Medical Assisting 4e

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9
Maintaining Patient Records
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Learning Outcomes
9.1 Explain the purpose of compiling patient
medical records. 9.2 Describe the contents of
patient record forms. 9.3 Describe how to create
and maintain a patient record. 9.4 Identify and
describe common approaches to documenting
information in medical records.
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Learning Outcomes (cont.)

• 9.5 Discuss the need for neatness, timeliness,
  accuracy, and professional tone in patient
  records.
• 9.6 Discuss tips for performing accurate
  transcription.
• 9.7 Explain how to correct a medical record.

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Learning Outcomes (cont.)

• 9.8 Explain how to update a medical record.
• 9.9 Identify when and how a medical record may be
  released.
• 9.10 Discuss the advantages and disadvantages of
  the electronic medical record, also known as the
  electronic health record.

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Introduction

• Medical records document the evaluation and
  treatment of patients
• Critical to patient care
• Sectioned to describe various aspects of patient
  information and care
• Legal documents
• Medical assistant has a major role in documenting
  in and maintaining patient records

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Importance of Patient Records
?

• The patients chart
• Past and present medical conditions
• Communication tool for health-care team
• Plan to provide for continuity of care
• Documentation for billing and coding
• Patient education and research
• Legal document admissible in court

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Importance of Patient Records (cont.)
?

• Information included in patient record
• Name and address
• Insurance coverage andperson responsible for
  payment
• Occupation
• Medical history

• Current complaint
• Health-care needs
• Medical treatment plan
• Response to care
• Lab and radiology reports

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Legal Guidelines for Patient Records

• Proof of event or procedure
• No documentation no proof that care was done
• Legal document
• Must document complete information about patient
  care
• Document if patient is noncompliant

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Standards for Records

• Complete, accurate, and well-documented records
  are evidence of appropriate care
• Incomplete, inaccurate, altered, or illegible
  records may imply a poor standard of care
• Everyone who documents in the patient record has
  a responsibility to the patient and employing
  physician

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Patient Records
Additional Uses of Patient Records
Quality ofTreatment
Patient Education

• Peer review
• TJC review
• Health-careanalysis andpolicy decisions

Research

• Test results
• Health issues
• Treatment instructions

• Source of data

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Apply Your Knowledge
What is the purpose of documentation in a
patients medical record?
ANSWER Documentation in the medical record
provides evidence of appropriate care. If a
procedure is not documented, it is considered not
done.
Good Job!
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Standard Chart Information

• Patient Registration Form
• Date
• Patient demographic information
• Age, DOB
• Address
• SSN
• Insurance/financial information
• Emergency contact

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Standard Chart Information (cont.)

• Patient medical history
• Illnesses, surgeries, allergies, and current
  medications
• Family medical history
• Social history (diet, exercise, smoking, use of
  drugs and alcohol)
• Occupational history
• Current patient complaint recorded in patients
  own words

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Standard Chart Information (cont.)

• Physical examination results
• Results of laboratory and other tests
• Records from other physicians or hospitals
• Include a copy of the patient consent authorizing
  release of information

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Standard Chart Information (cont.)

• Doctors diagnosis and treatment plan
• Treatment options and final treatment list
• Instructions to patient
• Medication prescribed
• Comments or impressions
• Operative reports, follow-up visits, and
  telephone calls
• These are part of the continuous patient record
• Document calls made to and from the patient

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Standard Chart Information (cont.)

• Informed consent forms
• Verify that the patient understands procedures,
  outcomes, and options
• Patient may withdraw consent at any time
• Hospital discharge summary forms
• Information summarizing the patients
  hospitalization
• Instructions for follow-up care
• Physician signature

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Standard Chart Information (cont.)

• Correspondence with or about the patient
• All written correspondence regarding the patient
• Record date item was received on the actual form
• Information received by fax request an original
  copy
• Date and initial everything you place in the chart

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Apply Your Knowledge
What section of the patient record contains
information about smoking, alcohol use, and
occupation?
ANSWER Information about smoking, alcohol use,
and occupation is part of the patients past
medical history.
Correct!
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Initiating and Maintaining Patient Records
Completing medical history forms
Documenting test results
Initial Interview
Examination, preparation,and vital signs
Documenting patient statements
Maintain patient privacy during interview
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Initiating and Maintaining Patient Records (cont.)

• Follow-up
• Transcribe notes the doctor dictates
• Post results of laboratory tests and examinations
  
• Record all telephone communication with the
  client
• Record all medical or discharge instructions
  given to the client

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Apply Your Knowledge

• In addition to transcribing notes the doctor
  dictates and posting lab results, what are two
  other follow-up tasks the medical assistant might
  be required to perform as part of follow-up to a
  patient appointment?

ANSWER The medical assistant may have to record
telephone calls with the patient, as well as
medical or discharge instructions given to the
patient.
Right!
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The Six Cs of Charting
C
Clients words Clarity Completeness C
onciseness Chronological order
confidentiality
Do not interpret patients words
Precise descriptions/medical terminology
Fill out forms completely
To the point/approved abbreviations
Legal issues
Follow HIPAA guidelines
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Apply Your Knowledge
What are the six Cs of charting?
ANSWER The six Cs of charting are Clients
words Conciseness Clarity Chronological
order Completeness Confidentiality
Great!
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Types of Medical Records
Source-Oriented Medical Records Problem-Oriented Medical Records
Conventional approach Information is arranged according to who supplied the data Problems and treatments are on the same form Difficult to track progress of specific events POMR records make it easier to track specific illnesses Information included Database Problem list Educational, diagnostic, and treatment plans Progress notes
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Types of Medical Records (cont.)

• SOAP documentation
• Orderly series of steps for dealing with any
  medical case
• Lists the following
• Patient symptoms
• Diagnosis
• Suggested treatment

SOAP
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SOAP Documentation
The treatment plan to correct the illness or
problem
The impression of the patients problem that
leads to diagnosis
What the physician observes during the examination
Information the patient tells you
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CHEDDAR Format

• Expands on SOAP format

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Apply Your Knowledge
Label the following items as either (S)
subjective or (O) objective. ____ headache
____ pulse 72 ____ vomited x 3
____ nausea ____ skin color ____ respirations
16, labored ____ chest pain ____ poor appetite
O
S
O
S
O
O
S
S
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Apply Your Knowledge
What type of documentation expands on the SOAP
format?
ANSWER CHEDDAR format of documentation.
GOOD!
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Appearance, Timeliness, and Accuracy of Records

• Neatness and legibility
• Use a good-quality pen
• Blue ink is preferred (differentiates original
  from copy)
• Highlight critical items such as allergies
• Handwriting must be legible
• Make corrections properly

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Appearance, Timeliness, and Accuracy of Records
(cont.)

• Timeliness
• Record all findings as soon as they are available
• For late entries, record both original date and
  current date
• Record date and time of telephone calls and
  information discussed
• Retrieve file quickly in event of an emergency

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Appearance, Timeliness, and Accuracy of Records
(cont.)

• Accuracy
• Check information carefully
• Never guess or assume
• Double-check accuracy findings and instructions
• Make sure most recent information is recorded

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Appearance, Timeliness, and Accuracy of Records
(cont.)

• Professional attitude and tone
• Record patient comments in his or her own words
• Do not record your personal or subjective
  comments, judgments, opinions, or speculations

You may call attention to problems or
observations by attaching a note to the chart,
but do not make such comments part of medical
record.
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Electronic Health Records

• Essential to quality of health care and
  patient safety

• Advantages
• Fewer lost records
• Reduced transcription costs
• Readability/legibility
• Chart access after hours
• Easier access to patient education materials
• Improved billing

• Disadvantages
• Costly
• Retraining of staff
• IT staff may be needed
• Possible damage to software and system

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Electronic Health Records (cont.)

• Advantages of computer records
• Can be accessed by more than one person at a
  time
• Can be used in teleconferences
• Useful for tickler files
• Security concerns protect patient
  confidentiality

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Apply Your Knowledge
What is important to remember when you are
documenting in the medical records?
ANSWER It is important that medical records be
neat and legible, timely, accurate, and maintain
a professional tone.
Very Good!
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Medical Transcription

• Transcription means transforming spoken words
  into written format
• Dictated information is part of the medical
  record and must be kept confidential
• Date and initial each transcription page
• Strive for ultimate accuracy and completeness of
  transcribed information

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Medical Transcription (cont.)

• Transcribing direct dictation
• Use a writing pad and pen that will not smear
• Use incomplete sentences and phrases to keep up
  with physicians pace
• Use abbreviations accurately
• Ask for clarification immediately if something is
  unclear
• Read the dictation back to verify accuracy
• Enter notes into patient record, date, and initial

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Medical Transcription (cont.)
Transcription reference books
Medical terminology books
Transcription Aids
Secretarial books
Medical reference books
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Apply Your Knowledge
When taking direct dictation, when should you
clarify information if you do not understand
something?
ANSWER You should immediately clarify
information that you do not understand when
taking direct dictation.
Excellent!
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Correcting and Updating Patient Records

• Medical records are created in due course
• Legal term meaning information is to be entered
  at the time of occurrence
• Information corrected or added after patients
  visit is regarded as convenient
• Make corrections as soon as possible after the
  original entry was made

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Correcting Patient Records

• When mistakes happen, correct them immediately
• Draw a line through the original information
• It must remain legible
• Insert correct information above or below
  original line or in margin
• Document why correction was made
• Date, time, and initial correction
• Have a witness, if possible

eror
m/d/yyyy 0000pm misspelled JHC
/chj
error
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Updating Patient Records

• Additions to record should not appear deceptive
• Document why late entry is made
• Date and initial added items
• May have a third party witness addition

Addition made to record because patient called
back with additional information. Mm/dd/yyyy JHC
/ chj
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Apply Your Knowledge
What is the appropriate way to correct an error
in a patients medical record?

• ANSWER To correct an error in a patients
  medical record
• Draw a line through the original information
• It must remain legible
• Insert correct information above or below
  original line or in margin
• Document why correction was made
• Date, time, and initial correction

Super Job!
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Release of Records

• Records are property of the practice
• Contain confidential patient health information
• Must have patients written consent to release
• Exceptions cases of contagious disease or court
  order

Release of Informationto HMO Insurance Company
I authorize Dr. J. Jones to release my
health-care information to the above-named
insurance company. Christopher Hansen
mm/dd/yyyyPatient Signature Date
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Release of Records (cont.)

• Procedures for releasing records
• Obtain a signed and newly dated release form
  authorizing the transfer of information, and
  place it in the patients record
• Make photocopies of original materials
• Copy and send only documents covered in the
  release authorization
• Call to confirm receipt of materials

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Release of Records (cont.)

• Special cases
• Divorce legal guardian of children (may be one
  or both parents)
• Death next of kin or legally authorized
  representative
• If unsure, ask supervisor

• Confidentiality
• 18-year-olds are considered adults in most states

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Apply Your Knowledge
The medical assistant receives a fax transmittal
authorizing transfer of medical record
information for a client to another physicians
office. What would you do in this situation?
ANSWER It is difficult to know the actual
originator of a fax transmittal and to verify the
signature. The safest solution would be not to
release any information based on a fax request
and release of information form. Request the
original form.
Nice Job!
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In Summary

• 9.1 Patients records should be compiled because
  they serve as legal documents, and may be used in
  medical malpractice cases and lawsuits.
• 9.2 The content of a patient record consists of
  standard chart information information received
  by fax dating and initialing of patients charts.

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In Summary (cont.)

• 9.3 To create and maintain patient records forms

• Include
• Registration form
• Medical history
• Exam results, lab and other tests
• Records from other physicians and hospitals
• Diagnosis and treatment plans
• Operative reports, consent forms, discharge
  summaries
• Correspondence with or about patients.

• Maintain the charts properly
• Documenting detailed notes about the contact with
  the patient, patient responses and progress, and
  treatment outcomes.

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In Summary (cont.)

• 9.4 The most common approaches in documenting
  information into medical records is through
  Conventional or Source Oriented records,
  Problem-Oriented Medical Records (POMR), SOAP,
  and CHEDDAR.
• 9.5 Neatness, legibility, accuracy, and
  professional tone are musts in maintaining
  medical records.

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In Summary (cont.)

• 9.6 When performing accurate transcription
• Use incomplete sentences or phrases to keep up
  with the physicians pace
• Use abbreviations whenever possible
• If physician speaks fast, ask him or her to speak
  slower and more clearly
• Read dictation back to physician for clarity
• Enter notes into patient record.

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In Summary (cont.)

• 9.7 When correcting medical records, make sure
  you correct as soon as possible. Use appropriate
  procedure to make corrections.
• 9.8 Each item that is added to the patient record
  as an update should be dated and initialed. If
  the information is extremely important, get a
  third party to witness and initial and date as
  well.

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In Summary (cont.)

• 9.9 Medical records can only be released with
  patients written consent or subpoena by the
  courts. Consent form must be on file.
• 9.10 The advantages of the electronic medical
  record outweigh the disadvantages. Evaluate
  software before purchasing. Maintain sensitivity
  to patient needs.

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End of Chapter 9
Organization is the power of the day without it,
nothing is accomplished. Sophia Palmer From A
Daybook for Nurses Making a Difference Each Day