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9-1
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Maintaining Patient RecordsMaintaining Patient Records
PowerPoint® presentation to accompany:
Medical AssistingThird Edition
Booth, Whicker, Wyman, Pugh, Thompson
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-2
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.
Learning Outcomes
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-3
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.
9.8 Explain how to update a medical record.
9.9 Identify when and how a medical record may be released.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-4
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-5
Importance of Patient Records The patient’s 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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-6
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-7
Patient Records: Legal Guidelines
Proof of event or procedure No documentation
No proof Care is considered not done
Legal document Must document complete information about
patient care Document if patient is noncompliant
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-8
Patient Records: Standards for Records
Complete, accurate, and well-documented records are evidence of appropriate care
Incomplete, inaccurate, altered, or illegible records may imply poor standards
Everyone who documents in the patient record has a responsibility to the patient and employing physician
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-9
Patient Records (cont.)
Patient Education
Quality ofTreatment
Research
Additional Uses of Patient Records
• Test results
• Health issues
• Treatment instructions
• Peer review
• JCAHO review
• Health-care analysis and policy decisions
• Source of data
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-10
Apply Your Knowledge
What is the purpose of documentation in a patient’s medical record?
ANSWER: Documentation in the medical record provides evidence of appropriate care. If a procedure is not documented, it is considered not done.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-11
Patient Charts: Standard Chart Information
Patient Registration Form
Date
Patient demographic information
Age, DOBAddress SSN
Insurance / financial information
Emergency contact
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-12
Past 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 patient’s
own words
Patient Charts:Standard Chart Information (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-13
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
Patient Charts: Standard Chart Information (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-14
Doctor’s 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
Patient Charts:Standard Chart Information (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-15
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 patient’s hospitalization Instructions for follow-up care Physician signature
Patient Charts: Standard Chart Information (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-16
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; if not available, make a
photocopy of the fax
Dating and initialing Be sure to date and place your initials on everything
you place in the chart
Patient Charts: Standard Chart Information (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-17
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 patient’s past medical history.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-18
Initiating and Maintaining Patient Records
Initial Interview
Completing medicalhistory forms
Documenting patient
statements
Documenting test results
Examination, preparation,
and vital signs
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-19
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
Initiating and Maintaining Patient Records (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-20
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!
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-21
The Six Cs of Charting
Client’s words –
Clarity –
Completeness – C
onciseness –
Chronological order –
confidentiality –
Do not interpret patient’s words
Precise descriptions / medical terminology
Fill out forms completely
To the point / approved abbreviations
Legal issues
Follow HIPAA guidelines
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-22
Apply Your Knowledge
What are the six Cs of charting?
ANSWER: The six C’s of charting are
Client’s words Conciseness
Clarity Chronological order
Completeness Confidentiality
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-23
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-24
Medical Records: SOAP Documentation
Orderly series of steps for dealing with any medical case
Lists the following Patient symptoms Diagnosis Suggested treatment
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-25
ubjective data
bjective data
ssessment
lan
Information the patient tells you
What the physician observes during the examination
The impression of the patient’s problem that leads to diagnosis
The treatment plan to correct the illness or problem
SOAP Documentation
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-26
Apply Your Knowledge
What type of documentation provides an orderly series of steps for dealing with any medical case, and what are the components of this type of documentation?ANSWER: SOAP documentation provides an orderly series of steps for dealing with any medical case. The components are
S – Subjective data A - Assessment
O – Objective date P - Plan
GOOD!
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-27
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 OS
S SOO
O
ANSWER:
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-28
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-29
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-30
Accuracy Check information carefully
Never guess or assume
Double-check accuracy findings and instructions
Make sure most recent information is recorded
Appearance, Timeliness, and Accuracy of Records (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-31
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.
Appearance, Timeliness, and Accuracy of Records (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-32
Computer records Accuracy is also important with electronic
records Advantages
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
Appearance, Timeliness, and Accuracy of Records (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-33
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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-34
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-35
Transcribing direct dictation Use a writing pad and pen that will not smear
Use incomplete sentences and phrases to keep up with physician’s pace
Use abbreviations
Ask for clarification immediately if something is unclear
Read the dictation back to verify accuracy
Enter notes into patient record, date, and initial
Medical Transcription (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-36
Transcription Aids
Transcriptionreference books
Medicalterminology books
Secretarialbooks
Medical referencebooks
Medical Transcription (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-37
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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-38
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 patient’s visit
is regarded as “convenient”
Use care with corrections It is more difficult to explain a chart that has been
altered after something was documented
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-39
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
m/d/yyyy 00:00pm misspelled JHC /chj
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-40
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-41
Apply Your Knowledge
What is the appropriate way to correct an error in a patient’s medical record?
ANSWER: To correct an error in a patient’s 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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-42
Release of Records
Records are property of physician Contain confidential patient
health information Must have patient’s 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 healthcare information to the above-named insurance company.
Christopher Hansen mm/dd/yyyyPatient Signature Date
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-43
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 patient’s record
Make photocopies of original materials Copy and send only documents covered in the release
authorization
Call to confirm receipt of materials
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-44
Special cases Divorce
Legal guardian of children (may be one or both parents)
Death Next of kin Legally authorized
representative If unsure, ask
supervisor
Confidentiality 18-year-olds
Considered adults in most states
Must have written consent to release their records
Legal and ethical principle:Protect patient’s right to privacy at all times.
Release of Records (cont.)
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-45
Apply Your Knowledge
The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another physician’s 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.
Nice Job!Nice Job!
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-46
In Summary Medical assistants must properly prepare and
maintain patient records
There are several methods for documentation, but regardless of method, records must be complete, legible, current, accurate, and professional
Properly maintain, correct, update, and release patient medical records
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-47
Organization is the power of the day; without it, nothing is accomplished.
~ Sophia Palmer
From A Daybook for Nurses: Making a Difference Each Day