Medical Assisting/Terminology Ch 14- Medical Records – Flashcards

The physician/medical facility (often called the "maker") is the rightful owner of the medical record, but the patients have vested interest and therefore has the right to demand confidentiality of all information placed in the chart.

The traditional patient record is source oriented, which means data is catalogued according to their source. Forms and progress notes are filed in REVERSE CHRONOLOGICAL ORDER.

A radical departure from the traditional system of keeping patient records. It divides it into 4 bases.

-The database -The problem list -The treatment plan -The progress notes

-Subjective impressions -Objective clinical evidence -Assessment or diagnosis -Plans for further studies, treatment, or management Some medical offices use an "E" to represent Evaluation. This is used to record an assessment of the patient's understanding and compliance with treatment plan.

-Subjective info from the patient -Objective info from the physician

Patient's case history always begins with routine personal data, which includes -Full name -Name of parents if patient is a minor -Sex -DOB -Marital status -Spouse -Number of children -Home address, telephone number, email`

Different color papers are often used for reporting different procedures.

A method by which the latest lab report always appears on top

Reports on the patient's progress are continually being added to the medical record. Medical assistant can stamp the date, and is required to when entering information.

Erasing, obliterating, using correction fluid is prohibited. To correct a handwritten entry 1. Draw a line through the error 2. Insert the correction above or immediately after the error 3. In the margin, write correction or Corr., the initial of the person correcting the entry, and the date.

In most medical offices, records are filed according to 3 classifications -Active files : patients currently receiving treatment -Inactive files : patients that haven't been seen for 6 months or longer. When they return, they become active. -Closed files : those of patients who have died, moved, or terminated relationship with physician.

Laws regarding this vary, and most government programs have their own guidelines, which range from 3 years to permanent retention. When no restriction exists for the retention of medical records, it is best to keep them for a10 year period. However, when retaining the records of a minor, the facility should keep the records until the minor reaches the age of majority, plus 3 years. In all cases, medical records should be kept for at least the statute of limitations for medical malpractice claims, which may be 3 or more years.

Recommends that records for patients who have died should be kept for at least 2 years.

The patient must sign a release for information to be given to any third party. Requests from patient's attorney or third party payors must be must be cleared by the patient to receive information.

A legal document presented by patient's attorney which authorizes them to see medical records. This must be signed as the patient, so it is a release.

-Dictating into a dictation unit -Listening to what has been dictated -Keyboarding the dictated text to a printed document using correct format and required punctuation.

There are 5 basic steps -Conditioning -Releasing -Indexing and Coding -Sorting -Storing and Filing

Involves removing all pins, brads, and paper clips from the papers.

Some mark is placed on the paper that indicates it's ready for filing.

Indexing means where to file the letter or paper, and coding means placing some indication of this decision on paper. This may be done by underling the name or subject or writing the subject or name in a conspicuous place. If there is more than one logical place to file the paper, the original is coded for the main location and a cross reference sheet prepared, indicating this location and coded for the second location.

Arranging the papers in filing sequence; sort before going to cabinet or shelf

Items should be placed face up, top edge to the left, with the most recent date at the top of the folder. Life folder 1 or 2 inches out of the drawer before inserting new material so that the sheets can drop down completely.

-Alphabetic by name -Numeric -Subject

Name comes from its intent to tickle the memory that something needs to be done or followed up. The tickler file is always a chronological arrangement.