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Maintaining Patient Records

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1 Maintaining Patient Records
9 Maintaining Patient Records

2 Introduction Medical records document the evaluation and treatment of patients Critical to patient care Sectioned to describe various aspects of patient information and care Legal documents Medical assistant has a major role in documenting in and maintaining patient records Learning Outcome: 9.1 Explain the purpose of compiling patient medical records. Parts of a medical record Personal information or data Physical and mental condition Medical history Medical care Medical future if patient is referred to other physicians

3 Importance of Patient Records
The patient’s chart Past and present medical conditions Communication tool for health-care team Plan to provide for continuity of care Documentation for billing and coding Patient education and research Legal document admissible in court Learning Outcomes: 9.1 Explain the purpose of compiling patient medical records. 9.2 Describe the contents of patient record forms. Chart should be consistently updated whenever patient has contact with office.

4 Importance of Patient Records (cont.)
Information included in patient record Name and address Insurance coverage and person responsible for payment Occupation Medical history Current complaint Health-care needs Medical treatment plan Response to care Lab and radiology reports Learning Outcomes: 9.1 Explain the purpose of compiling patient medical records. 9.2 Describe the contents of patient record forms.

5 Legal Guidelines for Patient Records
Proof of event or procedure No documentation – no proof that care was done Legal document Must document complete information about patient care Document if patient is noncompliant Learning Outcomes: 9.1 Explain the purpose of compiling patient medical records. 9.2 Describe the contents of patient record forms. Medical records must be kept for 7 years Pediatric records: 7 years from age of majority Many legal experts recommend 10 years instead of 7 Noncompliant: Patient who does not follow the medical advice he or she has been given.

6 Standards for Records Complete, accurate, and well-documented records are evidence of appropriate care Incomplete, inaccurate, altered, or illegible records may imply a poor standard of care Everyone who documents in the patient record has a responsibility to the patient and employing physician Learning Outcome: 9.1 Explain the purpose of compiling patient medical records. 9.5 Discuss the needs for neatness, timeliness, accuracy, and professional tone in patient records.

7 Patient Records Additional Uses of Patient Records
Quality of Treatment Patient Education Peer review TJC review Health-care analysis and policy decisions Research Test results Health issues Treatment instructions Learning Outcomes: 9.1 Explain the purpose of compiling patient medical records. 9.2 Describe the contents of patient record forms. Source of data

8 Apply Your Knowledge Good Job!
What is the purpose of documentation in a patient’s medical record? ANSWER: Documentation in the medical record provides evidence of appropriate care. If a procedure is not documented, it is considered not done. Good Job!

9 Standard Chart Information
Patient Registration Form Date Patient demographic information Age, DOB Address SSN Insurance/financial information Emergency contact Learning Outcome: 9.2 Describe the contents of patient record forms. The completed patient registration form is the basis of each patient’s financial record, which is created and filed separately from the medical record.

10 Standard Chart Information (cont.)
Patient medical history Illnesses, surgeries, allergies, and current medications Family medical history Social history (diet, exercise, smoking, use of drugs and alcohol) Occupational history Current patient complaint recorded in patient’s own words Learning Outcome: 9.2 Describe the contents of patient record forms. Medicare and managed care plans now require the patient’s complaint to be entered into the medical record. The patient medical history forms the basis for each patient’s medical record.

11 Standard Chart Information (cont.)
Physical examination results Results of laboratory and other tests Records from other physicians or hospitals Include a copy of the patient consent authorizing release of information Learning Outcome: 9.2 Describe the contents of patient record forms.

12 Standard Chart Information (cont.)
Doctor’s diagnosis and treatment plan Treatment options and final treatment list Instructions to patient Medication prescribed Comments or impressions Operative reports, follow-up visits, and telephone calls These are part of the continuous patient record Document calls made to and from the patient Learning Outcome: 9.2 Describe the contents of patient record forms. Continuation of the medical record lasts as long as the patient is under the doctor’s care.

13 Standard Chart Information (cont.)
Informed consent forms Verify that the patient understands procedures, outcomes, and options Patient may withdraw consent at any time Hospital discharge summary forms Information summarizing the patient’s hospitalization Instructions for follow-up care Physician signature Learning Outcome: 9.2 Describe the contents of patient record forms.

14 Standard Chart Information (cont.)
Correspondence with or about the patient All written correspondence regarding the patient Record date item was received on the actual form Information received by fax – request an original copy Date and initial everything you place in the chart Learning Outcome: 9.2 Describe the contents of patient record forms.

15 Apply Your Knowledge Correct!
What section of the patient record contains information about smoking, alcohol use, and occupation? ANSWER: Information about smoking, alcohol use, and occupation is part of the patient’s past medical history. Correct!

16 Initiating and Maintaining Patient Records
Completing medical history forms Documenting test results Initial Interview Examination, preparation, and vital signs Documenting patient statements Learning Outcome: 9.3 Describe how to create and maintain a patient record. Documenting patient statements Record any signs, symptoms, or other information in the patient’s own words Record information in specific details Conduct interview in private room Do not include your opinion Exam prep Record vital signs Record medications patient is currently taking Record responses to treatment Ask patient, “Is there anything else you would like the doctor to know?” Maintain patient privacy during interview

17 Initiating and Maintaining Patient Records (cont.)
Follow-up Transcribe notes the doctor dictates Post results of laboratory tests and examinations Record all telephone communication with the client Record all medical or discharge instructions given to the client Learning Outcome: 9.3 Describe how to create and maintain a patient record. Documentation of telephone communication Date Content of conversation (document the call even if no one answers) Your initials

18 Right! Apply Your Knowledge
In addition to transcribing notes the doctor dictates and posting lab results, what are two other follow-up tasks the medical assistant might be required to perform as part of follow-up to a patient appointment? ANSWER: The medical assistant may have to record telephone calls with the patient, as well as medical or discharge instructions given to the patient. Right!

19 The Six Cs of Charting C Client’s words – Clarity – Completeness – C
onciseness – Chronological order – confidentiality – Do not interpret patient’s words Precise descriptions/medical terminology Fill out forms completely To the point/approved abbreviations Learning Outcomes: 9.3 Describe how to create and maintain a patient record. 9.4 Identify and describe common approaches to documenting information in medical records. Legal issues Follow HIPAA guidelines

20 Apply Your Knowledge Great! What are the six Cs of charting?
ANSWER: The six C’s of charting are Client’s words Conciseness Clarity Chronological order Completeness Confidentiality Great!

21 Types of Medical Records
Source-Oriented Medical Records Problem-Oriented Medical Records Conventional approach Information is arranged according to who supplied the data Problems and treatments are on the same form Difficult to track progress of specific events POMR records make it easier to track specific illnesses Information included Database Problem list Educational, diagnostic, and treatment plans Progress notes Learning Outcome: 9.4 Identify and describe common approaches to documenting information in medical records. POMR sections Database: Record of patient’s history and information from initial patient interview Findings and results from physical examinations Tests, x-rays, and other procedures Problem list: Each problem is given its own number and is dated Problem is identified by number throughout record Educational, diagnostic, and treatment plan Diagnostic workups, treatments, and instructions for the patient Progress notes Patient’s condition, complaints, problems, treatment, and responses to care. Arranged in chronological order Signs: Objective, external factors that can be seen or felt by the physician or measured by an instrument. Symptoms: Subjective, internal conditions felt by the patient.

22 Types of Medical Records (cont.)
SOAP documentation Orderly series of steps for dealing with any medical case Lists the following Patient symptoms Diagnosis Suggested treatment SOAP Learning Outcome: 9.4 Identify and describe common approaches to documenting information in medical records.

23 SOAP Documentation P A O S lan ssessment bjective data ubjective data
The treatment plan to correct the illness or problem The impression of the patient’s problem that leads to diagnosis P lan What the physician observes during the examination A ssessment Information the patient tells you O bjective data Learning Outcome: 9.4 Identify and describe common approaches to documenting information in medical records. SOAP notes can be used with both conventional and POMR charts. Use only approved medical abbreviations. S ubjective data

24 CHEDDAR Format Expands on SOAP format C
Chief complaint, presenting problems, subjective statements H History: social and physical history E Examination Learning Outcome: 9.4 Identify and describe common approaches to documenting information in medical records. D Details of problem and complaints D Drugs and dosage A Assessment of diagnostic process and diagnosis R Return visit information or referral

25 Apply Your Knowledge Label the following items as either (S) “subjective” or (O) “objective.” ____ headache ____ pulse 72 ____ vomited x 3 ____ nausea ____ skin color ____ respirations 16, labored ____ chest pain ____ poor appetite S O O S O O S S

26 GOOD! Apply Your Knowledge
What type of documentation expands on the SOAP format? ANSWER: CHEDDAR format of documentation. GOOD!

27 Appearance, Timeliness, and Accuracy of Records
Neatness and legibility Use a good-quality pen Blue ink is preferred (differentiates original from copy) Highlight critical items such as allergies Handwriting must be legible Make corrections properly Learning Outcome: 9.5 Discuss the needs for neatness, timeliness, accuracy, and professional tone in patient records.

28 Appearance, Timeliness, and Accuracy of Records (cont.)
Record all findings as soon as they are available For late entries, record both original date and current date Record date and time of telephone calls and information discussed Retrieve file quickly in event of an emergency Learning Outcome: 9.5 Discuss the needs for neatness, timeliness, accuracy, and professional tone in patient records. Medical records must be readily available when a doctor or other health-care professional needs them.

29 Appearance, Timeliness, and Accuracy of Records (cont.)
Check information carefully Never guess or assume Double-check accuracy findings and instructions Make sure most recent information is recorded Learning Outcome: 9.5 Discuss the needs for neatness, timeliness, accuracy, and professional tone in patient records.

30 Appearance, Timeliness, and Accuracy of Records (cont.)
Professional attitude and tone Record patient comments in his or her own words Do not record your personal or subjective comments, judgments, opinions, or speculations Learning Outcome: 9.5 Discuss the needs for neatness, timeliness, accuracy, and professional tone in patient records. You may call attention to problems or observations by attaching a note to the chart, but do not make such comments part of medical record.

31 Electronic Health Records
Essential to quality of health care and patient safety Advantages Fewer lost records Reduced transcription costs Readability/legibility Chart access after hours Easier access to patient education materials Improved billing Disadvantages Costly Retraining of staff IT staff may be needed Possible damage to software and system Learning Outcome: 9.10 Discuss the advantages and disadvantages of the electronic medical record, also known as the electronic health record. Medical records software vendors Medicware.com Allscripts (merged with Misys Computer Systems) Powermed.com Medicalcharting.com Before choosing an EHR system, compare available software Is the product licensed? What does each license actually provide? What technical support is available, and when? Is there a cost for technical support? How much? How is text imported into the system? Which image formats will the system support? What printers will the system support? What if you need to replace the system? Is everything in writing?

32 Electronic Health Records (cont.)
Advantages of computer records Can be accessed by more than one person at a time Can be used in teleconferences Useful for tickler files Security concerns – protect patient confidentiality Learning Outcome: 9.10 Discuss the advantages and disadvantages of the electronic medical record, also known as the electronic health record. Security concerns Records must be backed up on a regular basis to avoid data loss Policies must be in place to protect security and confidentiality

33 Apply Your Knowledge Very Good!
What is important to remember when you are documenting in the medical records? ANSWER: It is important that medical records be neat and legible, timely, accurate, and maintain a professional tone. Very Good!

34 Medical Transcription
Transcription means transforming spoken words into written format Dictated information is part of the medical record and must be kept confidential Date and initial each transcription page Strive for ultimate accuracy and completeness of transcribed information Learning Outcome: 9.6 Discuss tips for performing accurate transcription. Abbreviations in transcribed documents: “When in doubt, spell it out.”

35 Medical Transcription (cont.)
Transcribing direct dictation Use a writing pad and pen that will not smear Use incomplete sentences and phrases to keep up with physician’s pace Use abbreviations accurately Ask for clarification immediately if something is unclear Read the dictation back to verify accuracy Enter notes into patient record, date, and initial Learning Outcome: 9.6 Discuss tips for performing accurate transcription.

36 Medical Transcription (cont.)
reference books Medical terminology books Transcription Aids Learning Outcome: 9.6 Discuss tips for performing accurate transcription. Secretarial books Medical reference books

37 Apply Your Knowledge Excellent!
When taking direct dictation, when should you clarify information if you do not understand something? ANSWER: You should immediately clarify information that you do not understand when taking direct dictation. Excellent!

38 Correcting and Updating Patient Records
Medical records are created in “due course” Legal term meaning information is to be entered at the time of occurrence Information corrected or added after patient’s visit is regarded as “convenient” Make corrections as soon as possible after the original entry was made Learning Outcomes: 9.7 Explain how to correct a medical record. 9.8 Explain how to update a medical record. “Convenient” entries can damage a physician’s position in a lawsuit.

39 Correcting Patient Records
When mistakes happen, correct them immediately Draw a line through the original information It must remain legible Insert correct information above or below original line or in margin Document why correction was made Date, time, and initial correction Have a witness, if possible eror m/d/yyyy 00:00pm misspelled JHC /chj Learning Outcome: 9.7 Explain how to correct a medical record. If changes are not made correctly, the medical record can become a legal problem for the physician. error

40 Updating Patient Records
Additions to record should not appear deceptive Document why late entry is made Date and initial added items May have a third party witness addition Learning Outcome: 9.8 Explain how to update a medical record. Follow the detailed guidelines in your organization for late entries to a patient’s chart. Addition made to record because patient called back with additional information. Mm/dd/yyyy – JHC / chj

41 Apply Your Knowledge Super Job!
What is the appropriate way to correct an error in a patient’s medical record? ANSWER: To correct an error in a patient’s medical record: Draw a line through the original information It must remain legible Insert correct information above or below original line or in margin Document why correction was made Date, time, and initial correction Super Job!

42 Release of Information to HMO Insurance Company
Release of Records Records are property of the practice Contain confidential patient health information Must have patient’s written consent to release Exceptions: cases of contagious disease or court order Release of Information to HMO Insurance Company I authorize Dr. J. Jones to release my health-care information to the above-named insurance company. Christopher Hansen mm/dd/yyyy Patient Signature Date Learning Outcome: 9.9 Identify when and how a medical record may be released. Releasing information to insurance companies Under no circumstances should you release patient information to insurance companies over the telephone. Release the information in writing after the patient has signed a written release statement. All requests to release medical records should be approved by the physician.

43 Release of Records (cont.)
Procedures for releasing records Obtain a signed and newly dated release form authorizing the transfer of information, and place it in the patient’s record Make photocopies of original materials Copy and send only documents covered in the release authorization Call to confirm receipt of materials Learning Outcome: 9.9 Identify when and how a medical record may be released. Transfer: Giving information to another party outside the physician’s office. Verbal consent in person or over the telephone is not considered a valid release. Do not send originals unless Required by a court of law Originals cannot be copied (x-rays) When sending originals, require their return and follow up with recipient until they are returned.

44 Release of Records (cont.)
Special cases Divorce – legal guardian of children (may be one or both parents) Death – next of kin or legally authorized representative If unsure, ask supervisor Confidentiality 18-year-olds are considered adults in most states Legal and ethical principle: Protect patient’s right to privacy at all times. Learning Outcome: 9.9 Identify when and how a medical record may be released. Confidentiality and adulthood When a person reaches the age of legal adulthood in your state, no one, including the person’s parents, may see their medical records without their consent. In some states, the right to privacy is extended to emancipated minors (living on their own, married, or in the armed services).

45 Nice Job! Apply Your Knowledge
The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another physician’s office. What would you do in this situation? ANSWER: It is difficult to know the actual originator of a fax transmittal and to verify the signature. The safest solution would be not to release any information based on a fax request and release of information form. Request the original form. Nice Job!

46 In Summary 9.1 Patients’ records should be compiled because they serve as legal documents, and may be used in medical malpractice cases and lawsuits. 9.2 The content of a patient record consists of standard chart information; information received by fax; dating and initialing of patients’ charts.

47 In Summary (cont.) Include Maintain the charts properly
9.3 To create and maintain patient records forms Include Registration form Medical history Exam results, lab and other tests Records from other physicians and hospitals Diagnosis and treatment plans Operative reports, consent forms, discharge summaries Correspondence with or about patients. Maintain the charts properly Documenting detailed notes about the contact with the patient, patient responses and progress, and treatment outcomes.

48 In Summary (cont.) 9.4 The most common approaches in documenting information into medical records is through Conventional or Source Oriented records, Problem-Oriented Medical Records (POMR), SOAP, and CHEDDAR. 9.5 Neatness, legibility, accuracy, and professional tone are musts in maintaining medical records.

49 In Summary (cont.) 9.6 When performing accurate transcription:
Use incomplete sentences or phrases to keep up with the physician’s pace Use abbreviations whenever possible If physician speaks fast, ask him or her to speak slower and more clearly Read dictation back to physician for clarity Enter notes into patient record.

50 In Summary (cont.) 9.7 When correcting medical records, make sure you correct as soon as possible. Use appropriate procedure to make corrections. 9.8 Each item that is added to the patient record as an update should be dated and initialed. If the information is extremely important, get a third party to witness and initial and date as well.

51 In Summary (cont.) 9.9 Medical records can only be released with patient’s written consent or subpoena by the courts. Consent form must be on file. 9.10 The advantages of the electronic medical record outweigh the disadvantages. Evaluate software before purchasing. Maintain sensitivity to patient needs.

52 End of Chapter 9 Organization is the power of the day; without it, nothing is accomplished. ~ Sophia Palmer From A Daybook for Nurses: Making a Difference Each Day


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