CH. 13The Medical Record,
Documentation, and Filing
BEGINNING THE PATIENT’S RECORD Patient’s personal information
Demographic informationMarital status, children, and living
arrangementsSocial habitsOccupation information
Medical history and family historyMedicationsTesting performed
PURPOSE OF MEDICAL RECORDS
Maintains and documents the course of patient careProvider’s evaluationPrescribed treatmentResponses to treatment
Provides for a continuity of care Eliminates incompatible therapies, duplication
of efforts, or unnecessary expenses Provides legal protection Maximizes reimbursement Helps conduct research
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
EMR EMR
Electronic medical recordElectronic 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
EHR EHR
Electronic health recordAggregate 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”
PHR PHR
Personal health recordCollection of medical records compiled and
maintained by the individual
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
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
ADVANTAGES OF EHRS
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
INFORMATION IN THE RECORD Subjective
Provided by the patient
Routine information about the patient
Chief complaint
ObjectiveProvided by the
provider and health care team
Vital signsExam findingsDiagnostic tests
ADMINISTRATIVE, FINANCIAL, AND INSURANCE INFORMATION Demographics HIPAA Notice of Privacy Practices Insurance information
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
PAST MEDICAL HISTORY Records from previous providers or
facilitiesRelease of information formEnsures continuity of care
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
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
MEDICATIONS Medications administered in the office
Complete documentation Prescriptions
CHARTING IN THE PATIENT RECORD
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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
FILING MEDICAL RECORDSGenerally the medical assistant
files three types of items:
New patientrecordfolders
Individualdocuments
forexistingfolders
Previouslyfiled
patientrecordfolders
5 STEPS TO FILING
Place files in order to save time when storing Add an identifying mark to ensure that the file is put in the correct place
Coding
Name the file using the office classification system
Make sure document is ready to
be filed
Indexing
Sorting
Place the files in the appropriate location for easy retrieval when needed
Inspecting
Storing
FILING SYSTEMS Alphabetic Numeric Subject Geographic Chonologic
ALPHABETICAL With alphabetic filing systems
Each letter is assigned a colorThe first two letters of the last name are
color-coded with colored tabsCan easily tell if files are filed correctly
File these in the correct order:Allen, E.S.Allen, William C.Allard, Wm.Allens, M.R.Allen, Edna
NUMERIC With numeric filing systems
Numbers 1 to 9 assigned a distinct colorHelps identify numeric files that are out of
place
File these in the correct order:02-17-2512-25-3508-17-3510-07-25
SUBJECT Inventory Copies of orders Financial Records Tax records
TICKLER Tickler files
Reminder files
Check on a regular basis
Organized by month, week of month or day of week
Computers systems offer tickler files in the form of a calendar Reminders set to alert prior to event
FILING Take a close look at the contents of patient
records each time you pull or file them
Keep files neat Do not overstuff file folders Papers should not extend beyond edge of
folder
Remove file from drawer when adding documents Prevents damage to documents
LOCATING MISPLACED FILES Determine where the file was when last seen or used
Look for the file while retracing steps from that location
Check filing cabinet where it belongs Check neighboring files
Check underneath files in drawer or on shelf Check items to be filed Check with other staff members Check other file locations
Similar indexes Under patient’s first name Misfiled chart color
LOCATING MISPLACED FILES Ask if someone inadvertently picked up
the file with other materials
Have another person complete the steps to double-check your search
Straighten the office, carefully checking all piles of information
ACTIVE VS. INACTIVE FILES Active files are files that you use
frequently
Inactive files are files that you use infrequently
Closed filesFiles of patients that no longer consult the
officeThe physician determines when a file is
deemed inactive or closed
Certain records have legal criteria for the length they must be maintained in the office, such as ImmunizationsEmployee health recordsMedical office financial records
Criteria from IRS – financial recordsAMA, American Hospital AssociationHIPAA lawFederal and state laws
10-32
INACTIVE AND CLOSED FILE STORAGE
BasicStorageOptions
Computer Storage
Microfilm Paper Storage
Files remain in their original format Labeled boxes with lids to allow even stacking
If the paper becomes brittle, transfer documents to another storage medium.
Patient records can be scanned and saved on computer tapes, recordable CDs or DVDs, flash drives, or external hard drives.
Microfilm, microfiche and film cartridges offer a paperless way of storing records.
Some offices have extra storage space on-site
Smaller offices require the use of off-site storageUse a facility that takes precautions against fires
and floodsMaintain a list of all files stored at off-site locations Inactive and closed files must remain safe and secure
Evaluate storage sites carefully
Preferably place files in fireproof and waterproof containers
The storage site should be safe fromFire and floodsVandalism and theftExtremes of temperature