Administrative medical assisting 5th by lindh chapter14

Ownership of Medical Records• Property of those who create record • Information belongs to patient and is protected with privacy and confidentiality • Patients are allowed access to the

Chapter 14

Medical Records Management

Medical Records Management

and the TPMS

Purpose of Medical Records

• Provide base for managing patient care

• Provide interoffice and intraoffice

communication as necessary

• Determine any patterns that surface to signal provider of patient needs

Purpose of Medical Records

• Serve as basis for legal information to protect providers, staff, patients

• Provide clinical data for research

Ownership of Medical Records

• Property of those who create record

• Information belongs to patient and is protected with privacy and

confidentiality

• Patients are allowed access to their

medical records and can ask certain

information be added or excluded from their file

Ownership of Medical Records

• Providers who include their patients in their medical record keeping foster trust and respect with their patients

Authorization to Release Information

• Before information released from

medical record, patient notified and

written approval received

• Identify reason for release and what

information specifically requested

• Only that information released

• Does not include release of information

to patient’s chosen insurance carrier

Manual or Electronic

Medical Records

• Americans to have EHRs by 2014

• Planned projects: transmitting x-rays

and laboratory results electronically

• 2011: Electronic prescribing

(e-prescribing) of medications for Medicare

Manual or Electronic

Medical Records

• Manual

– Advantages

• Currently established and understood

• Easier to protect confidentiality

• No worry of computer malfunction

Manual or Electronic

Medical Records

• Manual

– Disadvantages

• Can be used by only one person at a time

• Easily misplaced or misfiled

• Equipment and storage space required

• More susceptible to error

Manual or Electronic

Medical Records

• Electronic

– Advantages

• Multiple users possible

• Not easily misplaced or misfiled

• Errors less likely

• Patterns and data more easily accessed

• Quickly available in emergencies

• Office storage space not required

• Legible, organized patient documentation

• Improved medication management

• Improved quality of care

Manual or Electronic

Medical Records

• Electronic

– Disadvantages

• Need protection to prevent loss of data

• Expensive to establish and maintain

• May require on-site assistance

• Can require up to 12 weeks for staff to prove productive

Manual or Electronic

Medical Records

• 2009: American Reinvestment and

Recovery Act (ARRA)

– Incentives for physicians and hospitals to make

The Importance of Accurate Medical Records

• Accuracy essential to patient care

• Critical to facility’s smooth functioning

• Important when referring patient to

outside specialists

• Essential in controlling costs

• May be needed in medical litigation

The Importance of Accurate Medical Records

• Creating paper and electronic charts

– Chart prepared on or before day of patient’s first visit

– Paper medical records require assembly of

appropriate file folders and forms

– Electronic medical charts prepared in much the same manner except that all information stored electronically

The Importance of Accurate Medical Records

• Correcting medical records

– Paper medical record

• Draw single line using red ink pen through error

• Make correction

• Write Corr or Correction above area corrected

• Indicate your initials and current date

• Never obliterate

• Forensic experts able to determine when and how corrections were made

The Importance of Accurate Medical Records

• Correcting medical records

– Errors in EMRs

• Draw line through error (using “tracking” device in word processing software)

• Correction made immediately after information lined out

• “Corr.” or “Correction” indicated with your initials and date correction made

• EMR software locks out chart additions after specified time

The Importance of Accurate Medical Records

• Correcting medical records

– If information or chart sent elsewhere, make copy

of corrected information and send it as quickly as possible

Types of Medical Records

• Problem-oriented medical records

(POMRs)

– Vital identification data, immunizations, allergies, medications, problems

– Identified by a number that corresponds to

charting relevant to that problem number

– Each problem followed with the SOAP(ER)

approach for all progress notes

Types of Medical Records

• Problem-oriented medical records (POMRs)

Types of Medical Records

• Problem-oriented medical records

Types of Medical Records

• Source-oriented medical records

(SOMRs)

– Groups information according to its source

– Makes different types of information quickly

Types of Medical Records

• Strict chronological arrangement

– Data filed strictly with most recently charted materials to top of folder

– Difficult for provider or MA to quickly assess patient’s clinical picture

– May fit specialty office where patients seen on short-term basis

Equipment and Supplies

Equipment and Supplies

• Guides and positions

• Out guides

An out guide indicating name

of person who has possession of the file >>

Basic Rules for Filing

• Alphabetizing is key to organizing files and charts

• Indexing rules developed by Association

of Medical Records Administrators

(AMRA)

Basic Rules for Filing

• Indexing units

– Unit identifies each part of a name

– Each unit identified according to unit 1

– Applied to individual names, organizations, clinics

• Filing identical names

– When names identical, address may be used to order files

– Preferred methods include date of birth or Social Security number

Steps for Filing Medical Documentation in Patient Files

Filing Techniques and Common Filing Systems

• Color-coding technique used in three

major filing systems

• Patient charts use alphabetic system of color coding

• Color coding can be used in numeric

filing

• Color coding makes retrieval of files

more efficient

Filing Techniques and Common Filing Systems

• Color coding

– Tab-Alpha system

– Alpha-Z system

– Customized color coding systems

• Colored File folders by first name

• Colored File folders by last name

• Color-coded numbers

Filing Techniques and Common Filing Systems

• Alphabetic filing

– Simplest filing methods; strictly maintained by assigning label to each file

• Numeric filing

– Organized by number rather than by letter

– Preserves patient confidentiality

– Straight numeric

– Terminal digit

– Middle digit

Filing Techniques and Common Filing Systems

• Components of numeric filing

– Serially numbered dividers with guides

– Miscellaneous (general) numeric file section – Alphabetic card file

– Accession record

Filing Techniques and Common Filing Systems

• Subject filing

– Convenient for locating frequently used services or for filing reference materials for patient needs

• Choosing a filing system

– Facility primary objectives with storage of patient files, business records, research files

– Selecting alphabetic or numeric system

– Confidentiality of charts

– HIPAA compliant

Filing Procedures

• Cross-referencing

– Store files for quick and accurate retrieval

– Especially helpful with foreign names, hyphenated names, stepfamilies

– Does not need to be elaborate

– Steps for cross-referencing

Filing Procedures

• Locating missing files or data

– Conduct systematic search

– Steps to searching

– Check files for proper filing order whenever

returning or retrieving file folder

– When finished with a record, refile it immediately

• Filing procedures for correspondence

– Remove paper clips and staple items together

– Inspect to see if item is ready to be filed

– On incoming correspondence, be sure letterhead

is related to letter

• Filing procedures for correspondence

– On outgoing correspondence, look at inside

address and reference line

– On incoming or outgoing correspondence, code indexing units of designated label

– Create miscellaneous folder for items that do not have enough in number to warrant individual folder

Electronic Medical Records

• Mandated; one day will replace all

paper/manual medical records

• Fewer errors created

• Create, store, edit, retrieve patient data

• Allow more than one person to access chart at same time

Electronic Medical Records

• Purchased as single computer

application or part of larger practice

management system

• EMR capability list

• Providers use computers to open and

view charts and write prescriptions

• System administrators can identify

access and privileges for confidentiality

• EMR fully recognized as legal document

Archival Storage

• Providers preserve patient medical

records for life of practice

• Computers help to solve space issues through EMRs

• Records copied onto optical disks or CDs

• Should have backup system

Archival Storage

• Confidentiality

– Major issue in using computer and online devices for storage and transfer of medical information

– Never discuss information outside clinic

– Unwise to discuss private information within facility

if it is not your concern