The Paper Medical Record 12th Edition Chapter 14

Discussion Question Why is proper filing and management of medical records so important with regard to time management in the medical office? Answer: Medical records include the long-term communication about a patient’s medical care and must be used for documentation each time the patient is seen. When the record cannot be found, the staff must spend time finding it. If the record is not found, the patient’s history of medical care is lost.

Discussion Question In what ways can time be saved when sorting medical records? Answer: Sorting information for filing and alphabetizing new materials prior to filing will save time. Also, using divider guides, OUtguides, color folders, and labels will help in finding medical records and in returning them to their proper place.

The Importance of Accurate Medical Records Help physician provide the best possible care to patient Important for continuity of care with other healthcare professionals Offer legal protection to those who provide care to the patient Provide statistical information that is helpful to researchers Vital for financial reimbursement The physician enters notes about the patient's examination and any test results into the medical record. These notes serve as pieces of a jigsaw puzzle to help the physician make an accurate diagnosis and treatment plan. The medical record provides a complete history of all the care given to the patient. An accurate record is the foundation for a legal defense in cases of medical professional liability. The information in the medical record supports claims for reimbursement and is required by most third-party payers.

Ownership of the Medical Record Physician or medical facility (the “maker”) Patient has right of access to information, but does not own physical record Patient has right to demand confidentiality The actual medical record should never leave the medical facility where it originated. Patients' records should be kept in a locked room or locked filing cabinets when the office is closed. Procedure 14-1 on p. 239 describes how to document patient care accurately.

Types of Records Paper Electronic Inefficient Possibility of misfiled information No easy access to data; information difficult to share Electronic More efficient than paper The two major types of patient records are the paper medical record and the electronic medical record. As computer technology advances, the paper medical record seems more and more inefficient.

Source-Oriented Records Observations and data cataloged according to their source Forms and progress notes filed in reverse chronologic order Separate sections of record The traditional patient record is source oriented; that is, observations and data are entered by the physician, laboratory, radiology department, nurse, technician, and others, with no recording of a logical relationship among them. Some files may be included in chronologic order; however, most patient files are in reverse chronologic order so that the physician and staff members do not have to search to the bottom of the chart to find a recent lab report on a test.

Problem-Oriented Medical Record Divides records into four bases: Database Problem list Treatment plan Progress notes The problem-oriented medical record (POMR) is a departure from the traditional system of keeping patient records, and divides medical action into four bases: The database, which includes the chief complaint, present illness, patient profile, review of systems , physical examination, and laboratory reports. The problem list, which is a numbered, titled list of every problem the patient has that requires management or workup. This may include social and demographic troubles in addition to strictly medical or surgical ones. The treatment plan includes management, additional workups needed, and therapy. Each plan is titled and numbered with respect to the problem. The progress notes include structured notes that are numbered to correspond with each problem number. The POMR has the advantage of imposing order and organization on the information added to a patient's medical record.

SOAP Notes Subjective impressions Objective clinical evidence Assessment or diagnosis Plans for further studies, treatment, or management Progress notes follow the SOAP approach. Some medical offices also use an E in the record to represent evaluation; others include E for education and R for response. The SOAP method forces a rational approach to the patient's problems and assists the formulation of a logical, orderly plan of patient care. The SOAP method often is used in the POMR.

CHEDDAR Method Chief complaint History Examination Details (of problem and complaints) Drugs and dosages Assessment Return visit information, if applicable Some facilities use the CHEDDAR method in medical records. The physician decides which recording method he or she prefers, and the medical assistant must conform to that standard.

Contents of the Complete Case History Most important record in a physician’s practice Contains subjective and objective information For completeness, each patient's record should contain subjective information provided by the patient and objective information provided by the physician. Procedure 14-2 on p. 243 describes how to organize a new patient's medical record.

Subjective Information Personal demographics Personal and medical history Family history Social history Chief complaint E.g. Nausea, pain, dizzy The patient's case history begins with routine personal data, usually supplied on the first visit with a patient information form. The personal and medical history provides information about any past illnesses or surgery and about injuries or physical defects. It also includes information about the patient's daily health habits. The family history comprises the physical condition of the various members of the patient's family, any illnesses or diseases individual members may have had, and a record of the causes of death. Why is this information important? (This information is important because certain diseases may have a hereditary pattern.) The social history includes information about the patient's lifestyle. The patient's chief complaint is a concise account of the patient's symptoms, explained in the patient's own words.

Objective Information Physical examination findings and laboratory and radiology reports E.g. vomiting, edema, temperature Diagnosis Treatment prescribed and progress notes Patient consent form required for surgery or other treatment Condition at time of termination of treatment Objective findings, sometimes referred to as signs, become evident from the physician's examination of the patient. These findings can be observed and measured. After the physician has examined the patient, the physical findings are recorded in the history, and any test results are recorded or attached to the history. What is a differential diagnosis? (A differential diagnosis is the process of weighing the probability of one disease causing the patient’s illness against the probability that other diseases are causative.) The physician's suggested treatment is listed after the diagnosis. Procedure 14-3 on p. 246 describes how to prepare an informed consent for treatment form.

Medical Assistant’s Role Obtaining the history Responsible for privacy and confidentiality Ask patient to complete questionnaire If paper, may be mailed ahead of time or completed in office If electronic, may be completed ahead of time The medical assistant usually collects the routine personal data. The personal and medical history and the patient's family history may be obtained by asking the patient to complete a questionnaire, with the physician augmenting the information provided during the patient interview.

Making Additions to the Patient’s Record Laboratory reports Different colored paper used for reporting different procedures Place small lab slips on 8½ ×11-inch colored paper Radiology reports Progress notes As long as a patient is under the physician's care, the medical history is building, with the latest information always on top. What is shingling? (It is a method of filing in which a report is laid on top of the older report, resembling the shingles of a roof.) Radiology reports usually are typed on standard letter-size stationery from the facility where the imaging was done. They are placed in the patient's history folder, with the most recent report on top. Reports on the patient's progress are continually added to the medical record. Each of the patient's visits should be entered into the chart, with the date preceding any notations about the visit. Initialing each entry is a wise course of action. Procedure 14-4 on p. 247 describes how to add supplementary items to patients' records.

Making Corrections and Alterations to Medical Records Correcting a handwritten entry: Draw a line through the error Insert the correction above or immediately after the error, in a spot where it can be read clearly If indicated by the policy and procedures manual, write “Correction” or “Corr.” in the margin The person making the correction should write his or her initials or signature below the correction and the date The first step is to verify the proper procedure for making corrections according to the facility's policy and procedures manual. Erasing, using correction fluid, or making any other type of obliteration is never acceptable. Errors made while using the computer are corrected in the usual way. However, an error discovered in an entry at a later date is corrected in the same manner as for a handwritten entry. This is sometimes called an addendum. Procedure 14-5 on p. 251 describes how to prepare a record release form.

Keeping Records Current Medical assistant responsible for methodically keeping record current After last patient, check each history Give physician any abnormal reports Always adhere to written policy Records should never leave office and should not be left out in view at night Transcribe any dictated notes After all records have been reviewed for the day, and if time is too short to file them, they should be placed in a file tray and locked away for the night. After the transcription is complete, the physician may want to check the notes, underline important points, and initial each entry to verify that each is correct, in the event of an audit or litigation. The notes then are returned to the medical assistant for insertion into the charts.

Regular Transfer of Files Records filed according to classification: Active files Inactive files Closed files Establish system for regular transfer of files from active to inactive or possible destruction Purging: process of moving a file from active to inactive status Active files are the files of patients currently receiving treatment. Inactive files are generally the files of patients whom the doctor has not seen for 6 months or longer. Closed files are the records of patients who have died, moved away, or otherwise terminated their relationship with the physician. Most medical facilities use a year sticker on the file folder that indicates the last year the patient visited the clinic.

Retention and Destruction Medical considerations are primary basis for deciding length of retention Always check state laws before destruction At a minimum, keep for at least period of statute of limitations for malpractice claims 3 years or longer Medicare and Medicaid patient records must be kept 10 years Contact patient before destruction, and be sure to preserve confidentiality Physicians have an obligation to retain patient records that may reasonably be of value to a patient, according to the American Medical Association (AMA) Council on Ethical and Judicial Affairs. Currently, no standard, nationwide rule exists for establishing a records retention schedule. Before old records are discarded, patients should be given an opportunity to claim a copy of the records or have them sent to another physician. To preserve confidentiality when discarding old records, destroy the documents by shredding or through a professional document destruction service.

Protection of Records Do not release original case histories to anyone outside the healthcare facility Prepare summary or photocopy materials needed Retain the original in the physician’s office Fax only required pages Use OUTfolder for rare occurrence when records are temp out of office If possible, call before faxing confidential patient information, and ask the recipient to retrieve it from the fax. In instances when a record must leave the facility, a colored OUTfolder should be inserted into the file in place of the regular folder and a notation made of the name, date, and to whom the record was released. Interim papers may be placed in the OUTfolder until the original is returned.

Long-Term Storage Options Microfilm may be used if EMR not currently in use For electronic storage, back up regularly Transfer of paper records onto optical disks Microfilm and optical disk technology are both expensive and probably are not practical for any but a very large group practice or health maintenance organization, so the facility should be moving toward some form of electronic storage.

Releasing Medical Record Information Patient must sign release form Requests for information should be made in writing Durable power of attorney often used in medical field Special considerations regarding release of minor records There are three situations in which the parent may not be legally entitled to review the records of his or her minor child: When the minor is the one who consents to care and the parent is not required to also consent to care under state law When the minor obtains medical care at the direction of a court or a person authorized by the court When the minor, parent, and physician all agree that the doctor and minor patient can have a private, confidential relationship Remember that the patient ultimately decides whether a record can be released. If any question arises about what is to be released, consult the office manager or the physician.

Dictation and Transcription Transcription can be done from: Handwritten notes, such as shorthand Machine dictation, using machine transcription unit or portable transcription unit System accessed by telephone Voice recognition software may also be used Transcribing dictation is a job that administrative medical assistants perform periodically.

Filing Equipment Drawer files Shelf files Rotary circular files Lateral files Automated files Card files Special items The most popular system today is color-coding on open shelves. What are some factors that should be considered when selecting filing equipment? (Office space availability; structural considerations; cost of space and equipment; size, type, and volume of records; confidentiality requirements; retrieval speed; and fire protection)

(Courtesy Bibbero Systems, Petaluma, Calif.) Filing Supplies Divider guides OUTguides File folders Labels Each file drawer or shelf should be equipped with plenty of dividers or guides. OUTguides are heavy guides used to replace a folder that has been removed temporarily. An example is shown here. The label is a necessary filing and finding device. Use labels to identify each shelf, drawer, divider guide, and folder. (Courtesy Bibbero Systems, Petaluma, Calif.)

Filing Procedures Conditioning Releasing Indexing and coding Sorting Storing and filing Locating misplaced files Conditioning of papers involves removing all pins, brads, and paper clips; stapling related papers together; attaching clippings or items smaller than page size to a regular sheet of paper with rubber cement or tape; and mending damaged records. The term releasing simply means that some mark is placed on the paper indicating that it is now ready for filing. Indexing means deciding where to file the letter or paper, and coding means placing some indication of this decision on the paper. Sorting means arranging the papers in filing sequence. Unless files are promptly replaced after use, they may become lost.

Indexing Rules Last names considered first in filing, first name considered second, and middle name or initial considered third Initials precede a name beginning with the same letter Hyphenated elements considered one unit Apostrophe disregarded in filing Indistinguishable foreign names Prefixes considered part of name Compare the names beginning with the first letter of the name. When a letter is different in the two names, that letter determines the order of filing. With hyphenated personal names, the hyphenated elements, whether first name, middle name, or surname, are considered to be one unit. When indexing a foreign name in which you cannot distinguish between the first and last names, index each part of the name in the order in which it is written. If you can make the distinction, use the last name as the first indexing unit.

Indexing Rules, cont’d Abbreviated parts are indexed as written Mac and Mc are filed in their regular place in the alphabet The name of a married woman is indexed by her legal name Titles may be used as the last filing unit if needed Degrees used only to distinguish from identical name Articles (e.g., the, a) disregarded in indexing If the files have a great many names beginning with Mac or Mc, some offices file them as a separate letter of the alphabet for convenience. When followed by a complete name, titles may be used as the last filing unit if needed to distinguish the name from another, identical name. Titles without complete names are considered the first indexing unit.

Filing Methods: Alphabetic Simplest, most commonly used Direct filing system Requires only a file cabinet or shelf, folders, and divider guides Some drawbacks Alphabetic filing is a direct filing system in that the person filing needs to know only the name to find the desired file. What are some drawbacks to this system? (The correct spelling of the name must be known. As the number of files increases, more space is needed for each section of the alphabet . This results in periodic shifting of folders to allow for expansion. As the files expand, more time is required for filing or retrieving each folder because of the greater number of folders involved in the search. The time can be greatly reduced by color-coding.) Procedure 14-6 on p. 258 describes how to file medical records using an alphabetic system.

Numeric Filing Indirect filing system: requires use of alpha cross-reference Advantages: Allows unlimited expansion Provides additional confidentiality Saves time in retrieving and filing Several types exist Requires more training, but fewer errors occur Some form of numeric filing combined with color and shelf filing is used by practically every large clinic or hospital. Several types of numeric filing systems can be used, including the straight, or consecutive, numeric system (patients are given consecutive numbers as they visit the practice); the terminal digit system; or use of the last four digits of a patient's Social Security number. Procedure 14-7 describes how to file medical records using a numeric system.

Other Filing Systems Subject filing Color-coding: specific color is selected to identify each letter of alphabet Alphabetic color-coding Numeric color-coding Additional color-coding applications Subject filing can be either alphabetic or alphanumeric and is used for general correspondence. The main difficulty with subject filing is indexing, or classifying; that is, deciding where to file a document. Many papers require cross-referencing. When a color-coding system is used, both filing and finding files is easier, and misfiling of folders is kept to a minimum. The use of color visually restricts the area of search for a specific record. Files can be color-coded in several ways. Color-coding is also used in numeric filing.

Organization of Files Health-related correspondence General correspondence Practice management files Active accounts Paid accounts Miscellaneous Tickler or follow-up files (chronologic arrangement) Transitory or temporary file Correspondence pertaining to patients' medical records should be filed with the case history. Other medical correspondence should be filed in a subject file. Correspondence of a general nature pertaining to the operation of the office is part of the business side of the practice. The most active financial record is the patient ledger. In facilities that still use a manual system, this is a card or vertical tray file, and the accounts are arranged alphabetically by name. Papers that do not warrant an individual folder are placed in a miscellaneous folder. The most frequently used follow-up method is a tickler file, so called because it tickles the memory that something needs to be done or followed up on a particular date. The transitory file is used for materials with no permanent value. The paper may be marked with a "T" and destroyed when the action is completed. Procedure 14-8 on p. 260 describes how to maintain organization by filing.

Closing Comments Advances in medical records occur rapidly Be willing to learn Adapt to changes Keep a positive attitude The medical assistant should always explain any paperwork that the patient may be required to complete or sign. Take the time to explain any form that needs completion or a signature so that the patient understands the reason for collecting the information and the medical staff's need to have it available. The authority to release information from the medical record lies solely with the patient unless such a release is required by law through a subpoena. Ownership of the record often is a subject of controversy. The record belongs to the physician; the information belongs to the patient.

Discussion Question You are a new medical assistant in a large medical practice in which each physician keeps his or her own medical records. In what ways can you reduce confusion and be sure physicians receive the proper medical records? Discussion Guidelines: Using color-coded files and labels will help ensure the file is returned to the correct physician if it has been used by another staff member. Color-coding all materials with highlighters and dots will also help in properly filing the materials.

Questions?