maintaining patient records

CHAPTER

© 2011 The McGraw-Hill Companies, Inc. All rights reserved.

9Maintaining Patient

Records


9-2

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


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.


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.


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


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


9-7

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


9-8

Legal Guidelines for Patient Records


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


9-10

Patient Records

Patient Education

Quality ofTreatment

Research

Additional Uses of Patient Records

• Test results

• Health issues

• Treatment instructions

• Peer review

• TJC review

• Health-careanalysis andpolicy decisions

• Source of data


9-11

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.


9-12

Standard Chart Information

Patient Registration Form

Date

Patient demographic information Age, DOBAddress SSN

Insurance/financial information

Emergency contact


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


9-14


• 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


9-15


• 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


9-16


• 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


9-17

• 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 you place in the chart



9-18


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.


9-19

Initiating and Maintaining Patient Records

Initial Interview

Completing medicalhistory forms

Documenting

patient statements

Documenting test results

Examination, preparation,

and vital signs


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 given to the client


9-21


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!


9-22

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


9-23


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


9-25

Types of Medical Records (cont.)

• 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


9-27

CHEDDAR Format

• Expands on SOAP format

C Chief complaint, presenting problems, subjective statements

H History: social and physical history

D Details of problem and complaints

E Examination

D Drugs and dosage

A Assessment of diagnostic process and diagnosis

R Return visit information or referral


9-28


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 O

S

S S

OO

O


9-29


What type of documentation expands on the SOAP format?

ANSWER: CHEDDAR format of documentation.

GOOD!


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 such as allergies

– Handwriting must be legible

– Make corrections properly


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 file quickly in event of an emergency


9-32

Accuracy Check information carefully

Never guess or assume

Double-check accuracy findings and instructions

Make sure most recent information is recorded



9-33


• 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.


9-34

Electronic Health Records

Essential to quality of health care and patient safety

• Advantages

– Fewer lost records

– Reduced transcription costs

– Readability/legibility

– Chart access after hours

– Easier access to patient education materials

– Improved billing

• Disadvantages

– Costly

– Retraining of staff

– IT staff may be needed

– Possible damage to software and system


9-35

Electronic Health Records (cont.)

• Advantages of computer records – 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


9-36


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.


9-37

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


9-38

• 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 accurately

– 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.)


9-39

Transcription Aids

Transcriptionreference books

Medicalterminology books

Secretarialbooks

Medical referencebooks

Medical Transcription (cont.)


9-40


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.


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


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


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


9-44


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


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 health-care information to the above-named insurance company.

Christopher Hansen mm/dd/yyyyPatient Signature Date


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


9-47

Release of Records (cont.)

• 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

• Confidentiality– 18-year-olds are

considered adults in most states

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


9-48


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. Request the original form.

Nice Job!Nice Job!


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.


9-50

In Summary (cont.)

9.3 To create and maintain patient records forms

• Include– 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.

• Maintain the charts properly– Documenting detailed

notes about the contact with the patient, patient responses and progress, and treatment outcomes.


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.


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.


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.


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.

9.10The advantages of the electronic medical record outweigh the disadvantages. Evaluate software before purchasing. Maintain sensitivity to patient needs.


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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

End of Chapter 9

maintaining patient records

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