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Chapter 16 Record-keeping
By Jahangir Moini, M.D., M.P.H. and Morvarid Moini, D.M.D., M.P.H.
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Overview Organized, easy-to-use records management system
Essential in health care All interactions recorded in patient’s medical record Secure handling required per Health Insurance Portability and Accountability Act (HIPAA)
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Contents of the medical record
Medical record: the only permanent legal document, including: All patient medical history Laboratory tests Appointments with professionals
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Admission sheet From patient’s first visit to a provider, it contains:
Name, address, phone number, birthdate Social Security number Gender, marital status, race Employer information Insurer information Co-payment or deductible information
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Admission sheet Usually updated every year
Copies of insurance cards may be attached Chief complaint, in patient’s own words From the initial visit to the provider
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Medical history Previous medical information: Family history:
Allergies Childhood diseases Hospitalizations Immunizations Previous illnesses Surgeries Current and past medications Family history: Diseases Causes of death
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Social history Patient education Occupation
Marital status, sexual history Diet, alcohol and tobacco use Hobbies
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Physical examination form
Review of body systems Results of general physical examination Review of systems, examination usually performed by physician, nurse practitioner, physician’s assistant Identification of signs and symptoms Patient responses to provider questions
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Physician orders Highly detailed, including:
Medications Tests Treatments Follow-up care Electrical medical orders allow: Easy sharing Elimination of errors
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Progress notes Document contacts between patients and providers
Findings summarized chronologically Provide brief overview of patient health Very important in hospitals with multiple caregivers: Entry dates Times Provider names
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Laboratory reports Results from tests:
Blood tests MRI scans Electrocardiographs X-rays CT scans Tests conducted in physician offices or elsewhere Reports section includes consultations with other providers
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Diagnostic imaging information
Recorded in the medical record: X-rays, MRI, other tests Cardiac catheterizations Echocardiography Cerebral angiograms Fetal ultrasound G.I. studies with contrast Often reproduced onto CDs or DVDs Patients can carry them For use by other health professionals
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Types of medical records
Source-oriented medical record (SOMR) Problem-oriented medical record (POMR) In both, more recent information appears first Called reverse chronology Date and time stamps Signature or initials of professional making entries Information only entered after an event occurs
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Source-oriented medical records
Information organized by: Type Who supplied the information Sometimes called conventional method or SOMR approach Tracking progress of conditions or illnesses: More difficult than in POMR format
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Problem-oriented medical records
Information organized based on problems: Each appears on first page Given a number and date of first occurrence All related information has same problem number Important to differentiate between: Objective, measurable signs Subjective, patient-experienced symptoms
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Problem-oriented medical records
Problem list Signs and symptoms Database Medical history Systems review Initial patient interview Exam results Lab and test results
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Problem-oriented medical records
Educational, diagnostic, and treatment plan Required tests and treatments Diagnostic workups Patient instructions Progress notes Grouped together Numbered according to problem list: Patient condition Problems Complaints Treatment Responses
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SOAP documentation Also called SOAP notes
Originated from the POMR format Clearly documents patient progress via: Subjective data Objective data Assessment Plan
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SOAP documentation Subjective data Objective data
Patient statements, symptoms in his or her exact words Objective data Provider observations of things seen, felt, heard, measured Test results Vital signs Procedures Diagnoses Reports Notes Treatments
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SOAP documentation Assessment Plan
Diagnosis based on subjective and objective data If no final diagnosis can be made Possible disorders ruled out can be listed Plan Describes what will be performed Testing Treatments Follow-ups
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CHEDDAR format More detailed method of documentation: Chief complaint
History Examination Details Drugs and dosage Assessment Return
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Electronic health records
Also known as electronic medical records (EMRs) Contain individual health information Created and gathered by more than one organization Electronic records are easier to: Store Retrieve Back up Edit Read
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Electronic health records
Only authorized personnel can use them Correct protocols required for corrections Computer terminals must be secured No sharing of passwords, computer signatures Sensitive material requires more confidentiality
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Electronic health records
Protected health information Never ed unless encrypted Electronic file copies documented in a log Patient information never left displayed on a monitor Could be seen by unauthorized personnel Records must be regularly backed up correctly
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Advantages of electronic health records
Component Comments Chart notes Immediately available; helps with referrals, consultations Coding CPT or ICD codes assigned; simplifies insurance filing Coordination Streamlines multiple providers; eliminates duplication Database Completely searchable information Ease of transmission Reduces treatment times and notification of critical values Electronic prescriptions Reduce errors, time; screens for problem conditions Photographs Helps avoid mistakes in identification of individuals Reminders Alerts about tests, vaccinations, procedures that are due Trending of information Information analysis over time identifies problems earlier Voice recognition Eliminates need for transcription; improves availability of printed records
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Personal health records
Must be accurate, complete, and legible Create a clear record of patient’s care Electronic errors Should be listed as “mistaken entries” Corrected, not deleted Paper-form errors Should be listed as “errors” Include dated correspondence
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Personal health records
Only universal abbreviations, acronyms are acceptable Otherwise, full terms should be written out Illegible handwriting increases errors Care must be taken to write legibly Whether on paper, or using electronic stylus pens
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Medical documentation
Allows communication between providers Dosages verified via vital signs, weight, etc. Test results are listed, plus changes over time Allergies, medications used are also listed Patient assessments are listed Quality of care over time is documented Medical records may be used as: Court evidence Injury/accident claims
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Medical documentation
Also used to train new medical professionals Also help for research and in new therapies OSHA requires: All health care employees who may be at risk for exposures to be documented
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HIPAA and the medical record
Health Insurance Portability and Accountability Act passed to: Improve portability, continuity of health insurance coverage Reduce waste, fraud, abuse Promote medical savings accounts Improve access to long-term care Simplify health insurance administration
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HIPAA and the medical record
Patients must sign HIPAA notice of privacy practices HIPAA is concerned with: Protecting patient health information privacy Establishing electronic transmission standards Security of all electronic health information
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HIPAA privacy rule Requires providers to:
Notify patients of privacy rights, usage of information Develop privacy procedures, train employees Designate certain individuals to oversee adherence to procedures Secure records with Individually Identifiable Health Information
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HIPAA notice of privacy practices
Clarifies uses and disclosures of: PHI Patient rights and duties How complaints are registered Also specifies effective dates, points of contact Must state that privacy practices can be changed
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HIPAA rules Allow providers to use information concerning:
Treatment Payment Operations Other information only used if written authorization is obtained HIPAA Security Rule describes how PHI is protected on: Internet Storage media Networks Extranets (private networks)
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Privacy officer A security officer assigned by each facility
All health care providers must demonstrate compliance in four areas
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The four areas of compliance under the HIPAA Security Rule
Confidentiality, integrity, availability of all electronic PHI composed, received, maintained, or sent out. Policies and procedures must protect against use, disclosures of this information that the Privacy Ruling does not allow. Other policies and procedures must protect against hazards, threats to this information. There must be compliance within the workplace to the Security Ruling.
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Audits Adhere to the four areas, so that when an audit occurs:
Documentation requested by Centers for Medicare and Medicaid Services (CMS) can be supplied Documentation will be needed for various safeguards and organizational requirements Employees must be trained in maintenance of records security
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