1. Seminar THREE The Patient Record:
Hospital, Physician Office, and Alternate Care Settings

2. Medical Record Content
Definition of Medical Record
Repository of Information
Business Record
Contains documentation of patient care and demographic data
Administrative Data
Clinical Data

3. Medical Record Content
Essential Principles of Healthcare Documentation
Unique patient identification must be assured within and across healthcare documentation systems.
Healthcare documentation must be accurate and consistent, complete, timely, interoperable across types of documentation systems, accessible at any time and at any place where patient care is needed and auditable.
Confidentiality and secure authentication and accountability must be provided

4. Medical Record Content
Joint Commission Standard RC states:
“Only authorized individuals may make entries in the medical record”
“Define the types of entries in the medical record made by nonindependent practitioners that require countersigning.”
AHIMA recommends”
“anyone documenting in the health record should be credentialed or have the authority and right to document as defined by the organization’s policy”
Who owns the Medical Record?

5. Medical Record Content
Authentication
Written Signatures
Counter signatures
Initials
Fax Signatures
Electronic Signatures
Signature Stamps
Abbreviations
Ms. Walker arrived with SOB

6. Medical Record Content

7. Medical Record Content
Legibility

8. Medical record content
Timeliness of Entries
COP requires an H&P be placed in the chart within 24 hours of Admission
The Joint Commission requires an H&P be placed in the chart within 48 hours of admission
Facility example: All entries must be signed within 24 hours

9. Medical record content
Completion of Records
Joint Commission requires a record be completed within 30 days of discharge
Records not completed within 30 days of discharge are considered delinquent
Delinquency Rate is calculated by dividing the number of records delinquent by the number of discharges for the time period.
Example: 150 delinquent records for the Month of May and 1200 discharges
150/1200 = 12.5% Delinquency
The Delinquency Rate must ALWAYS remain below 50% for Joint Commission compliance

10. Medical record content
Medical Record Completion

11. Medical record content
Amendments/Addendums
Necessary to correct information
Information cannot be “deleted” from the medical record
Electronic or hand-written
Can be requested by the patient

12. Chapter 4 Review – True / False
Archived records are also called active records.

13. Chapter 4 Review – True / False
Archived records are also called active records. FALSE

14. Chapter 4 Review – True / False
Behavioral health records include a behavioral health diagnosis, treatment plan, and psychiatric and medical history.

15. Chapter 4 Review – True / False
Behavioral health records include a behavioral health diagnosis, treatment plan, and psychiatric and medical history. TRUE

16. Chapter 4 Review – True / False
Clinical data includes patient financial information.

17. Chapter 4 Review – True / False
Clinical data includes patient financial information. FALSE

18. Chapter 4 Review – True / False
Telephone orders do not require countersignatures if the nurse taking the order records the name of the ordering physician.

19. Chapter 4 Review – True / False
Telephone orders do not require countersignatures if the nurse taking the order records the name of the ordering physician. FALSE

20. Chapter 4 Review – True / False
When correcting a documentation error, the author of the original entry should make the correction.

21. Chapter 4 Review – True / False
When correcting a documentation error, the author of the original entry should make the correction. TRUE

22. Chapter 4 Review – True / False
The abbreviation list should be approved by the medical staff.

23. Chapter 4 Review – True / False
The abbreviation list should be approved by the medical staff. TRUE

24. Chapter 4 Review – True / False
A history and physical report is an example of administrative data.

25. Chapter 4 Review – True / False
A history and physical report is an example of administrative data. FALSE

26. Chapter 4 Review – True / False
Over the last decade, there has bee an increase in the number of ambulatory visits.

27. Chapter 4 Review – True / False
Over the last decade, there has bee an increase in the number of ambulatory visits. TRUE

28. Chapter 4 Review – FILL IN THE BLANK
An abbreviation list contains acceptable explanations of meanings as ____ and ____.

29. Chapter 4 Review – FILL IN THE BLANK
An abbreviation list contains acceptable explanations of meanings as abbreviations and symbols.

30. Chapter 4 Review – FILL IN THE BLANK
A note that is added to the record after an original note has been documented is called an _______.

31. Chapter 4 Review – FILL IN THE BLANK
A note that is added to the record after an original note has been documented is called an addendum.

32. Chapter 4 Review – FILL IN THE BLANK
A preliminary diagnosis is called a provisional diagnosis, a working diagnosis, an admission diagnosis, or a _____ diagnosis.

33. Chapter 4 Review – FILL IN THE BLANK
A preliminary diagnosis is called a provisional diagnosis, a working diagnosis, an admission diagnosis, or a tentative diagnosis.

34. Chapter 4 Review – FILL IN THE BLANK
When a patient is discharged, the _________ is responsible for documenting the discharge summary.

35. Chapter 4 Review – FILL IN THE BLANK
When a patient is discharged, the attending physician is responsible for documenting the discharge summary.

36. Chapter 4 Review – FILL IN THE BLANK
Indexes, registers, and committee minutes are considered ______ ______ of patient information.

37. Chapter 4 Review – FILL IN THE BLANK
Indexes, registers, and committee minutes are considered secondary sources of patient information.

38. Chapter 4 Review – FILL IN THE BLANK
A document maintained by the health information department to identify the author by full signature when initials are used to authenticate entries is known as a _______ _____.

39. Chapter 4 Review – FILL IN THE BLANK
A document maintained by the health information department to identify the author by full signature when initials are used to authenticate entries is known as a signature legend.

40. Chapter 4 Review – FILL IN THE BLANK
A discharge summary is an example of ____________ data.

41. Chapter 4 Review – FILL IN THE BLANK
A discharge summary is an example of clinical data.

42. Chapter 4 Review – Multiple choice
Which is not a component of the problem oriented record?
Database
Problem list
Progress note
Table of contents

43. Chapter 4 Review – Multiple choice
Which is not a component of the problem oriented record?
Database
Problem list
Progress note
Table of contents

44. Chapter 4 Review – Multiple choice
The judgment, opinion, or evaluation made by a health care professional is documented in which section of a SOAP progress note?
Assessment
Objective
Plan
Subjective

45. Chapter 4 Review – Multiple choice
The judgment, opinion, or evaluation made by a health care professional is documented in which section of a SOAP progress note?
Assessment
Objective
Plan
Subjective

46. Chapter 4 Review – Multiple choice
When the order of the record reads like a diary, the forms are said to be filed in a
Chronological date order
Discharged record order
Integrated format
Reverse chronological date order

47. Chapter 4 Review – Multiple choice
When the order of the record reads like a diary, the forms are said to be filed in a
Chronological date order
Discharged record order
Integrated format
Reverse chronological date order

48. Chapter 4 Review – Multiple choice
Which is a disadvantage of the problem oriented record?
Difficulty following one diagnosis throughout the documentation
Filing of forms is time consuming
Poor degree of organization in the documentation
Retrieval of information is difficult

49. Chapter 4 Review – Multiple choice
Which is a disadvantage of the problem oriented record?
Difficulty following one diagnosis throughout the documentation
Filing of forms is time consuming
Poor degree of organization in the documentation
Retrieval of information is difficult

50. Chapter 4 Review – Multiple choice
Which type of microfilm storage uses Mylar film?
Cartridge
Jackets
Microfiche
Roll film

51. Chapter 4 Review – Multiple choice
Which type of microfilm storage uses Mylar film?
Cartridge
Jackets
Microfiche
Roll film

52. Unit THREE: Reminders
Reading: Essentials of HIM Chapters 4 and two AHIMA articles
Discussion Board: Post answer to DQ by Saturday, two responses to others due by Tuesday
Unit 3 Quiz
Personal Health Record Activity – You should be working on this activity. The first update is due in Unit Four.