Social History (PFSH) Past history Family history Social history

Elements of a Medical Record Patient medical history Review of Systems (ROS) Inventory of body systems Identify signs or symptoms Subjective: reported by patient

Elements of a Medical Record Physical examination Objective Physician findings by examination or tests Four Procedures Inspection: Observation Palpation: Touching Percussion: Striking Auscultation: Listening

Elements of a Medical Record Physical examination Levels of examination Problem focused (PF) Expanded problem focused (EPF) Detailed (D) Comprehensive (C)

Elements of a Medical Record Physical examination Body areas and organ systems See Table 9-1 See Examples 9-6 through 9-18 See Figures 9-6A and 9-6B

Elements of a Medical Record Complexity of medical decision making Four types Straightforward (SF) Low complexity (LC) Moderate complexity (MC) High complexity (HC)

Elements of a Medical Record Complexity of medical decision making Management options Number of diagnoses or management options Amount and complexity of data Diagnostic testing Old medical records History from other sources

Elements of a Medical Record Complexity of medical decision making Risk Complications Morbidities Comorbidities Mortality

Elements of a Medical Record Complexity of medical decision making Diagnosis Impression, assessment Treatment Recommended plan of care Prognosis Probable outcome

Elements of a Medical Record Progress or chart notes Each subsequent visit Figure 9-7 Self-adhesive chart notes Placed in order in paper record Electronic progress or chart notes Entered electronically

Elements of a Medical Record Medical reports Documentation of each examination Chronological Laboratory reports Laboratory log Figures 9-8, 9-9, and 9-10

Elements of a Medical Record Radiographs (X-Ray Films) Interpretation reports Films filed elsewhere Electrocardiograms Paper strips filed elsewhere

Abstracting from Medical Records Abstract data from a medical record Extraction of data Complete forms Compose summary Procedure 9-3

Audit of Medical Records Internal review Verify own record keeping procedures Review own documents Table 9-2

Audit of Medical Records External audit Done by: Government programs Managed care organizations Private insurance carriers Because of: Unusual billing patterns

Stop and Think Physician roles and titles Review the scenario What roles do the following physicians play and what are their current titles? Dr. Practon Dr. Skeleton Dr. Curtin

Stop and Think Chart documentation Review the scenario Write a narrative chart note describing the interaction that will serve both as a message and as documentation for the medical record