Lecture Medical assisting: Administrative and clinical procedures with anatomy and physiology (4e) – Chapter 9

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 documen

Maintaining Patient

Records

9.1 Explain the purpose of compiling patient

9.4 Identify and describe common approaches to

documenting information in medical records

Learning Outcomes

accuracy, and professional tone in patient

Learning Outcomes (cont.)

9.8 Explain how to update a medical record

9.9 Identify when and how a medical record may

be released

9.10 Discuss the advantages and disadvantages

of the electronic medical record, also known

as the electronic health record

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



• Information included in patient record

– Name and address

– Insurance coverage and

person responsible for payment

– Occupation

– Medical history

– Current complaint – Health-care needs – Medical treatment plan – Response to care

– Lab and radiology reports



Legal Guidelines for Patient Records

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

Patient

Education

Quality ofTreatmentResearch

Additional Uses of Patient Records

• Source of data

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.

Standard Chart Information

Patient Registration Form

• 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

– Treatment options and final treatment list

– 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

– All written correspondence regarding the

patient – Record date item was received on the actual

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.

Initial Interview

history forms

Documenting

patient statements

• 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

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

The Six Cs of Charting

Fill out forms completely

To the point/approved abbreviations

Legal issues Follow HIPAA guidelines

What are the six Cs of charting?

ANSWER: The six C’s of charting are

Types of Medical Records

• Problems and treatments are

on the same form

• Difficult to track progress of

specific events

• POMR records make it

easier to track specific illnesses

• Information included

– Database – Problem list – Educational, diagnostic, and

treatment plans – Progress notes

What the physician observes during the examination

The impression of the patient’s problem that leads to diagnosis

The treatment plan to correct the illness or problem

SOAP Documentation

• Expands on SOAP format

C Chief complaint, presenting problems, subjective statements

H History: social and physical history

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

S

O O

O

What type of documentation expands on the SOAP

format?

ANSWER: CHEDDAR format of documentation.

GOOD

!

 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

– 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

 Accuracy

 Check information carefully

 Never guess or assume

 Double-check accuracy findings and

instructions

 Make sure most recent information is

recorded

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.

Electronic Health Records

 Essential to quality of health care and patient safety

• 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

– 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.

• 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

• 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.)

books

Medical referencebooks

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.

• Medical records are created in “ due

– 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

m/d/yyyy 00:00pm misspelled JHC /chj

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

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 Information

Christopher Hansen mm/dd/yyyy

Patient 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

– Divorce – legal

guardian of children (may be one or both parents)

– Death – next of kin or

legally authorized representative

– If unsure, ask

supervisor

– 18-year-olds are considered adults in most states

Legal and ethical principle:

Protect patient’s right to privacy at all times.

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.

– 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.

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 When performing 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.

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

In Summary (cont.)

9.9 Medical records can only be released with

patient’s written consent or subpoena by the courts Consent form must be on file

9.10 The advantages of the electronic medical

record outweigh the disadvantages Evaluate software before purchasing Maintain

sensitivity to patient needs

Organization is the power of the day;

without it, nothing is accomplished.

~ Sophia Palmer

From A Daybook for Nurses:

Making a Difference Each Day