1. Health Information Management Records and Files
Differentiate between types and content of health records (patient, pharmacy, and laboratory).
Ensure that documentation in the health record reflects timeliness, completeness, and accuracy.
11.15 Adhere to information systems policies and procedures as required by national, state, local, and organizational levels.

2. Confidentiality
What do you remember about patient records and confidentiality?
They are legal documents
Records should not be released to other parties without the written consent of the patient.
The records belong to the physician or health agency.
Does the patient have a right to obtain copies of his/her medical records?
Teacher notes:
If students have been instructed on legal responsibilities, they should know about HIPAA and record confidentiality.

3. Statistical Data Sheet
Also called patient or medical information form.
Contains name, personal data and insurance information.
Often filled out by hand and then typed into computer.
Some are online.

4. Also called patient chart, medical chart or patient record.
Medical Record
Also called patient chart, medical chart or patient record.
Collection of documents pertaining to a patient.
Purpose of medical record:
Communication
Documentation
Legal protection
Who does a medical record protect?
Teacher Notes:
Who does a medical record protect? Students should be able to give examples of legal protection of the patient and healthcare worker.

5. What is in a Medical Record?
Medical History
A process of questioning by a healthcare professional for the purpose of gathering information used to help diagnose and care for a patient.
The history can vary based on circumstances.
Who would take a longer medical history – a paramedic responding to a patient with chest pain,
Or a psychiatrist who is evaluating a suicidal patient?

6. What is in a Medical Record?
Physician’s Orders
Communicates patient treatment plan.
Can be handwritten,
Pre-printed and checked off,
Or printed electronically.

7. What is in a Medical Record?
Diagnostic Tests
Laboratory reports
Radiology reports
EKGs
What other diagnostic tests might be included in a medical record?

8. What is in a Medical Record?
Reports
Can include operative reports, consultations, and other important information.
Consent forms
Meet informed consent requirements
Signed by patient and witness

9. What is in a Medical Record?
Medication Records
Documentation of all medication – drug, dosage, time administered, and by whom
Progress Notes
Healthcare workers document evaluation of patient’s clinical status and achievements during a hospital stay, or over a span of time.
Physicians will update findings after seeing patient.
Therapists will note what was done and results.
Nurses record treatment they perform and patient response.

10. Problem Oriented Charting - SOAP
S - Subjective
Subjective information – sensed by the patient
Chief complaint – reason patient is seeking medical care
O - Objective
Objective information – observed by health care worker
A – Assessment
Health care professional’s assessment of what is wrong, based on signs and symptoms
P – Plan
Procedures, treatments and patient instructions
Teacher notes:
Ask students for examples of subjective information.
Ask students for examples of objective information.
PRACTICE -

11. You Try It A friend comes to you and says “I have a sore throat.”
What is S?
“My throat is sore.”
“It hurts when I swallow.”
What is O?
You look in the throat and see redness.
What is A?
Local throat irritation could be caused by a virus or strep.
What is P?
Get a throat culture.
Gargle with warm salt water
PRACTICE – Have students write their SOAP on scratch paper before revealing the possible answers.
You can make up a few more situations of your own to allow students more practice. After 3 or 4 examples, they should understand the main concepts of problem-oriented charting and the SOAP method.

12. Computerized Medical Records
It’s the wave of the future for medical records.
Where have you seen the use of computerized medical records?
Why?
Teacher notes:
Through their own experiences and television, your students are probably very familiar with the use of computerized medical records, charting, and patient documentation. For some, the last time they got a prescription for a medication, it was in the form of a signed computer print-out as opposed to being handwritten.
Ask students to suggest reasons “why” the medical community is moving steadily toward the use of computers for health information management.

13. Computerized Medical Records
Advantages
Improved legibility of charting
Quicker to record which increases efficiency
Fewer errors
Improved communication among health team members
Records easily transmitted to other hospital departments and health care providers who need them.
Teacher notes:
Students may be able to suggest even more advantages.
This may also be a good time for a personal story and/or examples. For example, years ago, if a physical therapist wanted to see something on a patient’s chart, he/she had to walk up from physical therapy to the patient care floor to physically get the chart and look at a progress note, x-ray report, etc. Now, we computerized charting, the therapist can access the record from his/her computer in physical therapy and get the same information.
In a large hospital, the time savings could really add up for the therapist.

14. Computerized Medical Records
Disadvantages
Possible system crash
Cost of converting to a computerized system – hardware, software and training costs
Potential problems with confidentiality
What do you think is the biggest obstacle?
Teacher notes:
Ask students if they think healthcare workers are ever resistant to advances in technology in a health care setting?

15. Insurance Forms and Statements
Insurance card usually photocopied
Insurance information on patient data sheet
Most agencies now file insurance claims electronically
All purpose electronic claim form is CMS- 1500

16. Coding Systems International Classification of Diseases (ICD)
Used for diagnosis coding
Teacher Notes:
Explain to students that this coding system was developed by the World Health Organization to develop and international database of diagnoses to aid in tracking the presence of disease. The codes create international consistency.
Insurance companies use the codes for data tracking and payment often in reimbursement consideration.
If a patient has more than one diagnosis, the most important diagnosis and code is listed first.

17. Coding Systems Current Procedural Terminology (CPT)
Used for procedures and services
Teacher notes:
These codes are used in the medical field for billing purposes.
The ADA publishes a code book for dental offices.
Ask students if they recall a medical office visit when the physician or other caregiver circled codes on their bill?

18. Health Careers
What healthcare professionals work most closely in health information management?
Coder – certificate level
Transcriptionist
Medical records administrator
RHIA – Registered Health Information Administrator
Degree levels from certification to Master’s degree
American Health Information Management Association
Teacher notes:
A few examples of careers are listed. For more information, have students visit the AHIMA website.