1 / 27

Patient Medical Records

Patient Medical Records. Types of Records in an Office. Medical records of the patient’s state of health Correspondence pertaining to the field of health care Documents related to the business and financial management of the practice. Objectives. Components that make up medical records

Download Presentation

Patient Medical Records

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.


Presentation Transcript

  1. Patient Medical Records

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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.

  7. 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)

  8. 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

  9. The Soap Method of Record Keeping and the POMR Format

  10. 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

  11. 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)

  12. 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.

  13. 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

  14. 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

  15. 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

  16. Transcription Guidelines

  17. 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

  18. 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

  19. 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

  20. Basic Medical Transcription Guidelines • Skill in spelling, punctuation, capitalization • Knowledge of medical terminology, guidelines for medical abbreviations

  21. Areas to Know • Commas • Semicolons • Colons • Capital letters • Hyphens • Abbreviations • Numbers • Symbols • Memos • Grammar • Document formatting

  22. Record Retention, Ownership, and Quality Assurance

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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?

More Related