1. Medical Records Management
Chapter 14
Medical Records Management

2. Medical Records Management and the TPMS

3. Ownership of Medical Records
The property of the one creating the record
Information belongs to the patient and is protected with privacy and confidentiality
Patients are allowed access to their medical records and can ask that certain material be added or excluded from their file

4. Ownership of Medical Records
Providers who involve their patients in their medical record keeping foster trust and respect with their patients

5. The Purpose of Medical Records
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6. The Purpose of Medical Records
Provide a base for managing patient care
Provide interoffice and intraoffice communication as necessary
Determine any patterns that surface to signal the provider of patient needs

7. The Purpose of Medical Records
Serve as a basis for legal information necessary to protect providers, staff, and patients
Provide clinical data for research
(See Figure 14-1)

8. Authorization to Release Information
Even release of information required of a subpoena requires notification of the patient
Patients must sign a release form if information is to be given to others
May be yearly, when accepting insurance coverage, on case-by-case basis
Should be very specific in what information is and what information is not to be released

9. The Importance of Accurate Medical Records
Accuracy is essential to patient care
Critical to the facility’s smooth functioning
Necessary when referring patient to specialists
May be needed in litigation

10. Correcting Medical Records
On paper or in a manual medical record
Draw single line using red pen through the error
Make the correction
Write Corr. or Correction above the area corrected
Indicate your initials and current date
Never obliterate
Forensic experts are able to determine when and how corrections were made
(Procedures 14-4 and 14-5 in text)

11. Correcting Medical Records
Errors in EMRs
Draw a line through the error (using the “tracking” device in the word processing software)
The correction is made immediately after the information lined out
“Corr.” or “Correction” is indicated with your initials and date correction made
EMR software locks out any chart additions after a specified time

12. Correcting Medical Records
If information or a chart has been sent elsewhere, make a copy of the corrected information and send it ASAP

13. Manual or EMRs
Americans are to have EHRs by 2014 and e-prescribing of Medicare medications may be mandatory by 2011
Manual
Advantages
Established and understood
Easier to protect confidentiality
No worry of computer malfunction

14. Manual or EMRs Manual Disadvantages
Can be used by only one person at a time
Easily misplaced or misfiled
Great amount of equipment and storage space required
More susceptible to error

15. Manual or EMRs Electronic Advantages Multiple users possible
Not easily misplaced or misfiled
Data and patterns in data more easily accessed
Quickly available in emergencies
Office storage space not a problem
Legible and organized patient documentation
Improved medical management
Improved quality of care

16. Manual or EMRs Electronic Disadvantages
Need protection to prevent loss of data and security
Expensive to establish and maintain
May require on-site assistance
Can require up to 12 weeks for staff to prove productive

17. Manual or EMRs
Chosen records system must fit the facility and needs of providers
Must provide easy retrieval
Must be easily understood and grammatically correct

18. Types of Medical Records
Problem-Oriented Medical Records (POMRs)
Identifies problems numerically as listed by patients
Readily identifies frequency of recurring problems
Nearly always use SOAP/SOAPER for progress notes

19. Types of Medical Records
Source-Oriented Medical Records (SOMRs)
Groups information chronologically and by source
Makes it difficult to quickly assess a patient’s clinical picture

20. Equipment and Supplies
Vertical files
Open-shelf lateral files
Movable file units
File folders
Identification labels

21. Equipment and Supplies
Guides and positions
Used to separate file folders
Single captions and double captions
Out-guides

22. Basic Rules for Filing
Alphabetizing is key to organizing files and charts
Rules facilitate alphabetic process in maintaining files
Indexing units

23. Basic Rules for Filing
Filing patient charts
Filing identical names

24. Steps for Filing Medical Documentation in Patient Files
Inspect
Index
Code
Sort
File

25. Filing Techniques and Common Filing Systems
Alphabetic is intrinsic to all methods
Color coding used a high percentage of time
Numeric is used in very large ambulatory care and hospital systems
Subject filing often used for business records

26. Filing Techniques and Common Filing Systems
Color-coding
There are many systems
Usually have alphabetic base
Customized color-coding systems
Tab-Alpha
Alpha-Z
Customized Color-Coded Systems

27. Filing Techniques and Common Filing Systems
Alphabetic filing
Numeric filing
Straight numeric
Terminal digit
Middle digit
(Procedure 14-1)
(Procedure 14-2)

28. Filing Techniques and Common Filing Systems
Numeric filing
Components of numeric filing
Serially numbered dividers with guides
Miscellaneous (general) numeric file section
Alphabetic card file
Accession record

29. Filing Techniques and Common Filing Systems
Subject filing
Choosing a filing system
Consider type, purpose, and use of information
Take into account number of files or records
Recognize need for confidentiality
(Procedure 14-3)
(HIPAA note in the text)

30. Filing Procedures Cross-referencing
Helps store files for quick and accurate retrieval
Especially helpful with foreign names, hyphenated names, and stepfamilies
Should be simple
Steps for cross-referencing
Rules for cross-referencing
(See text for list)

31. Filing Procedures
Tickler files in manual system or calendar reminders in EMRs
A reminder that action needs to be taken
Should contain
Patient’s name
Tickler date when action should be taken
Required action
Additional relevant information

32. Filing Procedures Release marks Check-out system Provider’s initials
Quality control measure
Check-out system
Out-sheets or out-guides
List of information that should be included on out-sheet

33. Filing Procedures Locating missing files or data
Conduct a systematic search
Steps to searching

34. Filing Procedures Filing chart data Types of reports Clinical notes
Correspondence
Laboratory reports
Miscellaneous
(Procedure 14-6)

35. Filing Procedures Retention and purging Record purging Active files
Inactive files
Closed files

36. Correspondence Filing procedures for correspondence
Remove paper clips and staple items together
Inspect to see if item is ready to be filed
On incoming correspondence, be sure letterhead is related to letter

37. Correspondence Filing procedures for correspondence
On outgoing correspondence, look at inside address and reference line
On incoming or outgoing correspondence, code indexing units of designated label
Create a miscellaneous folder for items that do not have enough in number to warrant individual folder

38. Electronic Medical Records
Mandated and increasing in popularity
EMRs create, store, edit, and retrieve patient charts on a computer
(Procedure 14-7)

39. Electronic Medical Records
Costs are high, but money is saved in transcription and labor costs, copying expenses, and malpractice insurance costs
Purchased as a single computer application or part of a larger practice management system
Some clinics purchase a total practice management system in steps
EMRs can perform numerous tasks
(see the text for List)

40. Electronic Medical Records
EMRs require that the providers and all staff members use the computer for viewing charts, writing prescriptions, creating progress notes, recording laboratory results
May very soon respond to voice recognition rather than keyed entries
Confidentiality and privacy must be assured when using EMRs

41. Electronic Medical Records
Essential system backup assures availability of charts
Confidentiality
Medical assistants must always maintain confidentiality
Never appropriate to discuss any information outside the clinic unless authorized to do so
No discussion of patient information within the facility when not your concern
See HIPAA box in text detailing HIPAA compliance