Chapter 8 Medical Records Management – Flashcards
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OWNERSHIP OF MEDICAL RECORDS
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Information belong to the patient and is protected with privacy and confidentially; Medical facilities generated large amount of information, greatest bulk info is from medical records
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PURPOSE OF ACCURATE MEDICAL RECORDS
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Are essential for patient cause: • Maintain conscientious record of patient care • Assist in controlling cost of medical care • They are needed to provide referral for specialty care • Cannot be released without patient's knowledge. Patient has to have a signed released information.
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AUTHORIZATION TO RELEASE INFORMATION
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Even release of information required for a subpoena requires notification of patient • Patient must sign a release form if information is given to others. • May be yearly, when accepting insurance coverage, case-by-case basis • Should be very specific in what information is and what information is NOT to be release
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CORRECTING MEDICAL RECORDS-MANUAL RECORDS
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Draw a single line using red pen through the error; the use of red pen may vary from office to office. If it's not in the chart, it never happened.
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ELECTRONIC MEDICAL RECORDS
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Likely to be used by solo practioners
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POMR (PROBLEM-ORIENTED MEDICAL RECORDS)
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Identifies problems numerically as listed by patients; readily identifies frequency of recurring problems
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NEAR USED SOAP/SOAPER
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Soap - Subject Objective Assessment Plan Soaper - Education for patient response at patient to education and care given
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MOVEABLE FILE UNITS
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Moveable units electronically powered; used for offices with large record system
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OUTGUIDES
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Primary use is to indicate a chart has been removed; filing tool used to tack a patient's chart that has been removed from the storage area; primary information is who has possession of the chart
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FILING IDENTICAL NAMES
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Names have Jr. Sr. II or III; II or III is filed before Jr. or Sr.
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NUMERIC
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It is used in very large ambulatory care and hospital systems
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ALPHABETIC FILING
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One of the most simplest methods; Used when a limited number of is accessed
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NUMERIC FILING
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Preserves patient confidentiality; Has a straight terminal systems (chronological order); Equally distributed files
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CROSS-REFERENCING
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Helps store files for quick and accurate retrieval; helps identify location of file
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TICKLER FILES IN MANUAL SYSTEM OR CALENDAR IN EMRs
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A reminder that actions needs to be taken; Should contain: Patient's name, Tickler date when action should be taken, required action, additional relevant information
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FILING CHART DATA
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• Most common document/types of reports • Clinical notes • Correspondence • Laboratory reports • Misc.
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RECORD PURGING
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Sorting through records and removing those not actively used
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ACTIVE FILES
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Current patient files that need to be readily accessible
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PROGRESS NOTES
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Documentation for each patient's encounter
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SHINGLING
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taping the paper across the top to a regular-size sheet
