1. Maintaining Patient Records9
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