Types of Records in an Office • Medical records of the patient’s state of health • Correspondencepertaining to the field of health care • Documents related to the business and financial management of the practice
Objectives • Components that make up medical records • The SOAP format-the most common format used for recording medical information about patients • The 3 parts of the problem oriented medical record (POMR) format • Transcribe medical data dictated by a physician, apply guidelines for grammar • The preservation of medical records • Who actually owns a patient’s medical record • Standards to be used for quality assurance in maintaining medical records
The Medical Record • Patient’s medical record=“Patient’s Chart” • The source of info about all aspects of a patient’s health care • Accurate and up-to-date • Proper health care, financial and legal success • The AMA should be familiar with: • Why med. records are regarded as legal documents • The types of reports and information found in a MR • The importance of well-maintained MRs for the practice • The method for making corrections to a MR
MR as Legal Documents • A patient’s MR constitutes the legal record of the practice • May have to be produced in court • Uphold the rights of physician if involved in litigation or as a witness • Malpractice cases • Content and quality of MR is pivotal, can be more important than physician’s credentials, personality, or reputation • If data is incomplete, illegible or poorly maintained, an attorney can make the Dr. appear negligible
What is a MR? • Holds all the data about that patient • MRs include: • Chart notes • Chronological order of ongoing patient care and progress, made by physician, nurse, or other professional regarding pertinent points of a given visit or communication with patient • History and physical • Patient’s complete medical history(obtained in an interview on 1st visit), initial results of physical exam • Referral and consultation letters • Copies of letters sent to other physicians referring the patient for exams, tests, etc. • Medical Reports • Lab reports, X-ray reports, etc. • Correspondence • Copies of all correspondence with patient, including letters, faxes, and notes of phone conversations • Clinical Forms • Immunization records and pediatric growth and development records • Medication List • List of the all medications prescribed, including dosage, dispensing instructions, etc.
Reasons for Maintaining MRs • MRs are used in the following ways: • Main source of info for coordinating and carrying out patient care among all providers involved with the patient • Evidence of the course of an illness and a record of the treatment being used • A record of the quality of care provided to patients • A tool for ensuring communication and continuity of care from one medical facility to another • The legal record for the practice • The main record to ensure appropriate reimbursement • A source of data for research purposes (lecture, bk, article)
Making Corrections • Remember: No part of a record should be altered, removed, deleted, or destroyed • If error or discrepancy occurs, an addendum to the record must be made • How to make a correction: • Use strike-through feature-must be able to read the incorrect material • Enter the word “error” next to the deleted statement • Write your initials and date next to correction • Enter the correct information into the MR
SOAP Method • The most common system for outlining and structuring chart notes for a MR • Facilitates the creation of uniform and complete notes in a simple format that is easy to read • SOAP-Subjective, Objective, Assessment, Plan
SOAP: Subjective • The patient’s description of the problem or complaint, including symptoms troubling the patient, when they began, remedies tried, past medical treatment, etc. • Subjective record includes the following headings: • Chief complaint (CC): Reason for the visit • History of present illness (HPI): Info about symptoms • Past medical history (PMH): list of illnesses and treatments • Family history (FH): facts about family’s health related to you • Social history (SH): Social and marital history (eating, drinking, smoking, occupation, interests, etc.) • Review of systems (ROS): physician’s review of each body ststem with the patient (Ex: respiratory system)
SOAP: Objective • Physician’s examination of the patient • May be dictated under the heading Physical Exam (PE) • Complete physical exam • Subheadings for a physical exam: • Vital signs (VS) • General: description of the patient might be • HEENT: Head, eyes, ears, nose, throat • Neck • Heart • Etc.
SOAP: Assessment • Physician's interpretation of the subjective and objective findings • “Assessment” is used interchangeably with “Diagnosis (Dx)” and “Impression” • Gives a name to the condition from which the patient is suffering • Rule out (R/O): The diagnosis is not likely and further tests must be performed
SOAP: Plan • Plan-treatment • This section lists the following: • Prescribed medications and their exact dosages • Instructions given to the patient • Recommendations for hospitalization or surgery • Any special tests that need to be performed
Problem-Oriented Medical Records (POMR) • Another form of record keeping revolves around a list of the patient’s problems • 3 essential components: • Database • Complete history of the patient, problem, history, family, social, etc. • Initial plan • Based on the database and initial problems of the patient • Problem list • A running account of the patient’s problems • Referred to a updated at each visit • Used for: • Organizing entries within the problem list • To outline the history and physical for the database section
Transcription Guidelines • AMA’s role is to transcribe physicians’ chart notes and other medical documents • Physician may dictate and then give recording to an AMA for transcription
Listening Techniques • Dictation equipment: digital media (CD, analog media) • Tone, volume, rate of speed can be regulated for the assistant’s own comfort and rate of transcription • Confidential info-headphones • Foot pedal starts and reverses the machine
Office Policy • Every office uses its own format for transcribing chart notes • Include instructions or corrections when transcribing • You may not add anything that is not there
Basic Medical Transcription Guidelines • Skill in spelling, punctuation, capitalization • Knowledge of medical terminology, guidelines for medical abbreviations
Areas to Know • Commas • Semicolons • Colons • Capital letters • Hyphens • Abbreviations • Numbers • Symbols • Memos • Grammar • Document formatting
Preservation of Files • Patient MRs need to be preserved-importance to the practice and value as legal document • Kept until possible malpractice suit has passed or for four years after patient has left the practice • Many are kept in an inactive file permanently, however
Ownership • American Medical Association Council on Ethical and Judicial Affairs-deals with the ownership of MRs • Notes made by the physician and MRs are physician’s property • Used for physician’s use in treatment of patients • Info inside belongs to the patient-nature of the diagnosis, etc. • Physician cannot use or withhold the info in the recird according to his or her own wishes • Ex: Dr. is ethically obligated to furnish copies of office notes to any physician who is assuming responsibility for care of the patient (with a record release form signed and dated by patient) • Patient’s have the right to control the amount and type of info that is released from the MR • Patient’s alone have the authority to release info to anyone not directly involved with their care-fee may be charged
Quality Assurance • Best record of the care given a patient • AMAs job is to make certain the info recorded in the MR is accurate and up-to-date • If AMA is unsure of what was dictated, they must flag it for the physician • The AMA should make sure each record contains the following: • Dated notations describing the service received by the patient • Notations regarding q. procedure performed • Accurate notations. An addendum must be made by physician if a discrepancy occurs • Justification for hospitalization • If necessary, a discharge summary regarding hospitalization before the patient arrives for a follow-up visit
Key Terms (Define) • Assessment-the physician’s interpretation of the subjective and objective findings • Chief complaint (CC)-reason for the visit or why they are seeking medical advice • Diagnosis (Dx)-what the physician determines is the problem with the patient • Family history (FH)-facts about the health of the patient’s siblings, parents, blood relatives • History of present illness (HPI)-info about the symptoms troublign the patient: when they began, what affects them • Impression objective past medical history (PMH)-listing of any illnesses the patient has had in the past along with the treatments administered or performed • Physical exam (PE)-a complete physical examination where findings for each of the major areas of the body are covered • Plan-treatment for patient as directed by the physician • Problem-oriented medical record (POMR)-see PowerPoint • Review of systems (ROS)-physician’s review of each body system (ex: respiratory system) • Rule out (R/O)-the diagnosis is not likely and that further tests will be performed • SOAP-see PowerPoint • Social history (SH)-info regarding the patient’s eating, drinking, smoking habits, occupation, interests • Subjective-the patient’s description of the problem or complaint
Thinking It Through (Answer.) • How does the use of the SOAP format for record keeping minimize a provider’s exposure to legal risk? • Where in the POMR file would you look for information regarding a patient’s family history of intestinal cancer? • A former patient calls asking to retrieve x-rays taken more than five years ago. What do you say? • You are transcribing the physician’s dictation and cannot understand several words. What do you do?