Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1 Medical Office Administration 2nd edition Brenda A. Potter, CPC
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2 Chapter 9 Health Information Management
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3 What is Health Information Management? Directing activities that relate to keeping patients’ medical information Maintaining medical records Preparing medical reports Releasing medical information Compiling statistics Coding for billing and insurance
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4 Purposes of Recordkeeping Documentation of care given to patient Legal purposes Documentation for insurance claims Data used in planning for healthcare services Education and research
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5 Types of Records Paper Electronic EHR – electronic health record (preferred by AHIMA) CPR – computerized patient record EMR – electronic medical record EPR – electronic patient record
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6 Confidentiality All information seen, heard, and done must be kept confidential Releasing information without permission is breach of confidentiality
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7 Confidentiality Agreements All employees and volunteers should be required to sign confidentiality agreements
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8 Confidentiality and Computerized Records Portion or entire record can be stored on a computer Computer systems must be protected
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9 Health Insurance Portability and Accountability Act of 1996 (HIPAA) Regulation includes Requirements for protecting information Patient’s right to know how information is used Patient’s right to a copy of his/her record Restrictions on using information Civil and criminal penalties for violations
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10 Notice of Privacy Practices Written notice detailing how the healthcare provider responsibilities pertaining to the patient’s health information Sign and dated by patient and retained by provider
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11 Components of the Medical Record in a Medical Office Summary sheet Medical history Progress notes SOAP note Chart note Chart entries Medication list Immunization record
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12 Laboratory report Pathology report Radiology report Other specialized documents Pediatric growth chart Pregnancy flow sheet EKGs, EEGs, EMGs Photographs, CDs, DVDs Correspondence
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13 Entering Information in a Patient’s Record Specific guidelines should detail Who may document information in a patient’s record What type of information should be documented In a paper record Do not leave large gaps in progress notes section Handwritten entries done in black ink
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14 Hospital Records History and Physical (H&P) Operative report Discharge summary
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15 Corrections in Records Person making the mistake should correct the entry Do not obliterate information Electronic records may require an entirely new entry to correct a mistake
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16 Medical Transcription Production of a typewritten report from physician’s dictation Dictation saves time for a physician Transcription is more legible compared to handwriting Transcriptionists are medical language experts
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17 Transcription Equipment Digital equipment is the norm Tapes are outdated
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18 Signature Reports and other documents placed in a patient’s chart must be signed or initialed by patient’s physician Signature or initials verify that physician has reviewed documents Electronic signatures used for electronic reports
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19 Organizing Medical Record Source-oriented (SOMR) Similar information is kept together Most commonly used Problem-oriented (POMR) Information pertaining to a specific problem is grouped together
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20 Chart Order Dividers can separate sections of a chart Each office should establish specific chart order
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21 Documentation Guidelines A Joint Commission requirement Medicare 1995 documentation guidelines Use of abbreviations Dangerous abbreviations
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22 What Does Not Belong in the Record A report without a physician's signature or initials – EVEN normal lab results Information regarding a patient’s financial status Callous remarks about a patient
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23 Records Flow Chart is pulled for appointment When patient is placed in exam room, chart is placed outside door Nurse records vital signs in chart Physician brings chart into exam room Chart returned to records room after visit
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24 Quantitative Analysis Verifies that all essential information is in chart Incomplete records should not be filed Deficiency form
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25 Filing Supplies Charts – durable heavy-stock folder Labels – numeric or alpha Outguides – hold place of record
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26 Filing Methods Filing should be kept up-to-date for easy retrieval of records Numerical system Accession ledger – tracks each chart number as assigned Alphabetical system Alphanumeric system
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27 Consecutive Number Filing Charts filed from lowest to highest number Easy to learn Numbers may be transposed Master patient index for numeric systems requires knowledge of alpha filing rules
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28 Terminal Digit Filing Chart number broken into groups of numbers Chart # becomes 65 – primary unit 53 – secondary unit 14 – tertiary unit
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 29 Alphanumeric System Combination of letters and numbers
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 30 Alphabetical Filing Offices should adopt one set of rules Every name indexed: last name, first name, MI Complete legal name should be obtained – no nicknames Abbreviations indexed as spelled out Identical names filed with oldest DBO first Nothing comes before something Prefixes are included with name Punctuation is disregarded Professional and religious titles disregarded Entry of names in computer system should be consistent Cross-references important
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 31 Color Coding Assigning a color to a letter or number Reduces misfiles Saves time when locating chart
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 32 Locating Missing Files Check before and after the chart’s location and inside other nearby charts Check all areas of office Determine last department or individual who used the chart Scan shelves for color out of place Check areas behind shelves or drawers If alpha filing, check other possible spellings for patient’s last name
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 33 Records Retention and Disposal Verify state requirements for retention Medicare requirements – minimum of 5 years after last visit Minor records may have special requirements Active record – current patient Inactive record – patient has not received treatment in a specific period of time Closed record – patient has died or moved away Local obituaries should be checked with office’s patient database Disposed records should be properly destroyed
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 34 Tickler File File that reminds assistant of specific tasks Electronic tickler files available in many computer calendar packages
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 35 File Storage and Protection Lateral shelving is common and often works best Shelving with pull-out drawers or file cabinets also used Be aware of fire codes Duty of medical office to protect records from destruction
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 36 Disaster Plan Medical office is responsible for protecting records from destruction Fire codes must be considered when setting up a records room Fire suppression system Computer backups
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 37 Multiple Locations One chart may be shipped between locations Each location may have separate chart Electronic record ideal for multiple sites
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 38 Release of Information Written documentation necessary to release information In most instances, patient must authorize release information Copy of release kept with patient’s record Photocopies of records, not originals, are sent Fax machines not encouraged for releasing information Redisclosure – office cannot copy and release records received from another office Release not required in some instances (small number of exceptions)
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 39 Ownership of Medical Record Physician owns the paper Patient owns the content HIPAA standards – patient has a right to a copy of his or her record Psychiatric records may not be released to patient
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 40 HIV and AIDS Records Patients may be required to sign consent form for HIV testing Take great care to protect record privacy Patients may have to authorize listing the diagnosis on an insurance claim
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 41 Future of Health Records Increased use of computers for health information activities