9 Maintaining Patient Records
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
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
Current complaint Health-care needs Medical treatment plan Response to care Lab and radiology reports Importance of Patient Records (cont.) • Information included in patient record • Name and address • Insurance coverage andperson responsible for payment • Occupation • Medical history
Proof of event or procedure No documentation – no proof that care was done Legal document Must document complete information about patient care Document if patient is noncompliant Legal Guidelines for Patient Records
Standards for Records • Complete, accurate, and well-documented records are evidence of appropriate care • Incomplete, inaccurate, altered, or illegible records may imply a poor standard of care • Everyone who documents in the patient record has a responsibility to the patient and employing physician
Patient Records Additional Uses of Patient Records Quality ofTreatment Patient Education • Peer review • TJC review • Health-careanalysis andpolicy decisions Research • Test results • Health issues • Treatment instructions • Source of data
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. Good Job!
Standard Chart Information • Patient Registration Form • Date • Patient demographic information • Age, DOB • Address • SSN • Insurance/financial information • Emergency contact
Standard Chart Information (cont.) • Patient 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
Standard Chart Information (cont.) • 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
Standard Chart Information (cont.) • 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
Standard Chart Information (cont.) • 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
Standard Chart Information (cont.) • 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 • Date and initial everything you place in the chart
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. Correct!
Initiating and Maintaining Patient Records Completing medical history forms Documenting test results Initial Interview Examination, preparation,and vital signs Documenting patient statements Maintain patient privacy during interview
Initiating and Maintaining Patient Records (cont.) • 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
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!
The Six Cs of Charting C 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
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 Great!
Types of Medical Records (cont.) • SOAP documentation • Orderly series of steps for dealing with any medical case • Lists the following • Patient symptoms • Diagnosis • Suggested treatment SOAP
P lan A ssessment O bjective data S ubjective data SOAP Documentation The treatment plan to correct the illness or problem The impression of the patient’s problem that leads to diagnosis What the physician observes during the examination Information the patient tells you
CHEDDAR Format • Expands on SOAP format C Chief complaint, presenting problems, subjective statements H History: social and physical history E Examination D Details of problem and complaints D Drugs and dosage A Assessment of diagnostic process and diagnosis R Return visit information or referral
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 O S O S O O S S
Apply Your Knowledge What type of documentation expands on the SOAP format? ANSWER: CHEDDAR format of documentation. GOOD!
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
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
Appearance, Timeliness, and Accuracy of Records (cont.) • 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.) • 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.
Advantages Fewer lost records Reduced transcription costs Readability/legibility Chart access after hours Easier access to patient education materials Improved billing • Disadvantages • Costly • Retraining of staff • IT staff may be needed • Possible damage to software and system Electronic Health Records • Essential to quality of health care and patient safety
Electronic Health Records (cont.) • Advantages of computer records • 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
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. Very Good!
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
Medical Transcription (cont.) • 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 accurately • 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.) Transcription reference books Medical terminology books Transcription Aids Secretarial books Medical reference books
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. Excellent!
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” • Make corrections as soon as possible after the original entry was made
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 eror m/d/yyyy 00:00pm misspelled JHC /chj error
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
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 Super Job!
Release of Records • Records are property of the practice • 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 health-care information to the above-named insurance company. Christopher Hansenmm/dd/yyyyPatient Signature Date
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
Special cases Divorce – legal guardian of children (may be one or both parents) Death – next of kin or legally authorized representative If unsure, ask supervisor Confidentiality 18-year-olds are considered adults in most states Legal and ethical principle:Protect patient’s right to privacy at all times. Release of Records(cont.)
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. Request the original form. Nice Job!
9.1 Patients’ records should be compiled because they serve as legal documents, and may be used in medical malpractice cases and lawsuits. 9.2 The content of a patient record consists of standard chart information; information received by fax; dating and initialing of patients’ charts. In Summary
9.3 To create and maintain patient records forms Include Registration form Medical history Exam results, lab and other tests Records from other physicians and hospitals Diagnosis and treatment plans Operative reports, consent forms, discharge summaries Correspondence with or about patients. • Maintain the charts properly • Documenting detailed notes about the contact with the patient, patient responses and progress, and treatment outcomes. In Summary (cont.)
In Summary (cont.) 9.4 The most common approaches in documenting information into medical records is through Conventional or Source Oriented records, Problem-Oriented Medical Records (POMR), SOAP, and CHEDDAR. 9.5 Neatness, legibility, accuracy, and professional tone are musts in maintaining medical records.
In Summary (cont.) 9.6 Whenperforming accurate transcription: • Use incomplete sentences or phrases to keep up with the physician’s pace • Use abbreviations whenever possible • If physician speaks fast, ask him or her to speak slower and more clearly • Read dictation back to physician for clarity • Enter notes into patient record.
In Summary (cont.) 9.7 When correcting medical records, make sure you correct as soon as possible. Use appropriate procedure to make corrections. 9.8 Each item that is added to the patient record as an update should be dated and initialed. If the information is extremely important, get a third party to witness and initial and date as well.