1. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Chapter 9 Medical Records

2. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Objectives Review the learning and performance objectives for this chapter By the end of this chapter, demonstrate the procedures in the textbook and the job skills in the workbook 2

3. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Heart of the Health Care Professional Service –Consider the medical record as a diary put in your care and have a high regard for it 3

4. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Patients’ Medical Records Medical Record –Aids in diagnosis and treatment –Provides written documentation of care –Ensures continuity of care –Verifies medical necessity –Assists in research 4

5. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Patients’ Medical Records Medical Record –Substantiates billing codes –Complies with laws –Defends the physician Prepare and Compile a Medical Record for a New Patient −Procedure 9-1 5

6. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Record Systems Paper-Based Medical Record System –Costly to manage, move, and store –Paper records are vulnerable Hybrid records 6

7. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Record Systems Health Care Reform –2009 Health Information Technology for Economic and Clinical Health (HITECH) –Electronic Health Record (EHR) incentive program –See Table 9-1: Objectives for Eligible Providers Converting Paper Records to Electronic Records 7

8. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Record Systems Electronic Health Record Practice Management System –Everything electronic Master database with patient records Communicates with systems outside office –Laboratory results –Radiology/operative reports –E-prescriptions Fast, secure, centralized access to health care Viewed electronically in various secure locations 8

9. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Record Systems Electronic Health Record Practice Management System –Other system benefits Tracks patient histories Detects inconsistencies Decreases errors Alerts for drug prescription reactions Eliminates filing and file storage 9

10. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Record Systems Electronic Medical Record System –Key directly into computer –Document clinical findings in free-text narrative –Transcribe directly into EMR –Use templates 10

11. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Record Systems Electronic Medical Record System Stationary computers in exam rooms –Laptops brought into exam rooms –Electronic mobile devices Hand-held tablets, Internet “mouse calls” 11

12. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Record Systems Medical Record Organizational Systems –Problem-Oriented Medical Record (POMR) System Tracks specific data Cross referencing Flow sheets 12

13. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Record Systems 13

14. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical Record Systems Medical Record Organizational Systems –Source-Oriented Record (SOR) System Most common Organized by sections –Integrated Record System All documents in chronologic order Disregards source 14

15. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping –Physician hand enters data –Physician dictates –Physician keys data –Medical assistant enters data 15

16. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Recordkeepers –Comply with all regulations –Oversees: Medical record system File clerks Documentation requirements Coding Internal audits Authorization requests Outside record requests 16

17. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documenters –Attending physician –Consulting physician –Ordering physician –Referring physician –Treating or performing physician 17

18. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Authentication of Documents –Each document must be signed Attests to content and accuracy –Manual Signatures Handwritten –Electronic Signatures Electronic or digital signatures most common Facsimile of actual signature Identification encryption 18

19. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping HIPAA Rule on Copying Records –“Reasonable cost-based fee” –Charges vary by state –Written requests required –Typically 5 days to produce 19

20. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Format –SOAP format Subjective Objective Assessment Plan 20

21. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Format –CHEDDAR format Chief complaint History of present illness Examination Details Drugs and dosages Assessment Return visit information or referral 21

22. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Guidelines –Follow Documentation Guidelines to Record Information in a Medical Record Procedure 9-2 –Patient name and current date –Complete encounter information Legible Accurate Chronologic order 22

23. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation –Enter in a timely fashion Objective Specific Reason for encounter Assessment and diagnosis Plan of care Date and identity of observer 23

24. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Guidelines –Standard, approved abbreviations –Allergies and adverse reactions –Immunizations and injections –Patient’s problem list Significant illnesses Medical conditions 24

25. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Guidelines –Rationale for ordering tests –Reason for treatment deviation –Past and present diagnoses accessible –Identify risk factors –Past medical history 25

26. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Guidelines –Smoking habits –Alcohol and/or substance abuse –Patient’s current medical condition –Telephone conversations –Progress and response to treatment 26

27. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Guidelines –Support codes with documentation –Lab, x-ray, and ECG results –Legible entries –Photocopy prescriptions –Names of all staff assisting 27

28. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Guidelines –Drug samples given –Patient education and instructions –Sign each entry –Use standard technique for corrections See Figure 9-5 –Use caution when applying electronic “templated” language 28

29. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Guidelines –Medicare documentation guidelines No formal requirement Claims processors may use in audit May affect reimbursement 29

30. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Terminology –Use accurate words and phrases –Describe condition –Normal – Do not use: Negative Noncontributory Within normal limits (WNL) –Acute versus chronic or intermittent 30

31. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Terminology –Acronyms and abbreviations Use standard acronyms and abbreviations Do not invent new abbreviations –Illustrations Keep in chart Legible Dated and signed 31

32. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recordkeeping Documentation Terminology –Digital images Photographs Graphics –Measurements Use metric system Lesions: site, size, number, method of destruction –Do not use “small, medium, large” 32

33. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Correcting a Medical Record –Never erase –Never use correction fluid –Do not obscure original entry –Correct a Medical Record Procedure 9-3 33

34. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record These video clips preview the administrative and clinical parts of a medical record –Parts of the medical record: Administrative data –Parts of the medical record: Clinical data 34 Click Here to Play Movie

35. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Patient Information Form –Registration –Patient’s personal data –Demographics –Insurance information All scanned into EMR system 35

36. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Patient Medical History –Chief complaint (CC) Subjective: patient’s own words Describe symptom, problem, condition –History of present illness (HPI) Detailed account of of illness or injury the patient is being seen for 36

37. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Patient Medical History –Past, family, and social history (PFSH) Past history (PH) Family history (FH) Social history (SH) 37

38. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Patient Medical History –Review of systems (ROS) Inventory of body systems Begins at top of body Continues through each system 38

39. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Physical Examination –Objective Physician findings by examination or tests –Four procedures Inspection: Observation Palpation: Touching Percussion: Striking Auscultation: Listening 39

40. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Physical Examination –Levels of examination Problem focused (PF) Expanded problem focused (EPF) Detailed (D) Comprehensive (C) 40

41. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Physical Examination –Body areas and organ systems –See Table 9-2: List of Body Areas and Organ Systems for Purposes of Examination –See Examples 9-7 through 9-19 41

42. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Complexity of Medical Decision Making –Four types Straightforward (SF) Low complexity (LC) Moderate complexity (MC) High complexity (HC) 42

43. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Complexity of Medical Decision Making –Management options Number and types of problems addressed Number of diagnoses –Amount and complexity of data Diagnostic testing ordered Old medical records reviewed History from other sources 43

44. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Complexity of Medical Decision Making –Risk Complications Morbidities Comorbidities Mortality 44

45. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Complexity of Medical Decision Making –Diagnosis Impression, assessment, final conclusion –Treatment Treatment for diagnosis Recommended plan of care –Prognosis Probable outcome Prospect of recovery 45

46. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Progress or Chart Notes –Each subsequent visit –Self-adhesive chart notes Placed in order in paper record –Electronic progress or chart notes Entered electronically 46

47. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Medical Reports –Permanent, legal document –Letter or report format Elements performed Results of examination Recommended treatment 47

48. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Laboratory Reports –Physician’s office laboratory (POL) –Outside laboratory –Hospital laboratory Normal value ranges indicated Physician to review and initial/sign MA: Do not interpret reports 48

49. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Laboratory Tracking –Log or notebook Radiographs (X-Ray Films) –Interpretation reports –Films filed separately Numeric filing system 49

50. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Elements of a Medical Record Electrocardiograms (EKG, ECG) –Interpretation reports –Paper strips filed separately –Machine may interface with EHR software Results go directly into EMR 50

51. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Abstracting from Medical Records Abstract Data from a Medical Record –Procedure 9-4 –Extraction of data Complete reports and forms Compose summary “Chart abstraction” feature in some EHR systems 51

52. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Audit of Medical Records Internal Review –Verify own record keeping procedures –Review own documents Prospective review Retrospective review –See Table 9-3: Examples of Documents Found in a Medical Record 52

53. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Audit of Medical Records External Audit –Performed by: Government programs Managed care organizations Private insurance carriers –Because of: Unusual billing patterns Random –Points awarded for extent of elements in MR 53

54. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Stop and Think Case Scenarios Review the scenario “Physician Roles and Titles” –What roles do the following physicians play and what are their current titles? Dr. Practon Dr. Skeleton Dr. Cutis 54

55. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Stop and Think Case Scenarios Review the scenario “Chart Documentation” –Write a narrative chart note describing the interaction that will serve both as a message and as documentation for the medical record 55