bsbmed303b maintain patient records - mediweb€¦ · bsbmed303b: maintain patient records . this...
TRANSCRIPT
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 1
BSBMED303B Maintain Patient
Records
Medical Administration Training
Written by Jennifer Atkins www.mediweb.com.au
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 2
Copyright
Copyright © Jennifer Atkins 2013.2
© 2009 Version 1
This training manual is copyright under the Copyright Act 1968.
Any third party copyright material included in this publication is attributed.
Jennifer Atkins asserts her ownership of the Intellectual Property contained in this
training manual. All rights are reserved. No part of this publication may be
reproduced, transmitted, transcribed, stored in a retrieval system, utilised,
distributed, or translated into any other language in whole or in part, in any form or
by any means, by any other party whether it be electronic, manual, photocopying,
recording, or otherwise.
Copying without authorisation is illegal.
Disclaimer
Every attempt has been made to ensure this workbook is free from errors or
omissions. However, as an educational resource, all effort should be made to
ensure you seek professional advice before relying on any statement or fact
contained herein. Material in this workbook is current at the time of writing.
Jennifer Atkins Medical Administration Training
www.mediweb.com.au
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 3
Table of Contents
Resources: Helpful Websites ................................................................................. 4
Chapter 1 – Identify and clarify own role and procedures for patient record
keeping ............................................................................................................... 9
Your role and responsibilities (1.1) ............................................................................ 10
Access procedures for patient record keeping (1.2) .................................................. 15
Policies and procedures.............................................................................................. 15
Privacy Act .................................................................................................................. 20
Seek clarification from others (1.3) ............................................................................ 22
Chapter 2 – Access patient records ...................................................................... 25
Gain access to patient records (2.1) ........................................................................... 25
Types of filing methods .............................................................................................. 26
Check for currency and accuracy (2.2) ....................................................................... 34
Create new records (2.3) ............................................................................................ 36
Check patient records for follow-up (2.4) .................................................................. 38
Storage of files (2.5) ................................................................................................... 41
Chapter 3 – Help maintain records ...................................................................... 47
Check patient files (3.1) .............................................................................................. 47
Archiving patient files (3.2) ........................................................................................ 49
Kids' medical records abandoned in office ................................................................ 52
Transferring patient files (3.3) .................................................................................... 53
Chapter 4 - Monitor and review own role ............................................................ 59
Monitor own role (4.1) ............................................................................................... 59
Make recommendations for improvements (4.2) ...................................................... 63
Revision Sheet 1 ................................................................................................. 71
Revision Sheet 2 ................................................................................................. 75
Revision Sheet 3 ................................................................................................. 79
Revision Sheet 4 ................................................................................................. 83
Answers to Self Review Questions ...................................................................... 87
Glossary of Terms ............................................................................................... 90
ASSESSMENT CRITERIA ....................................................................................... 92
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 4
Resources: Helpful Websites
Professional Associations and Medical Standards
AGPAL Australian General Practice Accreditation Ltd www.qip.com.au
Australian Association of Practice Managers www.aapm.org.au
Australian Health Practitioner Regulation Agency http://www.ahpra.gov.au/
Australian Medical Association (AMA) www.ama.com.au
General Practice Computer Standards http://www.racgp.org.au/your-
practice/e-health/cis/ciss/
General Practice Registrars Australia www.gpra.org.au
Health Services Commission http://www.health.vic.gov.au./hsc/
Medical Practice Act 1992
www.austlii.edu.au/au/legis/nsw/consol_act/mpa1992128/s167.html
NSW Rural Doctors Network www.nswrdn.com.au
Royal Australian College of General Practitioners (RACGP) www.racgp.org.au
State and Territory Doctors Health Advisory www.doctorshealth.org.au
Privacy Links
Privacy Act http://www.privacy.gov.au/law/act
Office of the Australian Information Commissioner http://www.oaic.gov.au
RACGP Handbook for the Management of Health Information in Private
Medical Practice http://www.racgp.org.au/privacy/handbook
National Health and Medical Research Council - National Statement on
Ethical Conduct in Research Involving Humans
http://www.nhmrc.gov.au/publications/synopses/e35syn.htm
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 5
Fees and Charges for Access to Medical Records
Victoria http://www.health.vic.gov.au/healthrecords/regs.htm
Northern Territory
http://www.health.nt.gov.au/Agency/Freedom_of_Information_and_Privacy/in
dex.aspx
Queensland: Access for Patients to Medical Records
http://www.ama.com.au/node/469
Queensland: Transfer of Medical Records Between Doctors
http://www.ama.com.au/node/522
Western Australia http://www.foi.wa.gov.au/HowTo.htm#Cost
New South Wales http://www.mcnsw.org.au/index.pl?page=64
Medical and Health Reference Sites
Alcohol Awareness Site
http://www.drinkingnightmare.gov.au/internet/DrinkingNightmare/publishing.nsf
Australian Doctor Online Newspaper http://www.australiandoctor.com.au
Cancer Screening Government Site http://www.cancerscreening.gov.au/
Department of Health and Aged Care www.health.gov.au
Department of Health, Victoria http://www.health.vic.gov.au
Doctors Reference Site www.drsref.com.au
Government Website About Health Issues www.healthinsite.gov.au
How Do You Measure Up
http://www.measureup.gov.au/internet/abhi/publishing.nsf
Infection Control Guidelines For a Health Setting
http://www.nhmrc.gov.au/node/30290
National Skin Cancer Awareness www.skincancer.gov.au
Quit Smoking www.quitnow.info.au
Royal District Nursing Service www.rdns.com.au
Seniors Reference Site www.seniors.gov.au
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 6
BSBMED303B: Maintain Patient Records
Description
This unit describes the performance outcomes, skills and knowledge required to
maintain patient records within an existing medical records management system,
whilst under the supervision of a senior receptionist or practice manager. This unit
pertains to medical administration workers who will be given tasks by a fellow
receptionist or practice manager. Medical workers may exercise tact and judgment
in using patient records while fully respecting patient privacy and the confidentiality
of their details.
Performance criteria
Element Performance Criteria
1.Identify and clarify own role and procedures for patient record keeping
1.1 Determine own role and responsibilities within patient record keeping system through consultation with relevant personnel or via organisational policy and procedures manual
1.2 Access documented procedures for patient record keeping system and read for understanding
1.3 Seek clarification with relevant personnel of unclear or ambiguous procedures
2. Access patient records
2.1 Gain access to patient records to facilitate patient visit
2.2 Check currency and accuracy of patient demographic and personal details
2.3 Create new records according to enterprise protocols
2.4 Check records following patient visits, for practitioners' instructions related to follow-up action
2.5 Store patient files following organisational policy and procedures
3. Help maintain records
3.1 Make checks of patient files
3.2 Carry out archiving of patient files as required
3.3 Transfer patient files to another health facility upon appropriate request for patient information
4. Monitor and review own role
4.1 Monitor and review own role and responsibilities in maintaining patient records to identify opportunities for improvements to system and own work practices
4.2 Make recommendations to relevant personnel for improvements to the established procedures and processes for maintaining patient records
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 7
About this workbook
This workbook is suitable for students in a range of situations, from classroom
based learning to distance education learning.
The workbook is developed as a step-by-step learning guide. You are to complete
each element before moving onto the next section. Activities are provided for you
to work through, and once the relevant skills are developed then you can move on
to the next part of the book.
As this is a nationally recognised unit, the activities throughout the book will
require you to draw upon your experiences in life, and your simulated experiences
in a medical environment. These exercises will be the basis of your learning so you
will develop the skills necessary to meet the required competency for the unit.
The focus of this resource is private practice, and all scenarios are based on a
private medical practice, referred to as Summerhill Medical Centre.
Employability Skills
Employability Skills are skills that apply across a variety of jobs and life contexts.
They are sometimes referred to as key competencies or transferable skills. The
current term is Employability Skills.
Employability Skills are defined as "skills required not only to gain employment, but
also to progress within an enterprise so as to achieve one's potential and contribute
successfully to enterprise strategic directions."
There are eight Employability Skills: communication, teamwork, problem solving,
initiative and enterprise, planning and organising, self-management, learning, and
technology.
These Employability Skills are covered in each area of your learning, which ensures
you have achieved these skills.
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 8
BSBMED303B: Maintain Patient Records
This unit focuses on the key skills and knowledge required to maintain patient
records within a medical practice, whilst under supervision. This unit does not
address the establishment of a new patient record system.
This unit has four chapters. Each chapter has a number of performance criteria
which explain what you need to do to ensure demonstrated competency in this
unit.
Chapter 1:
Identify and clarify own role and procedures for patient record keeping
This chapter discusses your responsibilities in the medical practice. it addresses
how to seek advice and clarification from managers, policies and procedures, when
working with patient records.
Chapter 2:
Access patient records
This chapter discusses the need for patient records to be accessed in a systematic
way. The currency, accuracy and creation of files is the focus of this section, as well
as the knowledge required to accurately store patient records.
Chapter 3:
Help maintain records
The techniques required for checking and archiving patient files is discussed in this
part. Transferring files to another health provider on the request of a patient is also
addressed.
Chapter 4:
Monitor and review own work role
The regular monitoring and ongoing need for improvements in the patient record
system is addressed. Self review of the medical workers own work is guaranteed.
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 9
Chapter 1 – Identify and clarify own role and procedures for patient
record keeping
Performance criteria addressed:
1.1 Determine own role and responsibilities within patient record keeping system through consultation with relevant personnel or via organisational policy and procedures manual
1.2 Access documented procedures for patient record keeping system and read for understanding
1.3 Seek clarification with relevant personnel of unclear or ambiguous procedures
Introduction
The management of health records is at the forefront of quality patient care.
Keeping current and accurate information about patients not only guarantees
records are accurate, but also ensures files are maintained in a way that meets
workplace policies and procedures.
Accurate and timely information is collected on the patient’s first consultation with
the medical practice, and at subsequent visits. Information is collected at each
consultation and recorded in line with recommended practices. Information
sources are the patient, medical doctor, specialist reports, pathology and x-ray
results and reports from other health providers, such as physiotherapists or
chiropractors.
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 10
Your role and responsibilities (1.1)
A medical administration worker can work in a variety of medical settings, such as a
medical centre, a specialist practice, a hospital or a community health centre.
Where you work will determine the procedures to access patients’ records.
Maintaining patient records can include duties such as:
Creating new records
Updating existing patient records
Ensuring all information is in the patient file
Ensuring patient records are kept in an orderly format
Retrieving patient records
Storing patient records
Archiving patient records
Releasing records upon the request of the patient.
Activity 1 - Your role and responsibilities
On the following page is a sample position description for a
medical receptionist. It describes the roles and responsibilities of
a medical receptionist working in a particular situation.
Read the position description and highlight or asterisk all the duties that would
necessitate contact with patient records. This may include:
Individual documents containing patient information
(i.e. correspondence from specialists)
Verbal information (i.e. patient discusses details over the telephone).
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 25
Chapter 2 – Access patient records
Performance criteria addressed:
2.1 Gain access to patient records to facilitate patient visit
2.2 Check currency and accuracy of patient demographic and personal details
2.3 Create new records according to enterprise protocols
2.4 Check records following patient visits, for practitioners' instructions related to follow-up action
2.5 Store patient files following organisational policy and procedures
Gain access to patient records (2.1)
Retrieving patient information is an important part of your role as a medical
administration worker. It is important that you know your medical practice’s
policies and procedures regarding:
Creating patient records
Accessing patient records
Storing patient records
When a patient attends the practice for an appointment, you need to be able to
retrieve their patient record in a timely manner. To access patient records means
you need to know which system of filing is used.
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 26
Types of filing methods
There are four commonly used methods for filing medical records:
1. Alphabetical
2. Numerical
3. Chronological
4. Geographical
Alphabetical
The most commonly used method of filing is the alphabetical system. Files are
arranged in alphabetical order according to the patient’s surname or business name,
just like a telephone book. This is the most commonly used system as it is easy to
use. There are a number of rules to remember when filing alphabetically.
Top filing rules
The titles rule - Ignore joining words and titles such as Dr, Mr, Mrs or
Miss.
The keyword rule - The keyword is the most important part of the
name. This will be the surname for a person, or the main part of the
business name for a company.
The hyphen rule - Hyphenated or compound names are treated as one
word
e.g. Winter-Smith, A’Beckett, and Von Blanche are both treated as one
single word.
The abbreviations rule -Abbreviations are treated as if the word was
written in full.
St is filed as Saint, therefore St and Saint entries are treated as if spelt
the same way, and intersorted. Mac and Mc are also intersorted e.g. Jay
McNeil would be filed before John MacNeil.
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 30
Activity 7 - Alphabetical filing
Arrange the following into alphabetic order.
Jennifer Johns
Jenni Johnson
Jane Johnson
Jeffrey Johnson
Julie Johns
Joshua Johns
Activity 8 - Alphabetical filing
Arrange the following into alphabetical order.
St John Rehabilitation
St John Medical Training
Saint John Backcare Supplies
St John Medical Centre
St John Orthopaedics
Saint John Radiology
St John Hospital
Stuart St John
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 45
Self-Review
Chapter 2 - True and False Questions Access Patient Records True or False
1. The numerical filing system is the most commonly used system
2. The alphabetical filing system is arranged just like a telephone book
3. The keyword is the most important part of the name in alphabetical filing
4. A hyphenated name is treated as two separate words
5. Abbreviations are treated as if the word is written in full
6. In alphabetical filing Dale St John would be filed before Dean Saint John
7. Numerical filing is only used for financial documents
8. The Medicare number is a good number to use for numerical filing
9. Numerical filing systems are an indirect method of filing
10. Alpha-numerical systems use both letters and numbers when filing
11. Geographical filing may be used by specialists attending different consulting rooms
Accurate Files
12. A patient’s Medicare card must be checked at each and every visit
13. It is a medical receptionist’s role to ensure the patient’s medical record is current
14. The patient’s name on the file must always match the name on their Medicare card
15. The Privacy Act has no requirement for keeping records up-to-date, only accurate at the first visit
New Patient Records
16. A pre-printed form is the best way to collect information from a new patient
17. Patient details such as religion may not always be necessary
18. It is inappropriate to ask patients if they are of Aboriginal descent
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 51
Activity 18 - Improper disposal of medical records
Read the following Australian newspaper reports and note
possible breaches of the standards health providers should
adhere to.
'Serious breach': medical records found in park
The Sydney West Area Health Service has been embarrassed by the discovery of
medical records in an abandoned amusement park.
Pathology results and slides were found when a container dumped in the former
Magic Kingdom park at Lansvale was set alight this week.
The health service's chief executive, Professor Steven Boyages, says it is a serious
breach and the health service is reviewing its waste disposal procedures.
"There are clear policy and procedures in place to manage records and disposal of
records and clear policies in place to manage and dispose of any clinical waste," he
said.
"It appears at first glance that the policy and procedures weren't followed by the
contractors who were engaged to do this."
ABC Jun 27, 2008 Article source: http://abc.com.au/news/stories/2008/06/27/2288377.htm Accessed on 12 July 2011
Report details private health records misplaced in public places
A new report reveals Victoria's Health Services Commissioner (HSC) uncovered
incidents of private health records being left in public places.
The office of Victoria's HSC operates a telephone service to receive complaints from
patients. For the past financial year, about a quarter of the complaints related to
access of health records and privacy.
The HSC's annual report states that in one case, a member of the public found a list
of in-patients of a public hospital ward, containing information on patients'
conditions and treatments.
In another case, the office received a complaint about a doctor who closed his
practice and threw out medical records, including patients' addresses, in a public
bin.
The report says steps were taken in both cases to make sure medical records were
not misplaced in the future.
ABC Oct 4, 2006 Article source: http://abc.com.au/news/stories/2006/10/04/1755345.htm Accessed on 12 July 2011
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 53
Transferring patient files (3.3)
A patient may request a transfer of their medical file to another health professional.
The doctor can provide a copy of the file for this purpose. The medical practice will
usually keep the original copy of the patient’s file until seven years after the last
appointment, after which time they may send the original file. Until that time, they
can only send a copy of the file.
Files must meet security requirements whilst being mailed. This means that files
should not be sent by ordinary mail. Express mail is also not the best option as the
documents are not tracked, they just arrive quickly. For this reason, registered mail
or courier are the appropriate options.
Sometimes another health provider will phone to request patient information over
the phone. They may simply require information about a test performed by another
practitioner. Privacy laws must still be maintained throughout the process of
disclosing the patient’s information to another health provider. In this situation the
doctor will need to use his discretion, yet still maintain the patient's privacy rights
during this conversation.
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 55
Activity 19 - Rules for transferring patient records
Are the following statements true or false? Explain.
Statement True or False
The patient’s original file is never sent
Explain:
A doctor can electronically transfer the patient’s file to
another health provider
Explain:
All requests for the transfer of medical information must be in
writing
Explain:
The request for patient information can be made verbally
from one doctor to another doctor
Explain:
The patient’s file should be sent via express mail only
Explain:
The Privacy Act requires that information is destroyed once it
is no longer used
Explain:
A patient can request a copy of their own file to be sent
directly to them
Explain:
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 70
Conclusion
The skills and knowledge you have learnt, will ensure you can work effectively
within an existing medical records system. The correct way to access patient
records and various types of filing systems has been shown, which ensures
familiarity with common filing procedures in a medical environment. An awareness
of current legislation and procedures has been developed, ensuring you are able to
effectively protect the privacy of patients’ whilst maintaining their patient records.
Self-Review
Chapter 4 - True and False Questions
Monitor Own Role True or False
1. Your role can be monitored by comparing your actions to the policy and procedure manual
2. Feedback is a poor way to monitor your own role as it often makes you feel worse about yourself
3. The Privacy Act can provide you with feedback on your role
Make Recommendations for Improvements
4. Filing problems always means there is a bigger issue
5. Filing problems are always caused by human error
6. Unclear procedures for filing can be a cause of filing problems
7. Suggestions for improvements should always be made in writing as it provides a formal route for discussion
8. Recommendations are best made to the practice manager
Answers are provided at the back of the book.
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 71
BSBMED303B Maintain Patient
Records
Revision Sheet 1
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 73
1. Record Keeping Systems
a. Paper based files are referred to as _____________ copy and
electronic files are referred to as ____________ copy.
b. List 8 things a paper based file may contain
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
c. Electronic files do/do not require an internet connection to access
d. List 5 reasons why medical environments are often paper free
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
2. Policies and Procedures
a. In your own words, answer the following. What is a policy?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 74
b. What is a procedure?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
3. Privacy Act
a. Privacy, confidentiality, use and disposal of medical records is
determined by (laws, doctor’s judgment, time constraints).
b. A patient’s health details (can, cannot) be de-identified and provided
to health researchers.
c. It (is, is not) at the doctor's discretion how often they update patient
details.
d. Confidentiality (is, is not) a core part of the Privacy Act.
e. The security of patient records (is, is not) determined by the number
of staff at the front reception.
4. Reviewing Policies
a. Policies are timeless, which means they are never changed once
they are written True/False
b. The reception staff are in the best position to write and review
policies as they are at the forefront of the activities of the medical
practice True/False
c. The review process needs to be documented True/False
www.mediweb.com.au
© Jennifer Atkins BSBMED303B Maintain Patient Records Page | 87
Answers to Self Review Questions
Chapter 1 - True and False Answers
Patient Files Privacy Act
Qn Answer Your results Qn Answer Your results
1 False 12 True
2 True 13 True
3 False 14 False
4 True 15 True
5 True 16 True
6 True 17 False
7 True 18 True
8 False ..... /8 19 False ..... /8
Seek Clarification
Policies and Procedures 20 False
9 False 21 True
10 False 22 True ..... /3
11 True ..... /3
Chapter 1 Total ....../22
Chapter 2 - True and False Answers
Access Patient Records New Patient Records
Qn Answer Your results Qn Answer Your results
1 False 16 True
2 True 17 True
3 True 18 False ...../3
4 False Referrals
5 True 19 True
6 True 20 True
7 False 21 True ...../3
8 False Storage of Patient Files
9 True 22 True
10 True 23 False
11 True ..... /11 24 True
Accurate Files 25 False
12 False 26 True
13 False 27 False
14 True 28 True
15 False ..... /4 29 False ..... /8
Chapter 2 Total ....../29
www.mediweb.com.au