1. The Medical Record, Documentation, and Filing
Chapter 13
The Medical Record, Documentation, and Filing

2. Beginning the Patient’s Record
Patient’s personal information
Demographic information
Marital status, children, and living arrangements
Social habits
Occupation information
Medical history and family history
Medications
Testing performed

3. Purpose of Medical Records
Maintains and documents the course of patient care
Provider’s evaluation
Prescribed treatment
Responses to treatment

4. Purpose of Medical Records
Provides for a continuity of care
Eliminates incompatible therapies, duplication of efforts, or unnecessary expenses
Provides legal protection
Maximizes reimbursement
Helps conduct research

5. HIPAA and the Medical Record
HIPAA Privacy Rule
HIPAA Security Rule
Ensures confidentiality of patient’s medical record
Protects against use or disclosure of information without the patient’s consent
All employees must comply with HIPAA

6. EMR, EHR, and PHR EMR Electronic medical record
Electronic record of health-related information for an individual that is created, gathered, managed, and consulted by licensed clinicians and staff that is maintained through a single organization

7. EMR, EHR, and PHR EHR Electronic health record
Aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization
Often used interchangeably with “EMR”

8. EMR, EHR, and PHR PHR Personal health record
Collection of medical records compiled and maintained by the individual

9. Advantages of EHRs Searchable databases
Results can be transmitted to different providers and departments immediately
Legible prescriptions sent to pharmacy immediately
Reminder systems for routine maintenance and testing

10. Advantages of EHRs
Encourages coordination of care between providers and departments
Plug-ins for voice recognition software to decrease transcribing needs
Automatic CPT/ICD code assignment
Photo upload capabilities to ensure correct patient is selected

11. Parts of the Medical Record
Administrative data
Financial and insurance information
Correspondence
Referrals
Past medical records
Clinical data
Progress notes
Diagnostic information
Lab information
Medications

12. Parts of the Medical Record

13. Information in the Record
Subjective
Provided by the patient
Routine information about the patient
Chief complaint
Objective
Provided by the provider and health care team
Vital signs
Exam findings
Diagnostic tests

14. Administrative, Financial, and Insurance Information
Demographics
HIPAA Notice of Privacy Practices
Insurance information

15. Correspondence and Referrals
All correspondence received by the medical office
Referral or follow-up letters from specialists
In an EHR, these are scanned and uploaded into the patient record

16. Past Medical History Records from previous providers or facilities
Release of information form
Ensures continuity of care

17. Progress Notes Arranged chronologically
Most recent note on top
Each entry is timed, dated, and signed
Medical office or provider will indicate preferred format for progress notes

18. Diagnostic and Lab Information
Imaging information
X-rays, MRIs, and many others
Lab reports
Critical values should be highlighted and presented to the provider for review

19. Medications Medications administered in the office Prescriptions
Complete documentation
Prescriptions

20. Charting in the Patient Record
Problem-oriented medical record (POMR)
SOAP
Subjective, objective, assessment, plan
HPIP
History, physical exam, impression, plan
CHEDDAR
Chief complain, history, examination, details, drugs/dosages, assessment, return visit

21. Filing Medical Records
Step One: Inspect
Step Two: Index
Step Three: Code
Step Four: Sort
Step Five: Store

22. Filing Systems
Alphabetic
Numeric
Subject
Geographic
Chonologic