1. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1 Medical Office Administration 2nd edition Brenda A. Potter, CPC

2. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2 Chapter 9 Health Information Management

3. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3 What is Health Information Management?  Directing activities that relate to keeping patients’ medical information  Maintaining medical records  Preparing medical reports  Releasing medical information  Compiling statistics  Coding for billing and insurance

4. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4 Purposes of Recordkeeping  Documentation of care given to patient  Legal purposes  Documentation for insurance claims  Data used in planning for healthcare services  Education and research

5. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5 Types of Records  Paper  Electronic  EHR – electronic health record (preferred by AHIMA)  CPR – computerized patient record  EMR – electronic medical record  EPR – electronic patient record

6. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6 Confidentiality  All information seen, heard, and done must be kept confidential  Releasing information without permission is breach of confidentiality

7. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7 Confidentiality Agreements  All employees and volunteers should be required to sign confidentiality agreements

8. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8 Confidentiality and Computerized Records  Portion or entire record can be stored on a computer  Computer systems must be protected

9. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9 Health Insurance Portability and Accountability Act of 1996 (HIPAA)  Regulation includes  Requirements for protecting information  Patient’s right to know how information is used  Patient’s right to a copy of his/her record  Restrictions on using information  Civil and criminal penalties for violations

10. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10 Notice of Privacy Practices  Written notice detailing how the healthcare provider responsibilities pertaining to the patient’s health information  Sign and dated by patient and retained by provider

11. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11 Components of the Medical Record in a Medical Office  Summary sheet  Medical history  Progress notes  SOAP note  Chart note  Chart entries  Medication list  Immunization record

12. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12  Laboratory report  Pathology report  Radiology report  Other specialized documents  Pediatric growth chart  Pregnancy flow sheet  EKGs, EEGs, EMGs  Photographs, CDs, DVDs  Correspondence

13. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13 Entering Information in a Patient’s Record  Specific guidelines should detail  Who may document information in a patient’s record  What type of information should be documented  In a paper record  Do not leave large gaps in progress notes section  Handwritten entries done in black ink

14. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14 Hospital Records  History and Physical (H&P)  Operative report  Discharge summary

15. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15 Corrections in Records  Person making the mistake should correct the entry  Do not obliterate information  Electronic records may require an entirely new entry to correct a mistake

16. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16 Medical Transcription  Production of a typewritten report from physician’s dictation  Dictation saves time for a physician  Transcription is more legible compared to handwriting  Transcriptionists are medical language experts

17. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17 Transcription Equipment  Digital equipment is the norm  Tapes are outdated

18. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18 Signature  Reports and other documents placed in a patient’s chart must be signed or initialed by patient’s physician  Signature or initials verify that physician has reviewed documents  Electronic signatures used for electronic reports

19. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19 Organizing Medical Record  Source-oriented (SOMR)  Similar information is kept together  Most commonly used  Problem-oriented (POMR)  Information pertaining to a specific problem is grouped together

20. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20 Chart Order  Dividers can separate sections of a chart  Each office should establish specific chart order

21. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21 Documentation Guidelines  A Joint Commission requirement  Medicare 1995 documentation guidelines  Use of abbreviations  Dangerous abbreviations

22. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22 What Does Not Belong in the Record  A report without a physician's signature or initials – EVEN normal lab results  Information regarding a patient’s financial status  Callous remarks about a patient

23. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23 Records Flow  Chart is pulled for appointment  When patient is placed in exam room, chart is placed outside door  Nurse records vital signs in chart  Physician brings chart into exam room  Chart returned to records room after visit

24. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24 Quantitative Analysis  Verifies that all essential information is in chart  Incomplete records should not be filed  Deficiency form

25. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25 Filing Supplies  Charts – durable heavy-stock folder  Labels – numeric or alpha  Outguides – hold place of record

26. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26 Filing Methods  Filing should be kept up-to-date for easy retrieval of records  Numerical system  Accession ledger – tracks each chart number as assigned  Alphabetical system  Alphanumeric system

27. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27 Consecutive Number Filing  Charts filed from lowest to highest number  Easy to learn  Numbers may be transposed  Master patient index for numeric systems requires knowledge of alpha filing rules

28. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28 Terminal Digit Filing  Chart number broken into groups of numbers  Chart #145365 becomes 14 53 65  65 – primary unit  53 – secondary unit  14 – tertiary unit

29. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 29 Alphanumeric System  Combination of letters and numbers

30. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 30 Alphabetical Filing  Offices should adopt one set of rules  Every name indexed: last name, first name, MI  Complete legal name should be obtained – no nicknames  Abbreviations indexed as spelled out  Identical names filed with oldest DBO first  Nothing comes before something  Prefixes are included with name  Punctuation is disregarded  Professional and religious titles disregarded  Entry of names in computer system should be consistent  Cross-references important

31. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 31 Color Coding  Assigning a color to a letter or number  Reduces misfiles  Saves time when locating chart

32. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 32 Locating Missing Files  Check before and after the chart’s location and inside other nearby charts  Check all areas of office  Determine last department or individual who used the chart  Scan shelves for color out of place  Check areas behind shelves or drawers  If alpha filing, check other possible spellings for patient’s last name

33. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 33 Records Retention and Disposal  Verify state requirements for retention  Medicare requirements – minimum of 5 years after last visit  Minor records may have special requirements  Active record – current patient  Inactive record – patient has not received treatment in a specific period of time  Closed record – patient has died or moved away  Local obituaries should be checked with office’s patient database  Disposed records should be properly destroyed

34. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 34 Tickler File  File that reminds assistant of specific tasks  Electronic tickler files available in many computer calendar packages

35. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 35 File Storage and Protection  Lateral shelving is common and often works best  Shelving with pull-out drawers or file cabinets also used  Be aware of fire codes  Duty of medical office to protect records from destruction

36. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 36 Disaster Plan  Medical office is responsible for protecting records from destruction  Fire codes must be considered when setting up a records room  Fire suppression system  Computer backups

37. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 37 Multiple Locations  One chart may be shipped between locations  Each location may have separate chart  Electronic record ideal for multiple sites

38. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 38 Release of Information  Written documentation necessary to release information  In most instances, patient must authorize release information  Copy of release kept with patient’s record  Photocopies of records, not originals, are sent  Fax machines not encouraged for releasing information  Redisclosure – office cannot copy and release records received from another office  Release not required in some instances (small number of exceptions)

39. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 39 Ownership of Medical Record  Physician owns the paper  Patient owns the content  HIPAA standards – patient has a right to a copy of his or her record  Psychiatric records may not be released to patient

40. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 40 HIV and AIDS Records  Patients may be required to sign consent form for HIV testing  Take great care to protect record privacy  Patients may have to authorize listing the diagnosis on an insurance claim

41. Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 41 Future of Health Records  Increased use of computers for health information activities