Seminar THREE The Patient Record: Hospital, Physician Office, and Alternate Care Settings

Medical Record Content Definition of Medical Record Repository of Information Business Record Contains documentation of patient care and demographic data Administrative Data Clinical Data

Medical Record Content Essential Principles of Healthcare Documentation Unique patient identification must be assured within and across healthcare documentation systems. Healthcare documentation must be accurate and consistent, complete, timely, interoperable across types of documentation systems, accessible at any time and at any place where patient care is needed and auditable. Confidentiality and secure authentication and accountability must be provided

Medical Record Content Joint Commission Standard RC.01.02.01 states: “Only authorized individuals may make entries in the medical record” “Define the types of entries in the medical record made by nonindependent practitioners that require countersigning.” AHIMA recommends” “anyone documenting in the health record should be credentialed or have the authority and right to document as defined by the organization’s policy” Who owns the Medical Record?

Medical Record Content Authentication Written Signatures Counter signatures Initials Fax Signatures Electronic Signatures Signature Stamps Abbreviations Ms. Walker arrived with SOB

Medical Record Content

Medical Record Content Legibility

Medical record content Timeliness of Entries COP requires an H&P be placed in the chart within 24 hours of Admission The Joint Commission requires an H&P be placed in the chart within 48 hours of admission Facility example: All entries must be signed within 24 hours

Medical record content Completion of Records Joint Commission requires a record be completed within 30 days of discharge Records not completed within 30 days of discharge are considered delinquent Delinquency Rate is calculated by dividing the number of records delinquent by the number of discharges for the time period. Example: 150 delinquent records for the Month of May and 1200 discharges 150/1200 = 12.5% Delinquency The Delinquency Rate must ALWAYS remain below 50% for Joint Commission compliance

Medical record content Medical Record Completion

Medical record content Amendments/Addendums Necessary to correct information Information cannot be “deleted” from the medical record Electronic or hand-written Can be requested by the patient

Chapter 4 Review – True / False Archived records are also called active records.

Chapter 4 Review – True / False Archived records are also called active records. FALSE

Chapter 4 Review – True / False Behavioral health records include a behavioral health diagnosis, treatment plan, and psychiatric and medical history.

Chapter 4 Review – True / False Behavioral health records include a behavioral health diagnosis, treatment plan, and psychiatric and medical history. TRUE

Chapter 4 Review – True / False Clinical data includes patient financial information.

Chapter 4 Review – True / False Clinical data includes patient financial information. FALSE

Chapter 4 Review – True / False Telephone orders do not require countersignatures if the nurse taking the order records the name of the ordering physician.

Chapter 4 Review – True / False Telephone orders do not require countersignatures if the nurse taking the order records the name of the ordering physician. FALSE

Chapter 4 Review – True / False When correcting a documentation error, the author of the original entry should make the correction.

Chapter 4 Review – True / False When correcting a documentation error, the author of the original entry should make the correction. TRUE

Chapter 4 Review – True / False The abbreviation list should be approved by the medical staff.

Chapter 4 Review – True / False The abbreviation list should be approved by the medical staff. TRUE

Chapter 4 Review – True / False A history and physical report is an example of administrative data.

Chapter 4 Review – True / False A history and physical report is an example of administrative data. FALSE

Chapter 4 Review – True / False Over the last decade, there has bee an increase in the number of ambulatory visits.

Chapter 4 Review – True / False Over the last decade, there has bee an increase in the number of ambulatory visits. TRUE

Chapter 4 Review – FILL IN THE BLANK An abbreviation list contains acceptable explanations of meanings as ____ and ____.

Chapter 4 Review – FILL IN THE BLANK An abbreviation list contains acceptable explanations of meanings as abbreviations and symbols.

Chapter 4 Review – FILL IN THE BLANK A note that is added to the record after an original note has been documented is called an _______.

Chapter 4 Review – FILL IN THE BLANK A note that is added to the record after an original note has been documented is called an addendum.

Chapter 4 Review – FILL IN THE BLANK A preliminary diagnosis is called a provisional diagnosis, a working diagnosis, an admission diagnosis, or a _____ diagnosis.

Chapter 4 Review – FILL IN THE BLANK A preliminary diagnosis is called a provisional diagnosis, a working diagnosis, an admission diagnosis, or a tentative diagnosis.

Chapter 4 Review – FILL IN THE BLANK When a patient is discharged, the _________ is responsible for documenting the discharge summary.

Chapter 4 Review – FILL IN THE BLANK When a patient is discharged, the attending physician is responsible for documenting the discharge summary.

Chapter 4 Review – FILL IN THE BLANK Indexes, registers, and committee minutes are considered ______ ______ of patient information.

Chapter 4 Review – FILL IN THE BLANK Indexes, registers, and committee minutes are considered secondary sources of patient information.

Chapter 4 Review – FILL IN THE BLANK A document maintained by the health information department to identify the author by full signature when initials are used to authenticate entries is known as a _______ _____.

Chapter 4 Review – FILL IN THE BLANK A document maintained by the health information department to identify the author by full signature when initials are used to authenticate entries is known as a signature legend.

Chapter 4 Review – FILL IN THE BLANK A discharge summary is an example of ____________ data.

Chapter 4 Review – FILL IN THE BLANK A discharge summary is an example of clinical data.

Chapter 4 Review – Multiple choice Which is not a component of the problem oriented record? Database Problem list Progress note Table of contents

Chapter 4 Review – Multiple choice Which is not a component of the problem oriented record? Database Problem list Progress note Table of contents

Chapter 4 Review – Multiple choice The judgment, opinion, or evaluation made by a health care professional is documented in which section of a SOAP progress note? Assessment Objective Plan Subjective

Chapter 4 Review – Multiple choice The judgment, opinion, or evaluation made by a health care professional is documented in which section of a SOAP progress note? Assessment Objective Plan Subjective

Chapter 4 Review – Multiple choice When the order of the record reads like a diary, the forms are said to be filed in a Chronological date order Discharged record order Integrated format Reverse chronological date order

Chapter 4 Review – Multiple choice When the order of the record reads like a diary, the forms are said to be filed in a Chronological date order Discharged record order Integrated format Reverse chronological date order

Chapter 4 Review – Multiple choice Which is a disadvantage of the problem oriented record? Difficulty following one diagnosis throughout the documentation Filing of forms is time consuming Poor degree of organization in the documentation Retrieval of information is difficult

Chapter 4 Review – Multiple choice Which is a disadvantage of the problem oriented record? Difficulty following one diagnosis throughout the documentation Filing of forms is time consuming Poor degree of organization in the documentation Retrieval of information is difficult

Chapter 4 Review – Multiple choice Which type of microfilm storage uses Mylar film? Cartridge Jackets Microfiche Roll film

Chapter 4 Review – Multiple choice Which type of microfilm storage uses Mylar film? Cartridge Jackets Microfiche Roll film

Unit THREE: Reminders Reading: Essentials of HIM Chapters 4 and two AHIMA articles Discussion Board: Post answer to DQ by Saturday, two responses to others due by Tuesday Unit 3 Quiz Personal Health Record Activity – You should be working on this activity. The first update is due in Unit Four.