chapter 09 maintaining patient records

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© 2009 The McGraw-Hill Companies, Inc. All rights reserved

Maintaining Patient RecordsMaintaining Patient Records

PowerPoint® presentation to accompany:

Medical AssistingThird Edition

Booth, Whicker, Wyman, Pugh, Thompson


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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.

Learning Outcomes


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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.

9.8 Explain how to update a medical record.

9.9 Identify when and how a medical record may be released.


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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


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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


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Importance of Patient Records (cont.)

Information included in patient record

Name and address

Insurance coverage andperson responsible for payment

Occupation

Medical history

Current complaint

Health-care needs

Medical treatment plan

Response to care

Lab and radiology reports


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Patient Records: Legal Guidelines

Proof of event or procedure No documentation

No proof Care is considered not done

Legal document Must document complete information about

patient care Document if patient is noncompliant


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Patient Records: Standards for Records

Complete, accurate, and well-documented records are evidence of appropriate care

Incomplete, inaccurate, altered, or illegible records may imply poor standards

Everyone who documents in the patient record has a responsibility to the patient and employing physician


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Patient Records (cont.)

Patient Education

Quality ofTreatment

Research

Additional Uses of Patient Records

• Test results

• Health issues

• Treatment instructions

• Peer review

• JCAHO review

• Health-care analysis and policy decisions

• Source of data


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Apply Your Knowledge

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.


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Patient Charts: Standard Chart Information

Patient Registration Form

Date

Patient demographic information

Age, DOBAddress SSN

Insurance / financial information

Emergency contact


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Past 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

Patient Charts:Standard Chart Information (cont.)


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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

Patient Charts: Standard Chart Information (cont.)


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Doctor’s diagnosis and treatment plan Treatment options and final treatment list Instructions to patient Medication prescribed Comments or impressions

Operative reports, follow-up visits, and telephone calls These are part of the continuous patient record Document calls made to and from the patient

Patient Charts:Standard Chart Information (cont.)


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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



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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; if not available, make a

photocopy of the fax

Dating and initialing Be sure to date and place your initials on everything

you place in the chart



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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.


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Initiating and Maintaining Patient Records

Initial Interview

Completing medicalhistory forms

Documenting patient

statements

Documenting test results

Examination, preparation,

and vital signs


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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

Initiating and Maintaining Patient Records (cont.)


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In addition to transcribing notes the doctor dictates 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 given to the patient. Right!


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The Six Cs of Charting

Client’s words –

Clarity –

Completeness – C

onciseness –

Chronological order –

confidentiality –

Do not interpret patient’s words

Precise descriptions / medical terminology

Fill out forms completely

To the point / approved abbreviations

Legal issues

Follow HIPAA guidelines


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What are the six Cs of charting?

ANSWER: The six C’s of charting are

Client’s words Conciseness

Clarity Chronological order

Completeness Confidentiality


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Types of Medical Records

Source-Oriented Medical Records

Problem-Oriented Medical Records

Conventional approach Information is arranged

according to who supplied the data

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


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Medical Records: SOAP Documentation

Orderly series of steps for dealing with any medical case

Lists the following Patient symptoms Diagnosis Suggested treatment


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ubjective data

bjective data

ssessment

lan

Information the patient tells you

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


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What type of documentation provides an orderly series of steps for dealing with any medical case, and what are the components of this type of documentation?ANSWER: SOAP documentation provides an orderly series of steps for dealing with any medical case. The components are

S – Subjective data A - Assessment

O – Objective date P - Plan

GOOD!


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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 OS

S SOO

O

ANSWER:


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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 such as allergies

Handwriting must be legible

Make corrections properly


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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 file quickly in event of an emergency


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Accuracy Check information carefully

Never guess or assume

Double-check accuracy findings and instructions

Make sure most recent information is recorded



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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.



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Computer records Accuracy is also important with electronic

records Advantages

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



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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.


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Medical Transcription 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


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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

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.)


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Transcription Aids

Transcriptionreference books

Medicalterminology books

Secretarialbooks

Medical referencebooks

Medical Transcription (cont.)


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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.


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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”

Use care with corrections It is more difficult to explain a chart that has been

altered after something was documented


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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


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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


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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


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Release of Records

Records are property of physician Contain confidential patient

health information Must have patient’s written

consent to release Exceptions: cases of contagious

disease or court order

Release of Informationto HMO Insurance

Company

I authorize Dr. J. Jones to release my healthcare information to the above-named insurance company.

Christopher Hansen mm/dd/yyyyPatient Signature Date


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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


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Special cases Divorce

Legal guardian of children (may be one or both parents)

Death Next of kin Legally authorized

representative If unsure, ask

supervisor

Confidentiality 18-year-olds

Considered adults in most states

Must have written consent to release their records

Legal and ethical principle:Protect patient’s right to privacy at all times.

Release of Records (cont.)


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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.

Nice Job!Nice Job!


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In Summary Medical assistants must properly prepare and

maintain patient records

There are several methods for documentation, but regardless of method, records must be complete, legible, current, accurate, and professional

Properly maintain, correct, update, and release patient medical records


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Organization is the power of the day; without it, nothing is accomplished.

~ Sophia Palmer

From A Daybook for Nurses: Making a Difference Each Day

chapter 09 maintaining patient records

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