Medical Records Management 1 Why are Medical Records

Medical Records Management 1

Why are Medical Records important? Ø Assist physician in providing best possible care. Ø Provides a complete history. Ø Provides critical information for others. Ø Provides continuity of care. 2

Why are Medical Records important? Ø Offer legal protection for those who are providing care. Ø Remember: “If it isn’t documented, it didn’t happen. ” 3

Why are Medical Records important? Ø Provide statistical information. Ø Provides information about medications taken and reactions to them. Ø Evaluate effectiveness of treatment. Ø Track drug effectiveness and side effects. 4

Why are Medical Records important? Ø Vital for financial reimbursement. Ø Usually required by third-party payors. Ø Supports medical necessity for billing and payment. 5

Who Owns the Medical Record? Ø The physician or medical facility owns it. Ø They are the “maker” of the record. Ø The patient has the right to demand access to the information contained in the record, but does not own it. 6

Security Ø Originals should never leave the premises. Ø Should an original leave the premises, a copy should be retained in the record and marked as such until the original is returned. Ø Records should be kept in a locked cabinet or locked room. 7

So tell me what you know… Ø Why are medical records important? Ø Who owns the medical record? Ø How should medical records be kept secure? Ø Who knows how to complete this statement – “If it isn’t documented, ____. ” Ø Why is this statement important? 8

Management of Records Ø Files should be organized at all times. Ø Adding documents to a chart should be able to be done efficiently. Ø A physician or provider should always have the most up-to-date information. Ø Above all, the system must work for the facility. 9

Types of Records Ø Paper based Ø Electronic based/Computer-based 10

Paper based Only one person can use the record at a time. Ø Not readily available for use by others. Ø Misfiled information is common. Ø Entire record can be misfiled or misplaced. Ø Data is difficult to retrieve for statistical and quality control purposes. Ø It is good evidence of patient care. Ø 11

Paper based Ø If you have patients who stay for a period of time and discharge (nursing home or hospital)… l It is generally a good idea to have a different color chart for each calendar year to allow for rapid year location. • • 2008 – green 2009 – blue 2010 – red 2011 – yellow 12

Paper based Ø Master Card File: This is a master file of all charts and storage location. Ø Master Card Files are often a 3 x 5 cardex type file and includes identifying patient information, dates of service, medical record number, etc. l l Master file is to be updated as files are relocated (closed files, relocated to make more room for current files). Master Card is to be noted with date of chart destruction. 13

Computer based Differs from Electronic based Ø The bulk of the record is computerized but may not include everything, such as x-rays or lab reports. Ø Guarding patient confidentiality is difficult. Ø Computer malfunctions may limit access to the record. Ø Access to records will be available even if the patient is not in his/her home town. Ø 14

Electronic based Ø All records are stored electronically. Ø Includes x-rays, MRIs, etc. Ø Anything not provided in an electronic format is scanned into the record. 15

So tell me what you know… Ø What are the pros/cons of a paper-based record system? Ø What are the pros/cons of a computerbased record system? Ø What are the pros/cons of an electronicbased record system? Ø How do you know which one is best for your office/hospital? Ø What is the purpose of a Master Cardex? 16

Chart Order Ø Forms are filed in Reverse Chronological Order Ø This means the most recent document is on top. Ø All like documents are kept together. Ø All physician's orders are together, all lab reports, all nurses’ notes and so on. 17

SOAP / SOAPE (SOAPIE) Ø Many doctors (or Nurse Practitioners) use the SOAP or the SOAPE (SOAPIE) approach to their progress notes. Ø This essentially forces a rational approach to patient problems and assist in formulating a logical and orderly plan of patient care. 18

SOAP Ø S = Subjective Impressions Ø O = Objective Clinical Evidence Ø A = Assessment or Diagnosis Ø P = plans for further studies or treatment 19

SOAPE (SOAPIE) Ø S = Subjective Impressions Ø O = Objective Clinical Evidence Ø A = Assessment or Diagnosis Ø P = plans for further studies or treatment Ø (I = Intervention) Ø E = Evaluation 20

So tell me what you know… Ø Explain what reverse chronological order means. Ø What does each letter of “SOAP” mean and give an example of information that would be written for each. 21

Demographic Information Ø Personal Demographics l l l l Full name (spelled correctly) Name of parents (if a child) Patient’s sex Date of Birth (DOB) Marital Status Name of spouse, if married Number of Children, if any Home address, telephone number and email 22

Demographic Information l l l l Occupation Name of employer Business Address and telephone number Employment information for spouse Healthcare Insurance Information Source of Referral Social Security Number 23

So tell me what you know… Ø Why is demographic information important? Ø How many examples of demographic information can you name? (Hint: You were just given 15 – no peeking!) 24

Personal and Medical History Ø Ø Ø Ø Often obtained by completing a questionnaire Past illnesses and surgeries Physical defects (congenital or acquired) Allergies Daily habits Advanced Directives Anything that needs to be in the forefront of the providers mind while providing care. 25

Family History Ø Illnesses or diseases Ø Causes of death for immediate family members Ø Many diseases and illnesses have hereditary patterns. 26

Social History Ø Information about a patient’s lifestyle Ø Do they consume alcohol? How much? Ø Do they smoke? How much? Ø Do they use drugs? How often? Ø Do they wear a seat belt? Ø Married? Single? Sexually active? 27

So tell me what you know… Ø Why is a patient’s personal and medical history important? Ø Why is their family history important? Ø How much of an impact does a patient’s social history have on their medical care? Ø What if the patient does not tell the truth? 28

Chief Complaint General information may be taken by a Medical Assistant, but should be reviewed in detail by the Physician/Nurse Practitioner. Ø Concise account of patient’s symptoms, explained in the patient’s own words. Ø Should include: Ø l l l Nature and duration of the pain, if any Time when patient first noticed the symptoms Patient’s opinion as to the cause of the difficulty Remedies patient tried before coming to see the doctor Other medical treatment rec’d for the same condition in the past 29

Objective Information “Signs” that become evident from the physician’s examination of the patient. Ø Physical findings Ø Test results or requests for tests Ø Diagnosis can be made. Ø l If some doubt remains, a provisional diagnosis can be made. Treatment is prescribed. Ø Timeframe for follow-up is noted. Ø 30

Obtaining the History Can be done orally, if privacy allows, to become better acquainted with the patient. Ø Can be done in writing. Ø If the records are kept electronically or the questionnaire is lengthy the form may be mailed prior to the appointment to allow for time to enter the information prior to the visit. Ø Will the office provide return postage? Ø 31

Forms Often different colors are used to make forms easy to locate within a paper record. Ø Such as: yellow for urinalysis, pink for blood counts, etc. Ø Shingling: Small forms taped to a 8 ½ by 11 sheet of paper one on top of another approximately ½ inch above each another starting from the bottom. This method allows for the most recent form to always be on top. Ø Shingle small forms such as half sheets, messages, post it notes, etc. Ø 32

Keeping Records Current Ø Never Procrastinate!!! Ø File Daily!!! Ø Make certain the physician has received all abnormal lab reports and urgent messages. 33

So tell me what you know… Ø Why is the chief complaint significant to the physician? Ø When you are responsible for maintaining records, why is consistent color coding important? Ø Why do you shingle records? Ø Can you think of records that would be beneficial to shingle? 34

Transfer, Destruction and Retention of Files Ø Active files: Patients currently receiving care Ø Inactive files: Patients the doctor has not seen in six months or longer Ø Closed files: Patients who have died, moved away, or otherwise terminated their relationship with the doctor. 35

Transfer, Destruction and Retention of Files No nationwide standard for retention Ø Medicare and Medicaid have their own guidelines. Ø When no restrictions exist it is best to keep records for ten years. Ø l l Ø Applies to Adult Charts Minor Charts should be kept until minor is age 18, plus several more years according to state law. In all cases, records should be kept for at least as long as the statute of limitations for medical malpractice claims. 36

Releasing Medical Record Information Ø The patient must sign a release for information to be given to any third party (except insurance companies). Ø All medical records requests should be in writing and retained with the record. 37

Releasing Medical Record Information Ø Take extreme care with telephone calls. Ø Just because I say I am – Am I really? ? ? 38

So tell me what you know… Ø What kind of patients have active files? Ø What kind of patients have inactive files? Ø What kind of patients have closed files? Ø How long should a medical record be maintained? Ø When is it okay to release a copy of the medical record? Ø Where should record of the release be stored? 39

Have questions? Still unclear? 40