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Chapter 9 Medical Records
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Objectives Review the learning and performance objectives for this chapter By the end of this chapter, demonstrate the procedures in the textbook and the job skills in the workbook
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Heart of the Health Care Professional
Service Consider the medical record as a diary put in your care and have a high regard for it.
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Patients’ Medical Records
Aid in diagnosis and treatment Provide documentation of care Verify medical necessity Assist in research Substantiate billing codes Comply with laws Defend the physician
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Patients’ Medical Records
Prepare and compile a medical record for a new patient File folder Labels Forms Procedure 9-1(See page 265)
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Medical Record Systems
Paper-based record system Costly to manage, move, and store Paper records are vulnerable Convert paper to electronic records Digitize using a scanner
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Medical Record Systems
Electronic medical record system Faster More secure Centralized access Less chance for error “Mouse Calls”
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Medical Record Systems
Medical record organizational systems Problem-oriented medical record system Flow sheets Track specific data Cross referencing
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Medical Record Systems
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Medical Record Systems
Medical record organizational systems Source-oriented record system Most common Organized by sections Integrated record system All records in chronologic order Disregards problem or source
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Record Keeping Record keeping Physician hand enters data
Physician dictates Physician keys data Medical assistant enters data
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Record Keeping Record keepers Oversee system and clerks
Documentation requirements Coding Internal audits Authorization requests Obtain outside records
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Record Keeping Documenters Attending physician Consulting physician
Ordering physician Referring physician Treating physician
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Record Keeping Authentication of documents
Each document must be signed Indicates document complete/correct Manual signatures Handwritten Electronic signatures Facsimile of actual signature Digital code or encryption
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Record Keeping Documentation format SOAP format Subjective Objective
Assessment Plan
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Record Keeping
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Record Keeping Documentation format CHEDDAR format Chief complaint
History of present illness Examination Details Drugs and dosages Assessment Return or referral
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Record Keeping Documentation guidelines Patient name and current date
Complete encounter information Legible Accurate Chronologic order
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Record Keeping Documentation guidelines Enter in a timely fashion
Objective Specific Reason for encounter Assessment and diagnosis Plan of care Date and identity of observer
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Record Keeping Documentation guidelines
Standard, approved abbreviations Allergies and adverse reactions Immunizations and injections Patient’s problem list Significant illnesses Medical conditions
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Record Keeping Documentation guidelines Rationale for ordering tests
Reason for treatment deviation Past and present diagnoses accessible Identify risk factors Past medical history
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Record Keeping Documentation guidelines Smoking habits
Alcohol and/or substance abuse Patient’s current medical condition Telephone conversations Progress and response
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Record Keeping Documentation guidelines
Support codes with documentation Lab, X-ray, and EKG results Legible Document/photocopy prescriptions Names of all staff assisting
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Record Keeping Documentation guidelines Any drug samples given
Patient education and instructions Each entry must be signed Standard technique for corrections See Figure 9-6
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Record Keeping Documentation guidelines
Medicare documentation guidelines No formal requirement Claims processors may use in audit May affect reimbursement
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Record Keeping Documentation terminology Accurate words and phrases
Normal Negative Noncontributory Within normal limits Acute versus chronic
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Record Keeping Documentation terminology Acronyms and abbreviations
Use standard abbreviations Do not invent new abbreviations Illustrations Keep in chart Legible Dated and signed
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Record Keeping Documentation terminology Digital images Measurements
Photographs Graphics Measurements Use metrics Lesions: Site, size, number Burns: Type, depth, site, percentage
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Correcting a Medical Record
Correct a medical record Never erase Never use correction fluid Addendum Maintain original entry Figure 9-5 Procedure 9-2
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Elements of a Medical Record
These video clips preview the administrative and clinical parts of a medical record. Parts of the medical record: Admin. data Parts of the medical record: Clinical data
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Elements of a Medical Record
Patient information form Registration Demographics Insurance
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Elements of a Medical Record
Patient medical history Chief Complaint (CC) Subjective: patient’s own words Describes the symptom or problem History of Present Illness (HPI) Detailed account of history of illness or injury
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Elements of a Medical Record
Patient medical history Past, Family, and Social History (PFSH) Past history Family history Social history
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Elements of a Medical Record
Patient medical history Review of Systems (ROS) Inventory of body systems Identify signs or symptoms Subjective: reported by patient
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Elements of a Medical Record
Physical examination Objective Physician findings by examination or tests Four Procedures Inspection: Observation Palpation: Touching Percussion: Striking Auscultation: Listening
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Elements of a Medical Record
Physical examination Levels of examination Problem focused (PF) Expanded problem focused (EPF) Detailed (D) Comprehensive (C)
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Elements of a Medical Record
Physical examination Body areas and organ systems See Table 9-1 See Examples 9-6 through 9-18 See Figures 9-6A and 9-6B
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Elements of a Medical Record
Complexity of medical decision making Four types Straightforward (SF) Low complexity (LC) Moderate complexity (MC) High complexity (HC)
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Elements of a Medical Record
Complexity of medical decision making Management options Number of diagnoses or management options Amount and complexity of data Diagnostic testing Old medical records History from other sources
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Elements of a Medical Record
Complexity of medical decision making Risk Complications Morbidities Comorbidities Mortality
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Elements of a Medical Record
Complexity of medical decision making Diagnosis Impression, assessment Treatment Recommended plan of care Prognosis Probable outcome
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Elements of a Medical Record
Progress or chart notes Each subsequent visit Figure 9-7 Self-adhesive chart notes Placed in order in paper record Electronic progress or chart notes Entered electronically
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Elements of a Medical Record
Medical reports Documentation of each examination Chronological Laboratory reports Laboratory log Figures 9-8, 9-9, and 9-10
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Elements of a Medical Record
Radiographs (X-Ray Films) Interpretation reports Films filed elsewhere Electrocardiograms Paper strips filed elsewhere
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Abstracting from Medical Records
Abstract data from a medical record Extraction of data Complete forms Compose summary Procedure 9-3
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Audit of Medical Records
Internal review Verify own record keeping procedures Review own documents Table 9-2
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Audit of Medical Records
External audit Done by: Government programs Managed care organizations Private insurance carriers Because of: Unusual billing patterns
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Stop and Think Physician roles and titles Review the scenario
What roles do the following physicians play and what are their current titles? Dr. Practon Dr. Skeleton Dr. Curtin
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Stop and Think Chart documentation Review the scenario
Write a narrative chart note describing the interaction that will serve both as a message and as documentation for the medical record
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