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27 Cards in this Set
- Front
- Back
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Legal Considerations
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*It assist the physicians and providing the best care to the patient
*keeping a recording of what happened, what type of test has been done, test results themselves so they can continue with the care of the patient *it offers legal protection for those who provide patient care *the recording is a documentation that could be used in the court of law *it provides statistical information for researchers *is vitual for financial reimbursement process |
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Ownership
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*The physical record belongs to the provider
-Referred to as "the Maker" *Patient owns information in the medical record *Patient has the right to access information *Patient has the right to demand confidentiality *The medical record should never leave the facility |
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Releasing Medical Record Information
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*Patient may request to view own record
*Patient must sign a release form for any third party *Request for medical information should be in writing *Patient needs to provide a list of authorized individuals to inquire about patient medical history *Patient can revoke request in writing *Provide only information requested *Fees may be charged for copying and postage |
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Types of Records
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*Paper Based
-Difficult to use for multiple purposes -Requires storage space -Information cannot be easily accessed *EMR-Electronic Medical Records *EHR-Electronic Medical Records -Can be used for multiple purposes -Raised concern about computer malfunctions -Easily stored, retrieved and forwarded -Information easily accessed |
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Documenting in the Medical Record
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*need to be very closed attention because of it being a legal document
*make sure you have the correct patients chart *you want to make sure that the information is clear and concise *make sure it is a legibale handwriting *use caution when using abbrevations or acronyms not all are universal *dates and initials on all entries *medical record is not a palce for you to enter your own opinions, own thoughts, or judgements enter only the facts that are relevant to the patients care |
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Protecting the Medical Record
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*Do not leave charts/files unattended in view of unauthorized personnel or visitors
*Make sure file drawers are closed when not in use *Files should be locked when office is closed *If records are electronic, protect view of screen from unauthorized individuals *For security purposes, use passwords to access files |
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Source Oriented Record
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*medical records needs to be organized especially if they are in a paper format
*needs to be a pattern in which information flows *are traditional patient records *filed in a reverse chronological order-filed by the last time the patient was seen *reports filed in a seperate section would include lab, radiology reports *Complex records-hospital, outside consultations, cardiology, urology depending on the particular practice |
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Problem Oriented Medical Record-POMR
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*Divides medical action into four bases
1.Database includes:chief complaint(cc), history of present illness(HPI), review of systems(ROS), Physical exam and lab reports 2.Each problem that requires management is numbered with the details listed below 3.Each numbered problem has a treatment plan that includes the management, tests and therapy necessary 4.Progress notes are referenced to correspond with each numbered problem |
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SOAP Approach
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*Subjective impressions
-Patient demographics -Medical history -Chief complaint *Objective Clinical evidence -Physical exam -Diagnostic testing *Assessment or diagnosis *Plans for further studies, treatment and management |
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Contents
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*Personal Demographics
*Medical History *Progress Notes *Encounter forms/Superbills *Radiology Reports *Laboratory Reports *Consultations *Med Sheet including allergies *Hospitals Discharge Summaries *Consent and disclosure forms *Insurance authorizations and referrals |
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Making a Handwritten Correction
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*To correct handwritten entry:
-Draw a line through the error -Write error or corr. and initial in margin including date -Insert the correct immediately after the error -Never use white out, black marker, or eraser -Do not hide errors, bring to the attention of provider if it could affect patients health and well-being |
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Making an Electronic Correction
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*new entries needs to be enteredwhich is an adminment to the record
*never delete an entry *the only time to delete an entry is when you've just entered the information *when putting in a new entry you want to identify that it is gonna be an adenum to something that incorrect in the record *notify the provider if it is something concerning the patient |
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Record Maintenance
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*Always verify correct medical chart has been pulled
*Mend chart as necessary *file documentation in a timely manner *Make sure required forms are kept up to date *Verify patient information periodically |
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Retention of Records
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*will vary from state to state by law
*there are government programs that have their own guidelines of the retnetion of records *10 years of the staute of limitations is usually a good time to work with *Minors records should be kept for reaching the age of majority plus the additional 3 years *infants records should be kept until the age of 24 or 25 *medicare and medicaid patients have a minimum of 6 years retention and a decease patientrecords should be kept 2 years and beyond |
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Discard, Protect and Store
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*Before disgarding of records allow patient the opportunity to obtain a copy or sent to another provider
*Old records must be destroyed by shredding or professional document destruction service *Protect records at all times *Long term storage can consist of transferring to: -Microfiche -CD-ROM -DVD-ROM |
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Classification of Records
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*Active
-Currently receiving treatment *Inactive -Not seen for 6 months *Closed -Moved -Terminated -Deceased |
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Types of Files
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*Draw files-pulls out
*shelf files-very common in the medical office -alphabetical order, long range/short range, *rotary circular files *lateral files *compatiable files *auotmated files |
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How to File
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*Alphabetical
-Oldest and simplest -Most Common *Numeric -Provides confidentiality -Allows for easy expansion of files *Terminal Digit -Two to three consecutive groups of numbers -Files are read right to left *Subject -Correspondence filed by subject, may require cross filing -Most recent on top |
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Filing Supplies
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*Chart Covers or folders
*Labels -Color coded -Alpha and numeric *OUTguides *Special notation labels -Allergies -Same name -Copays Primary care physician |
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Conditioning
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*is a process of removing the pens/paperclips and brads and stapling related papers togehter in a file
*amending any of the records/files being damaged |
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Releasing
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*Indication that the record is ready to be filed
-Signature -Initials -Date -Stamp |
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Indexing and Coding
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*is a process where a dodument is to be filed
*underlining the name or subject of how it needs to be filed *process for very large businesses *every records needs to have a name/date on it in a patients chart |
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Sorting
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*a process of ranging papers to put in for filing sequence
*it could be done alphabetically, or numerically, days of the week, days of the month or by the year *it depends on what is pacifically is being filed |
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Storing and Filing
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*needs to make sure the files are being filed faced up so they are easily identified
*make sure it is in a reverse chronilogically order with the most recent date is on the top *make sure the document is completly in the file |
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Locating Misplaced Files
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*Document only
-in the folder in front of or behind the correct folder -between folders -under the files -patient wwith a similar name *Entire Medical Record -Physicians desk -Billing department -Nursing Station -Office manager |
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Tickler File
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*Similar to recall scheduling
*Used for follow up *Divided by each month and then by day *To be effective must be checked daily |
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12 Rules of Indexing
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1.Last names are considered first, then first name second
2. Nothing comes before something -Smith, T. -Smith, Thomas 3. Hyphenated names are considered one unit -Susan Freeman-Miller 4. The apostrophe is disregarded 5. When a determined of order cannot be made, index in the order the name is written -Change Liu 6. Names with prefixes are considered part of the name -Von Hagen 7. Abbreviated names are filed as written -Ste.-Saint -Wm-William 8. Mac and Mc are filed in alphabetical order 9. Married woman is indexed by her legal name -Mrs Frank Jones 10. Titles are not used as filing units -Mr., Mrs. Dr., -Titles with complete names are considered the first indexing unit -Father John -Sister Teresa 11. Terms of seniority, profession or academic degree are only used to distinguish same names -PhD. Sr., MD 12.Articles(The and A) are disregarded when indexing |
