SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes International Monitor Group O’Hanlon Health Consulting Business for Health Business Skills for Private Medical Practices Module 8: Manage Medical Records

A Quick Start Welcome! While you are waiting for the class to begin, please take the Pre-Test and make sure your name is on it before you hand it to the facilitator. While you are waiting for the class to begin, please take the Pre-Test and make sure your name is on it before you hand it to the facilitator. Thank you!. 2Business Skills for Private Medical Practices

Agenda Welcome Outpatient Medical Records Medical Records Policies and Procedures Medical Records Audits Medical Records Management Manage Medical Records Summary and Evaluation Close 3Business Skills for Private Medical Practices

Learning Objectives During this session, you will: 1.propose the patient information and forms that should be included in outpatient medical records; 2.recommend how an outpatient medical record can be organized; 3.assess the content of your current medical records; 4Business Skills for Private Medical Practices

Learning Objectives 4.discuss your current medical records policies and procedures; 5.assess your current medical records policies and procedures; 6.design a checklist for auditing the completeness of medical records; 5Business Skills for Private Medical Practices

Learning Objectives 7.design a peer review checklist for auditing the quality of medical records; 8.assess your current medical records management; 9.decide how to handle issues related to medical records management; 10.discuss the next step; and 11.state your key take-away from this session. 6Business Skills for Private Medical Practices

Introduction You will have 1 minute to introduce yourself: 1.Your name 2.Your position 3.Your business 4. How long you have been in business 7Business Skills for Private Medical Practices

Outpatient Medical Records Business Skills for Private Medical Practices 8

Outpatient Medical Forms Design a well organized and complete outpatient medical record. Please identify: 1.The forms you need in the medical record 2.The information that should be collected on each form 3.The order in which the forms should be placed in the medical record, with # 1 being the first form you would see Business Skills for Private Medical Practices9

Medical Records Content Assessment Medical Records Should Contain: Business Skills for Private Medical Practices10 1. Problem list7. Personal data 2. Medications8. Pertinent history 3. Adverse drug reactions9. Physical exams 4. Allergies10. Documentation for each visit 5. Smoking status11. Lab/other studies 6. Alcohol/drug abuse12. Working diagnoses Etc.

Example of Primary Care Medical Record Documentation Standards CriteriaDescriptionPoints Biographical/Personal Data8 General Chart Organization5 Personal History38 Social Habits12 Office Visit/Follow Up29 Preventive Services20 Business Skills for Private Medical Practices11

Medical Records Policies and Procedures Business Skills for Private Medical Practices 12

Medical Records Policies and Procedures  Who prepares a new patient medical record?  What system is used for filing and retrieving medical records?  Who is allowed to make entries into the record? Business Skills for Private Medical Practices13

Medical Records Policies and Procedures  What procedure do you use to indicate the need to follow up on patient referrals or external diagnostic test results?  What are your security procedures regarding medical records?  How do you maintain patient confidentiality? Business Skills for Private Medical Practices14

Medical Records Policies and Procedure Assessment Business Skills for Private Medical Practices15 Patient Medical Record Information Management

References  Simple Ambulatory Medical Record Documentation Standard  Sample Clinical Records Management Policy  Policy and Procedures Writing Guide and Template Business Skills for Private Medical Practices16

Medical Record Audits Business Skills for Private Medical Practices 17

How to Conduct Medical Record Audits What are the best ways to conduct audits of medical records for completeness of data and documentation of quality of care? Business Skills for Private Medical Practices18

Auditing for Completeness of Medical Records Create a peer review audit checklist. For example: 1.Are all of the necessary forms in the record? 2.Are all clinical notes signed, dated and timed? 3.Are patient vital signs recorded for each visit? Business Skills for Private Medical Practices19

Reference  Sample Peer Review Policy and Procedure: Quality Audit  Sample Peer Review Worksheet Business Skills for Private Medical Practices20

Quality Issues in Medical Records Identify five issues that need a medical record peer review. For example: 1.Did the provider prescribe the correct drug? 2.Were the blood tests that were ordered the correct tests? 3.Was the chest x-ray consistent with the differential diagnosis? Business Skills for Private Medical Practices21

Auditing for Quality of Medical Records Create a peer review audit checklist based on the issues listed in the previous activity. Business Skills for Private Medical Practices22

Reference  Sample Peer Review Policy and Procedure: Quality Audit  Sample Peer Review Worksheet Business Skills for Private Medical Practices23

Medical Record Management Business Skills for Private Medical Practices 24

Medical Record Management Assessment ✔ 1. The practice maintains complete and accurate medical records ✔ 2. Medical records are stored in a secure location ✔ 3. There is a unique medical record for each patient ✔ 4. Records are organized for easy retrieval Business Skills for Private Medical Practices25

Manage Medical Records Business Skills for Private Medical Practices 26

Case Study: Filing Folly Working with your table, please identify: 1.the issues 2. the causes 3. how to avoid them in the future; and 4. what the hospital should do to manage the current situation. Business Skills for Private Medical Practices27

Case Study: Filing Folly Business Skills for Private Medical Practices28 1. Issues2. Causes3. How to Avoid 4. How to Handle the Current Situation

Summary and Evaluation Business Skills for Private Medical Practices 29

Evaluation Sheet 30Business Skills for Private Medical Practices

The Next Step 1.Develop a Medical Record Data Quality Checklist 2.Ensure your Medical Record Policies and Procedures include file management, confidentiality, and record retention 31Business Skills for Private Medical Practices

The Next Step 3.Design a monthly Patient Medical Record Peer Review process for quality and appropriate use of services 4.Randomly pull five patient medical records and conduct a review for data completeness and quality of service. Document results and take action when needed. 32Business Skills for Private Medical Practices

Let’s See How Much You’ve Learned Please take the Post-Test. We will compare it to your Pre-Test to see how much you’ve learned in this session. Thank you. Business Skills for Private Medical Practices33

My Key Take-Away 34Business Skills for Private Medical Practices