Allied Health Assisting

Allied Health Assisting
Chapter 13: The medical record, documentation, and filing

The purpose of records A complete accurate medical record is necessary
Personal information Medical history Family history Social habits Medications Occupational exposures Different types of testing performed

The purpose of records Personal information includes Gender Ethnicity
Religion Age Marital status Living arrangements Children Occupation Insurance information

The purpose of records Medical record serves as a way to maintain and document the course of medical evaluations, treatments, and changes in condition Charting Lays out a chronological account of the patient reports, providers evaluation, prescribed treatment, and responses to treatment Provides legal protection for both the patient and provider Used for insurance purposes Conducting research

HIPAA and the medical record
Health Insurance Portability and Accountability Act Established in 1996 Privacy of patient information is main focus Pertain primarily to records management Maintaining the privacy of health information Establishing standards for any electronic transmission of health information and related claims Ensuring the security of all electronic health information

HIPAA privacy rule for all medical data Effective in 2003 Provides standards for patients’ confidential, personal information Medical facilities need to limit what information was released and who it was released to HIPAA is more lenient than most realize The privacy rule allows each organization to do what it feels is reasonable within the maintained guidelines Most institutions employ a HIPAA office Understand the rulings Train the staff Keep up with changes

HIPAA security rule Ensure confidentiality, integrity, and availability of all electronic protected health information (PHI) the providers compose, receive, or maintain, or send out Have policies and procedures in place to protect against use or disclosures of the electronic information that is not required or permitted under the Privacy Ruling Have policies and procedures in place to protect against threats or hazards to the PHI records Demonstrate compliance with the Security Ruling within the workplace

Centers for Medicare and Medicaid Services (CMS) can audit and ask for documentation of compliance with the Security Rule Administrative safeguards Physical safeguards Technical safeguards Organizational requirements Documentation New employee orientation and periodic updates should include training in maintaining security of records

Electronic health records
National Alliance for Health Information Technology (NAHIT) has established definitions for: Electronic Medical Records (EMR) Electronic record of health-related information for an individual that is created, gathered, managed, and consulted by licensed clinicians as staff that is maintained through a single organization Electronic Health Record (EHR) Differs from EMR is that is it the aggregate electronic record of health-related information that is created and gathered cumulatively across more that one organization Personal Health Records (PHR) Collection of medical records compiled and maintained by the individual

EHRs provide improved management of patient records Facilitate more efficient billing services Federal government provides incentives for practices to convert to EHRs Provider must satisfy meaningful use Practice must actually use the system, not just have it in place 40% of prescriptions must be submitted electronically Provide patients with copies of their health information within 3 days more than 50% of the time Obtain patient demographic data a minimum of 50% of the time

Advantages of EHRs Availability of a searchable database that records patients’ demographics, allergies, lab results, and improved accessibility of the record to health care providers Radiology and laboratory departments that can transmit results directly to the provider, reducing the time to treatment and notification of critical values Electronically entered prescriptions that minimize errors related to illegible handwriting and reduce the time for prescriptions to be available to the patient. Software also screens medications for interactions and allergies Aiding in reminding the health care provider when routine testing should occur, such as mammography, vaccinations, and cardiovascular procedures In a multi-specialty facility or practice, facilitating coordination of care among providers and elimination duplicate or incomplete testing and treatment

Advantages of EHRs Chart notes that can be available immediately when a patient needs a referral or consultation with another provider Voice recognition software that improves availability of printed records and decreases costs by eliminating the need for transcribing dictated notes Assigning the CPT and ICD codes at the time of the visit, streamlining the process of insurance filing A photograph of the patient, which can be included in some software applications to ensure the correct record has been selected Trending that might help identify problems that might not be identified as early when using traditional paper records Does not completely eliminate the need for paper records

Parts of the medical record
Divided into the following sections Administrative data Financial and insurance information Correspondence Referral Past medical records Clinical data Progress notes Diagnostic information Lab information medications

Subjective vs. Objective Information Subjective Supplied by the patient Signs Symptoms Complaints Objective Can be measured Seen touched

Administrative, financial, and insurance information Demographic and insurance information should be verified every visit Good idea to post a sign saying, “Do we have your current address and phone number?” Maintain accurate documentation of insurance and payment information

Correspondence and referrals All correspondence received, whether medical or financial, should be maintained in the record Referral or follow up letters from specialists Letters from insurance Correspondence from the patient In the EHR, correspondence is scanned and uploaded in the patients chart

Progress Notes Documents the progress of each patient Entered in chronological order Provider’s “Journal” Chief Complaint Brief description of why the patient came in In the patient’s own words Diagnostic Imaging Information Results from X-rays, CT scans, MRI’s, Ultrasounds, etc Dictated by Radiologist CD, DVD, Film copies Must request electronic format, if not just dictated report will be sent

Lab Information Any critical values should be highlighted Placed in chronological order with most current first Separated into groups

Medications All medications administered are documented Entry includes: Prescriber Medication name Dose Frequency Route Time given Observation period Copies of prescriptions

Charting in the patient record
Problem-Oriented medical record (POMR) Developed by Lawrence L. Weed M.D. in early 1970’s Progress notes are organized based on the source from which they come Works well in group settings Promotes continuity of patient care Same system incorporated into the EHR’s of today

SOAP Subjective impressions Objective Clinical Evidence Assessment or diagnosis Plans for further studies, treatment, management

SOAP Process makes the chart easier to review and helps in follow-up Example: Pt complains of two days of sever high epigastric pain and burning, radiating through the back. Pain accentuated after eating On examination there is extreme guarding and tenderness, high epigastric region, no rebound. Bowel sounds normal. BP 110/7, P 66, R 18 R/O gastric ulcer, pylorospasm Pt to have upper gastrointestinal series, Start on Cimetidine 300mg daily. Eliminate coffee, alcohol, ASA, and return in two days.

HPIP History Physical exam Impression Plan

HPIP Similar system to SOAP Example: C/O severe H/A Rt side of his head lasting several hours to up to 3 days; has had 4 in the past 6 wks, pain is increasing each time; takes ASA for pain. Neurologic exam shows slight tremor in both hands. R/O encephaloma. CAT scan o cranium. Refer to Clearbrook Neurological Associates

CHEDDAR Another method for charting that encourages providers to include greater detail than SOAP or HPIP Chief Complaint: Presenting problem. Should be recorded in the patients words Any unusual descriptions should be put in quotes As much subjective information should be obtained as possible History A list of patient’s prior medical history Social history Relevant family history

CHEDDAR Examination Objective findings by the examiner Details of problems and complaints Results of additional testing Drugs and dosages Complete list of ALL medications, both prescription and OTC Vitamins and supplements too Assessment Diagnosis Appropriate treatment Further testing

CHEDDAR Return visit Indicate if a return or follow-up visit is required

Dating, Correcting, and Maintaining the Chart
Date and time should always be notes when making any entry in the chart Always use military time In EHR’s date and time is automatically stamped Any entries in the chart must be signed by the person who made them Corrections and late entries Single line through incorrect entry Correct above or following Initial Time and date

Only use BLACK pen When you are finished with the chart, straighten and tidy the forms File the chart appropriately ASAP Transcribe dictated notes ASAP

Use the following steps for proper records Read accurately and spell names correctly Print or write legibly with black ink Record information as soon as possible Make corrections by drawing one line through the error Keep charts neat and file them in a timely manner

Tracking Medical Records Every office has a system to track outstanding work This work must be completed before releasing the chart to be filed EHR’s may have prompts to show what records are waiting

Filing medical records
Even with the use of electronic resources, proper filing is necessary Include staff needs and limitations in determining what filing system is needed Safety is an important consideration when working with filing cabinets Place files in bottom drawers first

Steps in filing Step one: Inspecting CMAA is usually first one to inspect reports Divided into negative/normal and positive/abnormal for provider to read Provider should review all reports Provider makes check mark in upper right corner and circles any abnormal findings in red Makes notation about follow up

Steps in filing Step two: Indexing Requires you to make a decision about the name, subject, or other identifier under which you file the material Materials for patients should be filed under patient name Research papers can be filed under illness, procedure, treatment, medication, or author A cross-reference can be helpful in finding things later

Steps in filing Step three: Coding Done by marking the index identifier on the papers to be filed If the name, subject, or a number appears on the paper, underline it, or circle it, or highlight it If it does not appear, write in the upper right corner

Steps in filing Step four: Sorting Place in alphabetical order

Steps in filing Step five: Storing Locate the file drawer or shelf with the appropriate caption Find the folder where the reports are stored Place on flat surface before adding any material Place back in drawer or on shelf IN ORDER!!

Filing Supplies Guides OUTguides Folders Vertical pockets Index tabs labels

Filing systems Most filing systems are based directly or indirectly on alphabetic arrangement Simplest and most common method of filing Numeric Filing Material is arranged in numeric order in the main file Main file is supplemented by an alphabetically arranged card index Subject filing Based on an outline or classification of the subject matter Reference materials Geographic Arranged alphabetically by political or geographic subdivisions Chronologic Filed according to the date, with the most current first

Rules for alphabetic filing
In filing the names of persons, the surname is considered first, the first name or initial second, and the middle name or initial third Ex. John E. Brown is filed as Brown, John E.

Names are filed alphabetically in an A-to-Z sequence from the first to the last letter, considering each letter in the same separately and each unit separately When the surnames of two persons are spelled differently, the first and middle names or initials are not considered When a shorter surname is identical with the first part of a longer surname, the shorter names is listed first. The rule is sometimes states as “nothing before something” When the surnames are alike, the order in filing is determined by the first names or initials. When surnames and first names are alike, the middle name is used

An initial is listed before a name beginning with the same letter. This again is an example of “nothing before something” An abbreviated first or middle name is treated as if it were spelled out in full.

Examples: Allard, Wm. Allen, E.S. Allen, Edna Allen, Wm. A. Allen, William C. Allens, M.R.

A prefix, such as Mc, Mac, De, Le, and Von, is considered as part of the surname Example: MacAdams, Bruce McAdams, Helen

Most firm names are filed as they are written. The apostrophe is disregarded in filing. Example: Herb’s Auto Service Walters Printing Company

Firm names that include the full name of an individual are filed with the name of the individual transposed Example: Edward Wenger Company is filed as Wegner, Edward Company

When the article the is part of a title, it is placed in parentheses and disregarded in filing Example: Sam the Barber is filed as Sam (the) Barber The Family Steakhouse is filed as Family Steakhouse (The)

And, for, of, and so on are disregarded in filing but are not omitted Example: Adams & Smith Pharmacy is filed as Adams (&) Smith Pharmacy

Abbreviations such as Co., Inc., or Ltd., in a firm name are indexed as though spelled out Example: Frank Smith Co. is filed as Smith, Frank Company

Hyphenated surnames and hyphenated firm names are indexed as one unit Example: Dunning-Lathrop & Assoc. Inc. is filed as Dunning-Lathrop (&) Associates, Incorporated Lester Smith-Mayes is files as Smith-Mayes, Lester

Numbers are usually filed as spelled out Example: 5th Avenue Store is filed as Fifth Avenue Store

Professional or honorary titles are not considered in filing but should be written in parentheses at the end of the name for identification purposes Example: Dr. Anne Lewis is filed as Lewis, Anne (Dr.) Titles are filed as written when they are part of a firm name. Foreign or religious titles followed by one name are also filed as they are written Dr. Scholl’s Foot Powder Prince Phillip

Terms of seniority, such as Junior, Senior, Second, or Third, are not considered in filing. If two names are otherwise identical, the address is used to make the decision Example: Keir, Willard, Sr. (Cleveland, Ohio) Keir, Willard, Jr. (Columbus, Ohio)

File the names of federal, state, or local government departments first by political division and then by the name of the department Example: Drug Enforcement Administration, Cincinnati, Ohio, is files as Cincinnati, Drug Enforcement Administration, Cincinnati, Ohio

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