1. Health Information Management: Electronic and Manual
Comprehensive Medical Assisting Fundamentals of Administrative Medical Assisting

2. The Health Insurance Portability and Accountability Act of 1996
Provide better access to insurance when changing jobs
Simplify claims and accelerate reimbursement
Goals
Facilitate and protect electronic communications
Protect communications between the physician and insurer
Regularize employer funding
The goals of the Health Insurance Portability and Accountability Act of 1996 (also known as HIPAA) are to:
- Simplify claims and accelerate reimbursement,
- Provide better access to insurance when changing jobs,
- Regularize employer funding,
- Facilitate and protect electronic communications,
- Protect communications between the physician and insurer.

3. The Health Insurance Portability and Accountability Act of 1996
Designated
Compliance Staff
Covered Entities
Insurance plans
Clearinghouses and providers
Transfers
Medical records
HIPAA officer
Administrative Simplification
Electronic transactions
Privacy
Security
National Identification
Entities that are covered by HIPAA include: insurance plans, clearinghouses and providers using electronic billing, transfers, and medical records.
Administrative simplification includes: electronic transactions, privacy, security, and national identification.
The designated compliance staff are: the HIPAA officer and the privacy officer.
Privacy officer

4. Releasing Medical Records
Protected Health Information
Any information linked to a specific person
Insurance plans
Clearinghouses and providers
Transfers
Medical records
Covered Entities
- Share PHI for health purposes only
- Avoid collecting unnecessary info
- Adopt written procedures
Designate a privacy officer
Train employees
PHI: Protected Health Information is any information linked to a specific person that must be protected.
Covered entities must:
Share PHI for health purposes only,
Avoid collecting unnecessary information,
Adopt written procedures,
Designate a privacy officer and train employees.
Release of any records must be authorized by the patient or the patient’s legal guardian.
Release of any records must be authorized by the patient or the patient’s legal guardian

5. Releasing Medical Records
Patients have the right to see and receive a copy of their medical records
Patients age 17 years and younger must have a signed consent from their parent or guardian
Patients have the right to see and receive a copy of their medical records. Patients age 17 years and younger must have signed consent to release their information from their parent or guardian. The physician decides what to copy.
The physician decides what to copy

6. Standard Medical Records
Examples of a Proper Authorization Release of Medical Information
Information must be:
Easily retrievable
Kept in an orderly manner
Complete
Legible
Accurate
Brief
Information on medical records must be:
- Easily retrievable
- Kept in an orderly manner
- Complete
- Legible
- Accurate
- Brief

7. Standard Medical Records
Jayne Dough
Patient Name:
Chief complaint:
Present illness:
Family and personal history:
Review of systems:
Medications Administered:
Diagnosis/Medical Impression:
Documented advance directives:
Physician/Assistant ID and signature:
X________________________________
Correspondence:
Sample Page from Patient’s Chart
Stomach ache, vomiting
None
Progress Notes
Reports:
Radiography Laboratory
Consultation
None
Food Poisoning
Hydration
Here is a sample page from a patient’s chart.
Medical records should include:
Chief complaint
Present illness
Family and personal history
Review of systems
Progress notes
Radiography, laboratory, and consultation reports
Medications administered
Diagnosis or medical impression
Documented advance directives
Physician’s or assistant’s ID and signature
Correspondence
Doc Terr

8. Electronic Medical Records
May include demographic and practice data only or the complete chart
ADVANTAGES
Electronic medical records may include demographic and practice data only or the complete chart.
Advantages are:
- Legibility (since handwriting can be hard to read)
- Easy storage and retrieval (You can search electronically rather than sorting through pages)
- Mandatory, error-trapped data entry
Diminished need for paper and storage space
Disadvantages are:
Downtime, equipment, and software failures
Cost
Security issues
Increased need for staff training to use the software
DISADVANTAGES
Legibility
Easy storage and retrieval
Mandatory, error-trapped data entry
Diminished need for paper and storage space
Downtime, equipment, and software failures
Cost
Security issues
Increased need for training

9. Electronic Medical Records
SECURITY
Need-to-know access
Firewall
Secure remote backup
To maintain security:
Use need-to-know access by limiting information access only to people who really need to see it;
Use a firewall;
Utilize secure remote backup (This means that files are backed up regularly and stored off-site);
Use password protocols;
Practice confidentiality policy, training, and discipline; and
Make sure all equipment is secure including all PDAs, laptops, and PCs.
Password protocols
Confidentiality policy, training, and discipline
PDAs, laptops, and PCs

10. Medical Record Organization
Formats
Narrative
(least structured)
Every provider encounter must be documented
Subjective Objective Assessment Plan
SOAP
Problem Oriented Medical Record
POMR
Every provider encounter must be documented.
The 3 formats are:
Narrative,
Subjective Objective Assessment Plan,
Problem-Oriented Medical Record, which is keyed to the patient’s specific medical problems. It has four components: database, problem list, treatment plan, and progress note.
Keyed to the patient’s specific medical problems
Database
Problem List
Treatment Plan
Progress Note

11. Documentation Forms Medical history forms Flow Sheets Progress Notes
Documentation forms and charts save space and time, and facilitate retrieval
Medical history forms
Flow Sheets
Progress Notes
Documentation forms and charts save space and time, and facilitate retrieval.
Some printed forms to keep on-hand are:
Medical history forms,
Flow sheets, and
Progress notes.

12. Medical Record Entries
Document every patient visit
The medical record should be:
Complete
Accurate
Legible
Document every external communication
Patients
Third
Parties
Include original documents
Transcribe or “shingle” for standard-size paging
The medical record should be complete, accurate and legible.
Don’t forget to:
Document every patient visit,
Document every external communication,
Include original documents, and
Transcribe or “shingle” for standard-size paging.

13. Workers’ Compensation Records
Open a new chart
(even for an existing patient)
These records belong to the employer
Maintain the record
for 2 years after
the last date of
treatment
Maintain data alongside
(not in) the existing chart
Exclude information not
directly pertinent
Previous health and family
history
Workers’ compensation records belong to the employer.
When opening a new chart, maintain data along side (and not in) the existing chart, exclude information that is not directly pertinent, and include previous health and family history.
Maintain the record for 2 years after the last date of treatment.
And always obtain verification before treating.
Obtain verification before treating

14. Storing Medical Records
Medical Record Preparation
Establish a routine
Replace worn folders and labels
Keep track of location with an “outguide” or barcode system
Prepare your medical records by:
- Establishing a routine,
- Replacing worn folders and labels, and
Keeping track of their location with an “outguide” or barcode system.
When filing medical records:
File them daily to keep charts current,
Shred records after scanning, and
Condition, index, sort, and store hardcopy records.
Filing Procedures
File daily to keep charts current
Shred records after scanning
Condition, index, sort, and store hardcopy records

15. Filing Systems Alphabetic Filing Numeric Filing Other Systems
Dough, Jayne, T.
For non-patient records
04/13/1980
04/13/1980
Isolate a cross reference index for confidentiality
By “unit” (e.g., last name, first name, middle name)
Birthdate
Color coding
May be read as:
Single digits
Pairs
Pairs in reverse order (terminal digit filing)
The alphabet filing system files by unit. If all units are the same, use the birthdate. This system can also be supplemented with color coding.
When using the numeric filing system, isolate a cross-reference index for confidentiality. Six digits may be read as: single digits, pairs, or pairs in reverse order.
Other systems can be used for non-patient records.

16. Storing Health Information
When storing medical records:
Shelf files with side labels
Drawer files are more convenient but use more space
Rotary circular or lateral files use the least space
Saved
Information
Safe
Fireproof
Remote
Electronic data must be backed up daily to a safe, fireproof, remote location. Backup may be “hot” which means files are backed up in real-time, or “inactive” which means files are backed up on a schedule.
When storing medical records, keep the following in mind:
- Shelf files with side labels.
- Drawer files are more convenient but use more space.
- Rotary circular or lateral files use the least space.
Backup may be “hot” or inactive

17. Storing Health Information
Classification of Records
Storage
ACTIVE
Patients seen within recent years
INACTIVE
Patients not seen recently
CLOSED
Patients who have terminated the relationship
Classify records accordingly:
Active records are for patients who have been seen within recent years. Store these for easiest access.
Inactive records are for patients who haven’t been seen recently. Store these records out of the way.
Closed records are for patietns who have terminated the relationship. It’s best to store these on microfilm or microfiche.
Storage

18. Record Retention
Record Retention.
Records MUST be kept until the statute of limitations has tolled.
Records SHOULD be kept permanently if feasible.
Records in closing practices should be released to patients.
Records must be kept until the statute of limitations has tolled.
Records should be kept permanently if feasible.
Records in closing practices should be released to patients.

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