Medical Records and Documentation

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11

• Medical Records and Documentation

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Learning Outcomes (cont.)

• 11.1 Explain the importance of patient medical
  records.
• 11.2 Identify the documents that comprise a
  patient medical record.
• 11.3 Compare SOMR, POMR, SOAP, and CHEDDAR
  medical record formats.
• 11.4 Identify the six Cs of charting, giving an
  example of each.

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Learning Outcomes (cont.)

• 11.5 Describe the need for neatness, timeliness,
  accuracy, and professional tone in patient
  records.
• 11.6 Illustrate the correct procedure for
  correcting and updating a medical record.
• 11.7 Describe the steps in responding to a
  written request for release of medical records.

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Introduction

• Medical assistants role regarding patient health
  records
• Documentation
• Maintenance
• Medical records critical to patient care
• Evaluation
• Management
• Treatment

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The Importance of Medical Records

• Past medical history and present condition
• Communication tool for healthcare team
• Legal documentation
• Patient and staff education
• Quality control and research
• Documentation for billing and coding

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Importance of Patient Records (cont.)

• General information
• Contact information
• Occupation
• Medical history
• Current complaint
• Healthcare needs
• Treatment plan or services provided
• Radiology and laboratory reports
• Response to care

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Legal Guidelines for Patient Records

• Support a malpractice claim
• Support defense for a malpractice claim
• Back up financial records
• Documentation
• Medical care, evaluation and instructions
• Noncompliant patient

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Standards for Records

• Evidence of appropriate care
• Complete
• Accurate
• Everyone who documents in the patient record has
  a responsibility to the patient and physician

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Additional Uses of Patient Records
Patient Education
Quality ofTreatment
Research

• Test results
• Health issues
• Treatment instructions

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

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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Contents of Patient Medical Records

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

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Contents of Patient Medical Records (cont.)

• Patient medical history
• Past medical history
• Family medical history
• Social and occupational history
• History of present illness (chief complaint)

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Contents of Patient Medical Records (cont.)

• Physical examination results
• Review of systems
• Form ensures consistency
• Results of laboratory and other tests
• Documents from Other Sources

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Contents of Patient Medical Records (cont.)

• Doctors diagnosis and treatment plan
• Treatment options and plan
• Instructions
• Medication prescribed
• Comments or impressions
• Operative reports, follow-up visits, and
  telephone calls

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Contents of Patient Medical Records (cont.)

• Hospital discharge summary forms
• Consent forms
• Verify that the patient understands procedures,
  outcomes, and options
• Patient may withdraw consent at any time

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Contents of Patient Medical Records (cont.)

• Correspondence with or about the patient
• Information received by fax request an original
  copy
• Date and initial everything you place in the chart

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Maintaining Confidentiality

1. The right to notice of privacy practices.
2. The right to limit or request restriction on
   their PHI and its use and disclosure.
3. The right to confidential communications.

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Maintaining Confidentiality (cont.)

• 4. The right to inspect and obtain a copy of
  their PHI.
• 5. The right to request an amendment to
  their PHI.
• 6. The right to know if their PHI has been
  disclosed and why.

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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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Types of Medical Records

• Source-Oriented Medical Records
• Information is arranged according to who
  supplied the data
• Problems and treatments are on the same form
• Difficult to track progress of specific events

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Types of Medical Records (cont.)

• Problem-Oriented Medical Records
• Data Base
• Problem List
• Each problem numbered
• Sign vs. symptom
• An Educational, Diagnostic, and Treatment Plan
  per each problem
• 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
Information the patient tells you
What the physician observes during the examination
The impression of the patients problem that
leads to diagnosis
The treatment plan to correct the illness or
problem
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CHEDDAR Format

• Expands on SOAP format

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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
S
O
S
O
O
O
S
S
Excellent!
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Documenting and the Six Cs of Charting

• Updating medical forms
• Documenting test results
• Examination Preparation and Vital Signs

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Follow-Up

• Transcribe notes the doctor dictates
• Post results of laboratory tests and examinations
  
• Record telephone communication with the client
• Record all instructions and education

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The Six Cs of Charting
C
Clients words Clarity Completeness C
onciseness Chronological order confidentiality
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Apply Your Knowledge

1. What are the six Cs of charting?

ANSWER The six Cs of charting are Clients
words Conciseness Clarity Chronological
order Completeness Confidentiality
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Apply Your Knowledge

1. 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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Appearance, Timeliness, and Accuracy of Records

• Neatness and legibility
• Medical transcription
• Handwritten notes
• Blue ink
• Highlight specific items such as allergies
• Make corrections properly

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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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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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Professional Attitude and Tone

• Record patient comments
• Do not record 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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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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Correcting and Updating Medical Records

• Medical records are created in due course
• Information is entered at the time of occurrence
• Untimely submissions may be regarded as
  convenient

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Using Care with Corrections

• Correct mistakes immediately
• Draw a line through the original information
• Insert correct information
• 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 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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Responding to Release of Records Request

• Records are property of the practice
• Contain confidential PHI which belongs to the
  patient
• Must have patients written consent to release

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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Procedures for Releasing Records

• New authorization to transfer records
• Verbal consent is not valid
• File in medical record
• Copy original materials only information
  requested
• Call to confirm receipt of materials

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Procedures for Releasing Records (cont.)

• Special cases
• Not always clear who can authorize release
• If unsure, ask your supervisor

• Confidentiality
• 18 years old
• Emancipated minor
• Mature minor

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Auditing Medical Records

• Examination and review
• Completeness
• Accuracy
• Types
• Internal
• External

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Apply Your Knowledge
The medical assistant receives phone call
authorizing transfer of medical record
information for a client to another physicians
office. What would you do in this situation?
ANSWER Never release information based on
telephone authorization. You cannot be sure who
the caller is. Tell them you need a written and
signed release of information.
Nice Job!
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In Summary

• 11.1 Medical records are legal documents that
  give a complete, concise, chronological history
  of a patients past medical history, current
  medical issues, treatment plan, and treatment
  outcome.
• Additionally, they act as a communication tool
  between care providers.
• The patient medical record provides physicians
  and other healthcare providers with all the
  important information, observations, and
  opinions that have been recorded about a patient.

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In Summary

• 11.2 The records that comprise the patient
  medical record include, but are not limited to
  the following

• patient registration form
• medical history form
• physical exam form
• laboratory and other test results
• records from physicians or hospitals,
• physician diagnosis and treatment plan

• operative reports
• hospital discharge summaries
• follow-up notes
• records of telephone calls
• signed informed consents
• correspondence with or about the patient

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In Summary (cont.)

• 11.3 SOMR files documents in the medical record
  in strict chronological order.
• POMR files the same documents according to
  numbered problems found on the patient problem
  list.
• SOAP notes organize medical record documentation
  according to subjective, objective, assessment
  and plan.
• The CHEDDAR format breaks down this information
  even further into chief complaint, history,
  exam, details, drugs, assessment, and return
  visit plan.

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In Summary (cont.)

• 11.4 The six Cs of charting are clients words,
  clarity, completeness, conciseness,
  chronological order, and confidentiality.
• 11.5 Neatness, legibility, accuracy, and
  professional tone are musts in maintaining
  medical records.
• Remember that patient medical records are legal
  documents.
• Personal thoughts and observations should never
  be a permanent part of the patient medical
  record.

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In Summary (cont.)

• 11.6 The proper way to make corrections in a
  medical record is to draw a single line through
  the error so that the original entry is still
  legible.
• Any additions to a medical record should also be
  made as soon as the need for the addition is
  noted, and the reason for the addition or change
  should also be clearly documented.
• 11.7 In order to release any confidential
  medical information, express written permission
  from the patient must be received. Only release
  records that are expressly requested and
  authorized by the patient.

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End of Chapter 11
Organization is the power of the day without it,
nothing is accomplished. Sophia Palmer From A
Daybook for Nurses Making a Difference Each Day