1. Medical Records Management
Chapter 14
Medical Records Management

2. Medical Records Management and the TPMS
[FIGURE 14-1]

3. Purpose of Medical Records
Provide base for managing patient care
Provide interoffice and intraoffice communication as necessary
Determine any patterns that surface to signal provider of patient needs

4. Purpose of Medical Records
Serve as basis for legal information to protect providers, staff, patients
Provide clinical data for research

5. Ownership of Medical Records
Property of those who create record
Information belongs to patient and is protected with privacy and confidentiality
Patients are allowed access to their medical records and can ask certain information be added or excluded from their file

6. Ownership of Medical Records
Providers who include their patients in their medical record keeping foster trust and respect with their patients

7. Authorization to Release Information
Before information released from medical record, patient notified and written approval received
Identify reason for release and what information specifically requested
Only that information released
Does not include release of information to patient’s chosen insurance carrier

8. Manual or Electronic Medical Records
Americans to have EHRs by 2014
Planned projects: transmitting x-rays and laboratory results electronically
2011: Electronic prescribing (e-prescribing) of medications for Medicare

9. Manual or Electronic Medical Records
2009: American Reinvestment and Recovery Act (ARRA)
Incentives for physicians and hospitals to make transition to EMR
Solo practitioners least likely to use EMRs
EMRs grow faster in larger, multi-provider clinics
Medical record system must fit facility

10. The Importance of Accurate Medical Records
Accuracy essential to patient care
Critical to facility’s smooth functioning
Important when referring patient to outside specialists
Essential in controlling costs
May be needed in medical litigation

11. The Importance of Accurate Medical Records
Creating paper and electronic charts
Chart prepared on or before day of patient’s first visit
Paper medical records require assembly of appropriate file folders and forms
Electronic medical charts prepared in much the same manner except that all information stored electronically
(See Procedure 14-1: Establishing a Paper Medical Chart for a New Patient)
(See Procedure 14-2: Registering a New Patient Using Medical Office Simulation Software)

12. The Importance of Accurate Medical Records
Correcting medical records
Paper medical record
Draw single line using red ink pen through error
Make correction
Write Corr. or Correction above area corrected
Indicate your initials and current date
Never obliterate
Forensic experts able to determine when and how corrections were made
(See Procedure 14-3: Correcting a Paper Medical Record)

13. The Importance of Accurate Medical Records
Correcting medical records
If information or chart sent elsewhere, make copy of corrected information and send it as quickly as possible

14. Types of Medical Records
Problem-oriented medical records (POMRs)
Vital identification data, immunizations, allergies, medications, problems
Identified by a number that corresponds to charting relevant to that problem number
Each problem followed with the SOAP(ER) approach for all progress notes

15. Types of Medical Records
Problem-oriented medical records (POMRs)
S: Subjective impressions
O: Objective clinical evidence
A: Assessment or diagnosis
P: Plans for further studies, treatment, management
E: Education for patient
R: Response of patient to education and care given

16. Types of Medical Records
Problem-oriented medical records (POMRs)
Internists, family practitioners, pediatricians use POMR system
Used in manual medical records as well as EMRs
Various formats for POMR manual charts

17. Basic Rules for Filing
Alphabetizing is key to organizing files and charts
Indexing rules developed by Association of Medical Records Administrators (AMRA)

18. Filing Techniques and Common Filing Systems
Color-coding technique used in three major filing systems
Patient charts use alphabetic system of color coding
Color coding can be used in numeric filing
Color coding makes retrieval of files more efficient

19. Filing Techniques and Common Filing Systems
Alphabetic filing
Simplest filing methods; strictly maintained by assigning label to each file
Numeric filing
Organized by number rather than by letter
Preserves patient confidentiality
Straight numeric
Terminal digit
Middle digit
(See Procedure 14-5: Steps for Manual Filing with an Alphabetic System)
(See Procedure 14-6: Steps for Manual Filing with a Numeric System)

20. Filing Techniques and Common Filing Systems
Subject filing
Convenient for locating frequently used services or for filing reference materials for patient needs
Choosing a filing system
Facility primary objectives with storage of patient files, business records, research files
Selecting alphabetic or numeric system
Confidentiality of charts
HIPAA compliant
(See Critical Thinking box)

21. Filing Procedures Tickler files
Reminder that some action needs to be taken at date in future
Can be accomplished manually or electronically
Should contain the following:
Patient name
Tickler date when action should be taken
Required action
Additional relevant information

22. Filing Procedures Filing chart data Types of reports Clinical notes
Correspondence
Laboratory reports
Miscellaneous

23. Filing Procedures Retention and purging Record purging Active files
Inactive files
Closed files
(See Table 14-2: Records for Retention)

24. Correspondence Filing procedures for correspondence
Remove paper clips and staple items together
Inspect to see if item is ready to be filed
On incoming correspondence, be sure letterhead is related to letter

25. Correspondence Filing procedures for correspondence
On outgoing correspondence, look at inside address and reference line
On incoming or outgoing correspondence, code indexing units of designated label
Create miscellaneous folder for items that do not have enough in number to warrant individual folder

26. Electronic Medical Records
Mandated; one day will replace all paper/manual medical records
Fewer errors created
Create, store, edit, retrieve patient data
Allow more than one person to access chart at same time

27. Electronic Medical Records
Purchased as single computer application or part of larger practice management system
EMR capability list
Providers use computers to open and view charts and write prescriptions
System administrators can identify access and privileges for confidentiality
EMR fully recognized as legal document

28. Archival Storage
Providers preserve patient medical records for life of practice
Computers help to solve space issues through EMRs
Records copied onto optical disks or CDs
Should have backup system

29. Archival Storage Transfer of data
EMRs easily ed in whole or in part
Faxing
Scanners (optical character recognition)

30. Archival Storage Confidentiality
Major issue in using computer and online devices for storage and transfer of medical information
Never discuss information outside clinic
Unwise to discuss private information within facility if it is not your concern