Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 11 Medical Records

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Congratulations! Believe it or not, you are nearly at the halfway point of the review chapters. The road to completion becomes easier from here. Don’t give up your goal to become a nationally certified health professional. Be sure to complete Chapter 4, “Law and Ethics,” before beginning this one—some material involving medical records is also covered in that chapter. Review Tip

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The term medical record is used synonymously with patient chart or chart; it contains all information related to a patient’s medical care. The Medical Records chapter is divided into three sections: ■ Medical records management ■ The individual medical record ■ Documentation guidelines Overview

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The medical assistant and medical administrative specialist are usually responsible for management of the office’s medical records. This responsibility involves several functions: ■ Assemble—place all the forms used by the specific practice in the patient record in the prescribed order ■ File—place active medical records in the secured storage area in the order prescribed by the filing system used by that facility ■ Maintain—ensure all documentation is in the medical record in the proper order and that the record is in a secured area Medical Records Management

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Retrieve—recover the medical record from the secured storage as needed and document when and where the record was taken ■ Transfer—send the record to another health care provider when the proper consent for release of medical records is obtained (send copies only, not originals) ■ Protect—ensure the medical record is in a secured area and kept intact and that all computer safeguards are in place for the electronic health record. ■ Audit—examine medical record files to ensure accuracy, completeness, and sequence of the documents; may be an internal file audit performed by the office staff or an external file audit performed by professional auditors of an organization or agency who are not employees of the practice Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Retain—keep the medical record in a secured area for the prescribed length of time (this is state-specific); the term conditioning is sometimes used to describe preparation of the chart for retention: secure all loose documents, and examine the record for completeness and correct filing order of documents ■ Purge—remove medical records that are beyond the time period of the statute of limitations ■ Destroy—shred or otherwise destroy the medical record, ensuring no identifying factors are recognizable, when the prescribed statute of limitations is reached; maintain a file indicating when the record was destroyed Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins In addition to the functions associated with medical records, you must know information about the organization and handling of medical records: ■ Types of files Active—patient seen within 2 to 5 years (dependent on practice type) Inactive—patient not seen within past 2 to 5 years (dependent on practice type) Closed—patient not expected to return to practice, such as if the patient is deceased, has moved, or has reached age limit in pediatrics ■ File equipment and storage Shelving units (active files) Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins - Open or closed shelving units - Vertical or lateral units - Stationary or moveable units ❍ Locked units or units locked in self-contained area Electronic health records, or EHR (active, inactive, and closed files)—complex Health Insurance Portability and Accountability Act (HIPAA) security issues; firewalls should be in place if located on a network or electronically transferred - Combination electronic and hard-copy records - Total electronic records - Floppy disk, CD-ROM - Microfiche (for closed or inactive records) - Scanned file Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins CMS (Centers for Medicare and Medicaid Services) has established a goal that by the year 2014, health care providers will have converted all paper, hard-copy records to electronic health records. This is based on published information available at the time this text was printed. ■ Medical record hard-copy supplies File folders—top or side identification areas with method to secure loose file forms Guides—dividers Labels—alphabetic or numeric color or other coding containing section names, such as progress notes or alerts Outguides—folders inserted on the file shelf when a medical record file is in use; designates who took it, when, and where (may be computerized instead of hard-copy folder) Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Long-term hard-copy storage (inactive and closed) - Boxed; maintained onsite - Boxed; maintained offsite ■ Filing systems Alphabetic—charts filed by the units of the patient’s name: letter by letter beginning with the patient’s last name - Unit 1—last name, letter by letter - Unit 2—first name, letter by letter - Unit 3—middle initial or middle name, letter by letter - Unit 4—prefixes and suffixes (e.g., Dr., Mrs., Jr., Sr., I, II, III): numbers appear first (e.g., I, II, III); Jr. follows numbers and comes before Sr. Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Numeric—each patient is assigned a medical record number through manual or computerized means; through a manual or computerized system, numbers are cross- referenced with the alphabetic file, sometimes referred to as a master file - Consecutive numeric order—patients are assigned numbers in the order of their first visit to the practice; charts are filed in this order; used by small practices - Terminal digit order—patients are assigned a six-digit number; to file the charts, the numbers are divided into three groups of two digits each and read from right to left Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Color coding—system filed in coordination with numbers or alphabet - Each letter or group of letters in the alphabet is designated a specific color, which makes the letters easier to locate - Each group of numbers in terminal digit filing is designated a color - In group practices, patients of the individual physicians may be designated a color in addition to the alphabetic or numeric system Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Alphanumeric—system using a combination of numbers and letters - Initial filing done alphabetically by first letter of last name or subject; then numbers are assigned - Seldom used for medical records; more frequently used for other office files Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Medical records retention (hard copy or electronic)— the length of time a medical record should be retained Guidelines from federal/state statute of limitations; retention for adults is usually 7 to 10 years Retention for minors is the age of majority plus the statute of limitations (7 to 10 years) Guidelines may also be issued by insurance companies and accrediting and legal organizations Functional storage and retrieval systems required Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Medical records destruction After completion of statute of limitations and recommended guidelines Total eradication (shredding, burning, deleting); safe shredding and disposal of documents may be done by an outside company specializing in those services saved notation of destruction and date Medical Records Management, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The individual medical record is all the information related to a patient’s medical care. This information may be in the form of paper (e.g., progress notes or letters), medical imaging (such as x- rays, ultrasounds), tapes (e.g., audio, visual), disks, electronic printouts (e.g., electrocardiogram tracings, fetal monitoring strips), photographs, and any other materials that tell the “story” of the patient’s medical journey. The medical record material is the property of the health care provider. The information in the medical record is the property of the patient. The Individual Medical Record

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Uses Facilitates good medical care through continuity Provides legal protection for the health care provider and the patient Functions as a quality of care monitor Facilitates research Provides resource for education ■ Determination of record organization and sequence Type of practice Physician preference Frequency of access The Individual Medical Record, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Individual Medical Record, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Potentials for legal and ethical dilemmas Confidentiality breach (see “Confidentiality” in Chapter 4) Improper release of information Withdrawal from care; discharge of patient Broken appointments Patient noncompliance with his or her care plan Questionable medical records - Delayed filing of tests or notes - Incomplete information - Illegible entries - Improperly corrected entries - Missing information - Lost record The Individual Medical Record, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Individual Medical Record, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Documentation, also referred to as charting, makes up the medical record. A caveat, referred to as the “golden rule,” is: If it is not documented, it was not done. ■ “Cs” of charting (a list of terms beginning with the letter “C” to help with proper documentation) Client’s words (use quotation marks or “patient states...”) Clear Complete Concise Chronologic or reverse chronologic order Confidential Documentation Guidelines

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Documentation inclusions Name of the patient, additional identifier (e.g., medical record number), and date on each page, front and back Dated entry for each visit and procedure Health care provider signature or initials and title for all entries Dated entry for no-shows, cancellations, or phone calls Dated entry for failure to follow treatment plan Dated entry for prescription refills Notations or copies of forms for outpatient and hospital visits Dated entry with explanation for termination of care Documentation of reported results and follow-up for all tests and procedures Acceptable error correction method Documentation Guidelines, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Documentation Guidelines, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Charting methods Source-oriented medical record (SOMR)—this file is divided into sections by guides, such as a section for progress notes or diagnostic reports; may be used in conjunction with other charting methods Problem-oriented medical record (POMR)—the patient’s problems are numbered and listed on a form (problem list) that is placed in the front of the chart; each visit or treatment is associated with a problem number (for example, if asthma is the primary problem it, is listed as #1 and documented as #1 throughout the chart); may be used in conjunction with other charting methods. In addition to the problem list, POMR usually contains the following: - Database—patient profile and demographics; baseline and assessment information including chief complaint (cc) and test results Documentation Guidelines, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins - Treatment plan—course of procedures, medications, and other instructions for the patient’s care -Progress notes—continuing narrative of the patient’s improvement or lack of improvement SOAP documentation—format for documenting each visit using subjective information, objective information, an assessment, and a plan, in that order; may be used in conjunction with other charting methods - S = subjective data (symptoms the patient states that cannot be seen, heard, or measured, such as a headache) - O = objective data (measurable and observable signs, such as swelling) - A = assessment (exam and impressions) - P =plan (design for tests, treatments, education, follow-up) Documentation Guidelines, cont’d.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Reverse chronologic order—format with the most recent records filed on top: visits in 2010 would be closer to the front of the chart than visits in 2009; may be used in conjunction with other charting methods Documentation Guidelines, cont’d.