CHAPTER Maintaining Patient Records © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-2 Learning Outcomes 9.1 Explain the purpose of compiling patient medical records 9.2 Describe the contents of patient record forms 9.3 Describe how to create and maintain a patient record 9.4 Identify and describe common approaches to documenting information in medical records © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-3 Learning Outcomes (cont.) 9.5 Discuss the need for neatness, timeliness, accuracy, and professional tone in patient records 9.6 Discuss tips for performing accurate transcription 9.7 Explain how to correct a medical record © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-4 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-5 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-6 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-7 Importance of Patient Records (cont.) • Information included in patient record – Name and address – Current complaint – Insurance coverage and person responsible for payment – Health-care needs – Occupation – Medical treatment plan – Medical history – Response to care – Lab and radiology reports © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-8 Legal Guidelines for Patient Records © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-9 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-10 Patient Records Patient Education • Test results • Health issues • Treatment instructions Additional Uses of Patient Records Research • Source of data Quality of Treatment • Peer review • TJC review • Health-care analysis and policy decisions © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-41 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-42 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-43 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-44 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-45 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 Information to HMO Insurance Company I authorize Dr J Jones to release my healthcare information to the above-named insurance company Christopher Hansen Patient Signature mm/dd/yyyy Date © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-46 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-47 Release of Records • 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 (cont.) • Confidentiality – 18-year-olds are considered adults in most states Legal and ethical principle: Protect patient’s right to privacy at all times © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-48 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 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! © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-49 In Summary 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-50 In Summary (cont.) • Include • Maintain the charts properly – 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 Documenting detailed notes about the contact with the patient, patient responses and progress, and treatment outcomes 9.3 To create and maintain patient records forms © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-51 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-52 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-53 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-54 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9-55 End of Chapter Organization is the power of the day; without it, nothing is accomplished ~ Sophia Palmer From A Daybook for Nurses: Making a Difference Each Day © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed [...]... rights reserv ed 9- 13 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9- 14 Standard Chart Information... visits, and telephone calls – These are part of the continuous patient record – Document calls made to and from the patient © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9- 16 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... allergies – Handwriting must be legible – Make corrections properly © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9- 31 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... – Chart access after hours – Easier access to patient education materials • Disadvantages – Costly – Retraining of staff – IT staff may be needed – Possible damage to software and system – Improved billing Essential to quality of health care and patient safety © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9- 35 Electronic Health Records (cont.) • Advantages of computer records –. .. 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9- 15 Standard Chart Information (cont.) • Doctor’s diagnosis and treatment plan – – – – Treatment options and final treatment list Instructions to patient... Interview Examination, preparation, and vital signs Documenting patient statements © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9- 20 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... ed 9- 24 Types of Medical Records Source-Oriented Medical Records Problem-Oriented Medical Records • Conventional approach • POMR records make it easier to track specific • Information is arranged illnesses according to who supplied the data • Information included – Database • Problems and treatments are on the same form – Problem list • Difficult to track progress of – Educational, diagnostic, and. .. A ll rights reserv ed 9- 29 Apply Your Knowledge What type of documentation expands on the SOAP format? ANSWER: CHEDDAR format of documentation GOOD ! © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9- 30 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... hospitalization – Instructions for follow-up care – Physician signature © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9- 17 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... ll rights reserv ed 9- 22 The Six Cs of Charting Client’s words – Do not interpret patient’s words Clarity – Precise descriptions /medical terminology Completeness – Fill C out forms completely onciseness – To the point/approved abbreviations Chronological order – Legal issues confidentiality – Follow HIPAA guidelines © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 9- 23 Apply Your Knowledge