Chapter 13: Managing Paper Medical Records- Notes
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- Legal document, a permanent record, and a tool used by staff members to communication within their office and with other offices regarding the services delivered to the patient.
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Medical Records
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- Established that the patient owns the information in the medical record and has the right to control under what circumstances, and with whom, it is shared.
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HIPAA
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- Should be written in black ink. - Handwriting should be clear and easy to read by anyone. - Sign and Date.
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Entries in Medical Records
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- Should be factual, based on statements of the patient and the physician's assessment.
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Documentation
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- Must not be erased or totally obliterated with products such as correcting fluid. - Draw a single line so the original entry can still be seen, enter your initials and date above the single line, and the word "Error"
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Errors
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- Who should always be present when a patient reviews their record?
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A staff member
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- Who owns the information in their medical records, but the facility that created the information owns the physical or electronic record. - Have the right to view their medical records, so medical offices must have a procedure in place to facilitate this.
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The patient
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- Parents of a minor child - Legal guardian - Agent (someone the patient selects to act on his or her behalf thorough a health care power of attorney)
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Persons allowed to sign release of records
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- Should never be removed from the office or taken home to complete work. - The risk of confidential irreplaceable information is too great.
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Medical records
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- Is a serious problem, and staff involved must take the required legal and ethical action of reporting it, regardless of any repercussions that may follow
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Loss of medical records
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1. Legibility 2. Accuracy 3. Timeliness 4. Accessibility
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4 standards of medical records
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Which standard of medial records states: - The medial records that are handwritten should be easily read by anyone. - Pay particular attention to numbers and spelling.
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Legibility
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Which standard of medial records states: - Because medical records are legal documents and can be used in a court of law, the physician must be able to trust the accuracy of the data. - Never guess about information and double-check your work to help ensure accuracy
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Accuracy
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Which standard of medial records states: - Do not wait to update records; make it an office habit to update records at the time of service or daily. - Includes documenting telephone calls, filing lab reports, and documenting office visits
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Timeliness
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Which standard of medial records states: - Make sure that the files are properly filed and easily accessed. - If there is a patient emergency, for example, the medial history will be needed immediately.
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Accessibility
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- Chronological Medical Record - Problem-oriented Medical Record - SOAP Charting - Source-Oriented Medical Reocrd
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Documentation formats of medial records
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Patient record organized according to diagnosis.
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Problem-Oriented Medical Record (POMR
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1. Database 2. Problem List 3. Plan 4. Progress Notes
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4 parts of PROM
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- Consists of physical examination, the patient history, and the results of baseline laboratory or diagnostic procedures.
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Database
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- List of patient problems that is kept in the front of the chart mush like a table of contents would be. - Assigns each problem a number with the date.
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Problem List
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- Very important part of the medical record because it tells what is intended for the patient. - Indicates a written plan for each numbered problem identified on the problem list. - May include tests to be ordered, treatment plans or plans for patent education about specific problems.
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Plan
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- Made up of several sections that follow a specific format; the first letter of each section title ( subjective, objective, Assessment, and plan, or SOAP) - Should be maintained in chronological order. - Also references the patient problem number.
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Progress Notes
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- The acronym for Subjective, Objective, Assessment, and Plan
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SOAP
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- Patient's name and medical record number - Date of Consultation - Medial Transcription's Initials -Referring Physician - Reason for the Consultation - Physical and Laboratory Evaluations - Consulting Physician's impression and Recommendations
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Parts of Consultation Report
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- The things that the patient believes he or she is seeing a physician for - Is usually the same as the chief complaint (CC) - Includes statements the patient makes about symptoms the patient has experienced, such as pain or dizziness or anxiety
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Subjective Information
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- Composed of the data gathered during the visit such as vital signs, weight change, fevers, blood work, physical examination results, and any other observable and measurable data.
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Objective Information
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- The physician's preliminary diagnosis - Plan section of the chart which discusses the strategy for care of the patient
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Assessment
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2/14/20YY Problem No. 1: Diabetes Problem No. 2: Hypertension, essential Is an example of what part of SOAP charting?
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Problem List
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2/14/20YY - Problem No. 1: Diabetic exchange diet -Regular insulin, 20 units subQ daily each morning - Monitor blood sugar levels during day - Problem No. 2: Norvasc 2.5 mg. daily Monitor blood pressure weekly Is an example of what part of SOAP charting?
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Plan
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2/14/20YY - Problem No. 1: Diabetes S- Patient states thirst has diminished and hunger lessened. 0- Urine +2, FBS positive, gained 4 pounds in past 3 weeks, skin turgor good A-- Diet and medication effective P- Continue medication, monitor blood sugar level daily, adjust insulin levels per instruction, return visit in 2 weeks Is an example of which part of SOAP charting?
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Progress Note
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- Patient chart notes organized according to symptoms, signs, assessment, and plan.
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SOAP charting
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- Report sent to a physician requesting by another physician who is asked to give a second option on a patient's case.
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Consultation Report
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- Patient's name and medical record number - Date of consultation - Medical transcription's initials - Referring physician - Reason for the consultation - Physical and laboratory evaluations - Consulting physicians' impression and recommendations This is information included in what type of report?
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Consultation Report
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- Describes a surgical procedure. - Surgeon is expected to dictate this report as soon as possible, preferably immediately after the procedure is completed.
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Operative Report
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- Type and amount of anesthetic agent used - Location and length of incisions - Layers of skin and tissue that were incised - Types of instruments used - Tissues and organs (if any)removed - Structures visualized - Gross (naked eye) observation and findings - Materials that were used in closing the wound - Estimated amount of blood loss - Sponge and needle count This is information included in which type of report?
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Operative Report
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- Vertical Files - Lateral Files - Movable Files
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Types of File Storage
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- Set up with 2-4 stacked pullout drawers holding up to a hundred files per drawer. - This type of file storage system is heavy and space consuming
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Vertical Files
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- Set up with shelves that allow files to be easily pulled off them. - A color-coded system for visual recognition of files is often used
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Lateral Files
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- Set up with electrally powered or manually controlled file units that move on stationary tracks in the floor. - This type of filing system saves space, because the file units can be moved close together when they are not needed. - This system is also useful for books and journals, because the floor can be reinforced when the track is installed.
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Movable Files
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- Designed to meet special needs - The top or side edge contains tabs at spaced intervals - Identification labels are applied to the tabs - Folders may be color coded to indicate the primary care physician. - These help keep files organized in large clinics
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File Folders
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- Used in medical offices to help keep files organized and make them easy to locate. - Dividers are used to separate files in drawers or on shelves. - Are of heavy pressboard and should be placed ever 1 1/2 to 2 inches to separate the file folders. - Separate files into subsections using a letter (e.g. A, B, C, A-B, Invoices, etc.) or by patient number.
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Guides
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- The main purpose of this item on the file is to identify what is in the file, such as the patient's name or medical record. - Can also indicate a color-coded stripe that can be sued for other purposes, such as identifying the primary care physician. - Medical offices also use special types as an alert to bring attention to patient allergies, required co-payment, and year of last visit; which assist staff to find pertinent information.
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Labels
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Which filing system is used to: - To decrease the number of misfiled charts and aid in file retrieval, many medical record departments use this system of labels to file. - The system assigns a unique color for each number from 0-9 and fore each letter A-Z
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Color-Coded
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What are 2 popular color-coding methods using a numeric system?
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Ames Color File System and Smead Corporation File System
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0-red = 0-yellow 1-gray = 1-blue 2-blue = 2-pink 3-orange = 3-purple 4-purple = 4-orange 5-black = 5-brown 6-yellow = 6-green 7-brown = 7-gray 8-pink = 8-red 9-green = 9-black
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Numeric Color- Coding System
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The following numbers represent which type of Numeric Color Coding System? 0-red 1-gray 2-blue 3-orange 4-purple 5-black 6-yellow 7-brown 8-pink 9-green
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Ames Color System
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The following numbers represent which type of Numeric Color Coding System? 0-yellow 1-blue 2-pink 3-purple 4-orange 5-brown 6-green 7-gray 8-red 9-black
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Smead Corporation File System
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Which filing system represents the following information: - Color-coded filing system which uses an alphabetic system discussed in the book - Is based on 13 colors with white letters on a colored background - Uses file labels to denote the patient's name, and a color label with the letter of the alphabet to indicate the index unit.
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Alpha-Z Alphabetic Color-Coding System
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Red= A = N Dark Blue Dark Green Light Blue Purple Orange Gray Dark Brown Pink Yellow Light Brown Lavender Light Green
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Alpha-Z Alphabetic Color-Coding System
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What are 3 commonly used systems for filing?
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Alphabetic, Numeric, and Subject
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- In this filing system the alphabet is used as a guideline to organize files - Requires that medial assistants know the alphabet well and are quickly able to determine which random letter comes before another.
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Alphabetic Filing
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In alphabetic filing Abbott should be field before or after Bacon?
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Before
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In alphabetic filing Abbott should be filed before or after Acker.
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Before
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Which filing system follows these rules? Divides the names and titles into units (first, second, and third). - Unit portion of the name that is used for filing or indexing purposes - Examples of Units: Unit 1: Last name Unit 2: First name Unit 3: Middle name
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Alphabetic Filing
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In the name Jacob James Jergens which unit is the last name (Jergens)?
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Unit 1
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In the name Jacob James Jergens which unit is the first name (Jergens)?
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Unit 2
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In the name Jacob James Jergens which unit is the middle name (Jergens)?
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Unit 3
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The following information describes what filing system? - Also called Patient Identification System - Provides the most privacy and is commonly used for medical records - A number is assigned to each patient's medical record, generally a six-digit number divided into 3 sections of 2 digits each (e.g., 05-72-21),
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Numeric Filing
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What are the 5 types of numeric filing discussed in the book?
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Straight Numeric, Terminal-Digit, Middle-Digit, Unit Numbering, and Serial Numbering
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- The simplest method of numeric filing - Each record is filed sequentially based on its assigned number - The numbers used in this system begin at 01 and continue upward
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Straight Numeric
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The following numbers are an example of which numeric filing system? 01- 101- 886 02- 102- 887 03- 103- 888 04- 104 889
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Straight Numeric
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- Numeric filing based on the last 2 digits of the ID number - Evenly distributes the files within the entire filing system - Eliminates the need for frequent refreshing of files, providing enough space was designated when the filing system was set up. - Requires dividing the files into a humdred primary sections, starting with 00 ending with 99 - 3 sections of numbers assigned to each file are designated as tertiary, secondary and primary sections
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Terminal-Digit
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The following numbers are an example of which numeric filing system? (05-72-21) 05= Tetiary 72= Secondary 21= Primary
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Terminal-Digit
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- Numeric Filing System which uses the same 6-digit numbering system as for the terminal-digit system - Places the middle digits as the primary numbers; the 1st 2 digits as Secondary numbers; and the 3rd 2 digits as the Tertiary numbers
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Middle-Digit
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The following numbers are an example of which numeric filing system? (05-72-21) 05= Secondary 72= Primary 21= Tertiary
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Middle-Digit
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- Numeric Filing System that is most commonly used by hospitals - A number is assigned to patients the first time they are seen or admitted to a hospital - All other hospitalizations or hospital visits use the same number - This method requires all records be kept at the same location
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Unit-Number
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- Numeric Filing System where the patient receives a different medical record number for each hospital visit - The patient acquires multiple records that are stored at different locations, for example, a hospitalization, laboratory work, and a mammogram all receive different numbers and are filed with in their own systems. - The assigned numbers are kept in an accession record in which numbers in sequential order (1, 2, 3, 4, 5, 6 . . .) have a name placed next to them as each new name is entered. - This record can also be maintained on the computer.
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Serial-Number
