Chapter 13: Managing Medical Records Lesson 1: Managing Medical Records

Lesson Objectives Lesson Objectives Upon completion of this lesson, students should be able to … Define, spell and use key terms. Discuss problem-oriented medical record (POMR) Discuss source-oriented medical Record (SOMR) Describe four components of SOAP charting method. Document cc, HPI, PMH 2

Medical Abbreviations cc HPI (not PHI!) PMH Px or PE Dx Rx Tx fx f/u WNL ROS Neuro HEENT Cor Lungs GI GU Skin Extremities

What questions would you ask? cc What is the reason for your visit? HPI Onset When did it start? Description: sudden, gradual Course Circumstance, description surrounding onset, how did it happen, is it getting better or worse? Duration How long does it last Frequency How often? Location Where is it? Quality What is it like, color, teture, odor, sharp vs. throbbing, crushing, pressure, burning etc. Intensity (if pain)/ Severity Pain level (1-10) Radiating (if pain) Aggravating factors Alleviating factors Meds Allergies

ROS Review of Systems Done by MD to make sure nothing missed! Head to toe, ask questions about major illnesses, symptoms Neuro HEENT Neck Chest Lungs Cor GI GU Skin Extremities

PMH Surgeries and hospitalizations Illnesses: chronic or acute What and when (include year) Illnesses: chronic or acute FH Family History Mother, father, grandparents, siblings SH Social History Marital status, children, living arrangements, alcohol, smoking, caffeine, sexual activity, illicit drugs, habits, sleep, exercise Occupational! Nutritional Type of diet or restrictions Preventive care Developmental since birth Full term, no complications…. Immunizations Lifestyle MUST INCLUDE SMOKING Hx

Ownership of Medical Records If pt. requests to view own medical record, access must be allowed unless physician determines it may be detrimental Prior to allowing pt to view their record, MA must first check with physician or office manager for approval Never leave pt or any one else alone with their record

Ownership of X-rays X-rays property of medical facility that performed X-rays Physicians able to loan films to referring physicians for further examination but pt must sign release Films must always be returned to original facility Sometimes can obtain duplicate copy of film for fee

Responsibilities of MA re: MR 7 c’s Cc in clients own words, concise, complete, clear, chronological, confidential, correct Be sure information accurate Ensure that pt records kept up to date, Chart in real time 9

Categories and Reports Found in Medical Record Demographics Insurance information Pt’s past medical records History and physical Office notes Progress notes Telephone messages Pathology results Nursing notes Medication records Copies of Prescriptions Medications Physician orders Radiology reports Laboratory reports Operative reports Consultation reports Pyschiatric notes ECGs, Spirometry Miscellaneous Everything EXCEPT _____

Formats for Recording Medical Information Chronological record Problem-oriented medical record (POMR) Source-oriented medical record (SOMR)

Chronological Record One of most common types of medical records Follows pt. over period of time Most recent on top (reverse chronological) Each visit consists of new entry by date This record sometimes make it more difficult to “catch” diagnoses

Problem-Oriented Medical Record Developed by Dr. Lawrence Weed in 1970 Used to identify pt problems and chart by those problems Functional aspect of this type of charting pt problem list found at front of chart As new problems and diagnoses identified, noted on problem list, helping health care provider to identify trends

Figure 13-2 An example of a medical history sheet to list patient problems.

Sections of Problem Oriented Medical Record Database Problem list Treatment plan Progress notes 15

SOAP Charting Method distinct because of four parts of approach “S” Identifies subjective information gathered from pt – things that pt believes they seeing a physician for, usually chief complaint “O” Stands for objective, data gathered during visit – such as vital signs, weight change, fevers, blood work, and other measurable data

SOAP Charting “A” For assessment, physician’s preliminary (clinical) diagnosis “P” Plan of care for this pt POMR and SOAP methods can be combined in one chart, making for very concise, clear set of information on any pt

SOAP What is wrong with this note?

SOAP Note DOB Time O: BP inaccurate A: obesity Signature

SOMR Source Oriented Medical Record Divided into sections Orders, labs, progress notes, etc. Each section chronological Very common in hospitals and institutions

Critical Thinking Question What types of information should not be included in pt chart, and why?

Information that SHOULD NOT be Included in a Pt’s Chart Your opinions Internal office problems Subjective comments Billing and balance information (separate file)

Utilization Review Review of charts to see if services being used according to best practice and law Used for Quality assurance (QA) Determine Insurance reimbursement

How to Correct Error in Medical Record Do not erase or totally obliterate original error with commercial products such as correcting fluid Draw single line through error so original entry can still be seen Initial above single line Date and write “error” Once this complete, write in correction 25

Correction to Chart Pt Name DOB

An example of a late entry to the medical record.

Correcting Errors Made When Documenting in EMR When documenting in EMR, prior to saving entry, errors may be corrected by deleting as you would with any other type of computer program However, if error discovered after entry saved, additional entry called addendum will be required Addendum - addition to original document When using EMR, entry automatically dated and signed electronically when saved 28

Steps for Adding Items to Chart Item added to pt record as soon as it discovered that item was omitted Locate last entry in medical record Using pen with black ink, on next line of record, immediately after last entry, place current date and time Stat, “Late entry” Sign entry with your full name and credentials

Guidelines for Changing Items in a Pt’s Record Locate information to be changed Using pen with black ink, draw one single line through incorrect information, So that incorrect information not obscured, but can still be read Place date of correction, your initials, and “error” above incorrect information Enter correct information

Chapter 13: Managing Medical Records Lesson 2: Filing

Lesson Objectives Lesson Objectives Compare and contrast alphabetic, numeric, and color-coded filing systems. State effective system used for cross-referencing. Understand how to find missing file. Define tickler file. 32

Categories of Medical Records Active records Inactive records Closed records 33

Active Records Relate to pts who have been seen within past three years and currently being treated Each medical practice may have its own policy regarding what constitutes “active” file, but it is usually from three to six years

Inactive Records Relate to pts who have not been seen within past three years or another time period determined by office policy (must keep for 7 years) Files still maintained by office but generally kept in separate storage file cabinet that may be off-site Pts have not received formal notification that physician terminated care. May return when medical problem develops.

Closed Records Records of pts who have actively terminated their contact with physician or have expired Files can be placed in storage boxes or converted and saved on computer disk Files referred to as archives, since they no longer needed but must be kept for legal reasons

Types of File Storage Vertical Lateral Movable 37

Options for Storing Medical Records Medical office building Another office or building near to medical office Business that specializes in archival and retrieval 38

Guidelines for Retaining Medical Records Legal statues to keep records and documents vary by state Standard set by most states for keeping records 2-7 years after last treatment, or seven years after pt reaches age of majority AMA recommends keeping records for 10 years Some worker’s comp (eg. Asbestos) require 30 yrs. To be absolutely safe, medical records should be retained forever 39

Issues Addressed in Medical Record Destruction Policy Length of time records kept Where records will be kept Person responsible for deciding what to keep and what to destroy Method used for documenting destruction of records Method of disposal 40

Traditional Hard Copy Pt Record May be placed within separate tabbed folder that remains in filing cabinet File folders may be color-coded to indicate primary care physician Each physician may be assigned folder color as well as special indicators This helps keep files in order in large clinics

Divider Guides Divides files into subsections using letter or by pt number

Out Guide Placed in file when file removed to indicate where file should be returned Can be used to indicate who removed file and when it was removed Especially helpful in large office when trying to locate charts Usually distinctive color, such as red, is used to indicate file missing

Figure 13-8 An example of an out guide.

Using color coded labels enables medical staff to quickly identify important information

Systems Used for Filing Alphabetic system Numeric system Subject filing Color-coding Let’s take closer look at each of these! 46

Rules for Alphabetic System Name with only initial first name is filed before full name Hyphenated names treated as one unit Apostrophes disregarded Titles and initials disregarded, but placed in parentheses after name Married women to be indexed using their legal name. Husband’s name can be cross-referenced. 47

Rules for Alphabetic System Seniority units filed numerically Numeric seniority terms filed before alphabetic terms 48

Numerical Filing or Pt Identification System Used in hospitals and many larger clinics Number is assigned to each pt’s medical record Generally six-digit number divided into three sections of two digits each 49

Types of Numerical Filing Straight numerical filing Terminal digit filing Middle digit filing Unit numbering Serial numbering 50

Numerical Filing Straight Numeric Simplest numerical method Each record filed sequentially based on assigned number Numbers used system begin at 01 and continue upward File space becomes depleted rapidly as new files added to one section requiring constant reshifting of files to make room for new files Also terminal digit or middle-digit filing

Alpha-Z System System based on 13 colors using white letters on colored background for first one-half of alphabet, and addition of white stripe on colored background for second half of alphabet Uses file labels to denote pt’s name, and color label with letter of alphabet to indicate index unit

Alpha-Z System Ideal for large practice with many pts having same surnames Can be adapted to particular office’s needs In large practices with several physicians, each physician may have color assigned to him or her

Methods to Ensure Location of Records is Known Write down name of removed file on master file sheet Use out guide to indicate removal of record

Guidelines for Locating Missing Files Look for file with “sound-alike” or “look-alike” name For color-coded files, look for folder with same color-coding For files filed numerically, look for transposed numbers. Look for transposed letters Look for different spellings 56

Guidelines for Locating Missing Files Look at folders filed before and after missing record Look in other areas throughout office For video on locating lost files click here, go to MyHealthProfessionsKit.com, or insert DVD-ROM found in back of your book. 57

Tickler Files Reminders for future events Should be reviewed daily Contents include: Pt’s names Telephone numbers Dates when action or activities should occur Action to be taken 58

Figure 13-11 Tickler file using a file drawer.

Questions? Competencies 13-1 Changing Item in Medical Record 13-2 Organizing Pt File 13-3 File Record Alphabetically Complete Alphabetizing exercise1 by hand, attach Document comp You are the Pt, you filed your record alphabetically in correct location daily 13-4 File record Numerically Stack of Charts will be given to sort and list of pt charts to put in sequence, list to sort on paper Document your assigned case study including chart # 13-5 Locating Missing File Video Lost File : Pt Karen Adams 60