managing patient records - what are the best practices?
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Managing Patient Records - What Are The Best Practices?. Chris York & Lynne Shoemaker, OCHIN. Electronic Medical Records are a Legal Document. Federal Rules of Evidence Accept Medical Records as “First Hand Evidence” in a Court of Law As Long As: - PowerPoint PPT PresentationTRANSCRIPT
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Managing Patient Records - What Are The Best Practices?Chris York & Lynne Shoemaker, OCHINElectronic Medical Records are a Legal DocumentFederal Rules of Evidence Accept Medical Records as First Hand Evidence in a Court of Law As Long As:The record was documented as part of the normal course of businessRecord was created at or near the time of the delivery of healthcareThe person that is documenting in the record had actual knowledge of the events that are being recorded and has the legal ability to document in the chart
1881 SW Naito Parkway Portland OR 97201-5195 Phone 503.943.2542 Fax 503.943.2501 Email: [email protected] www.ochin.orgCorrection of Errors in the Medical Record Must be Made Correctly in Order for the Record to Continue to be Considered a Legal DocumentErrors in the record should not be obliterated. They need to be documented as an error, and the correct information needs to be entered. The information still has to be viewable. One way of making an error correction is to create an addendum note that contains the corrected information.Making error correction changes in the medical record without the proper documentation is illegal and unethicalAn audit trail must show who made error correction changes in the medical record, the date and time of the error correctionIf errors are not corrected properly, the legality of the medical record in a court of law can be called into question 1881 SW Naito Parkway Portland OR 97201-5195 Phone 503.943.2542 Fax 503.943.2501 Email: [email protected] www.ochin.orgRelationship between Medical Record and BillingOnly the individual who is legally allowed by state law to document in the medical record should document or make changes in the chartThe provider is legally responsible for documentation contained in the patients medical and billing record, including ICD and CPT codingThe provider is legally responsible for the bills that are submitted to payors, e.g. Medicaid and MedicareBillers should not change codes without confirmation of the changes being made by the provider 1881 SW Naito Parkway Portland OR 97201-5195 Phone 503.943.2542 Fax 503.943.2501 Email: [email protected] www.ochin.orgWhose patient is it anyway?Single patient recordAvailable to anyone with a legitimate, medical need to access the informationWithin OCHIN and throughout community (via CareEverywhere) 1881 SW Naito Parkway Portland OR 97201-5195 Phone 503.943.2542 Fax 503.943.2501 Email: [email protected] www.ochin.orgWhat about non-patients?Non-patients information should not be documented in the patients medical recordRelease of information legal requirements for the non-patient can not be met by having the patient sign a release of information formWe get questions about PCP requirementsAccording to our report writing team - who manage the information for UDS and meaningful use, there is no requirement or measure for PCP assignments. 1881 SW Naito Parkway Portland OR 97201-5195 Phone 503.943.2542 Fax 503.943.2501 Email: [email protected] www.ochin.orgWhen a patient record is corruptedProvider makes an error in chartingCharts on the wrong patientLab results on the wrong patient
Process for fixing the patient record
1881 SW Naito Parkway Portland OR 97201-5195 Phone 503.943.2542 Fax 503.943.2501 Email: [email protected] www.ochin.orgChart Correction ProcessUn-mergeOn occasion a patient is merged incorrectly with another patientWhen that happens we can unmerge. Often there are charges that also need to be moved, and we can do that Contact moveWhen there is incorrect charting on a patient, one of the options is to move the encounter (contact) to a different patient in the system. OCHIN has such a patient: Zzzincorrect,LabClinical data moveWe can also move specific orders/results to the Zzzincorrect, Lab patient
1881 SW Naito Parkway Portland OR 97201-5195 Phone 503.943.2542 Fax 503.943.2501 Email: [email protected] www.ochin.orgChart Correction Process (cont)There have been occasions when a patient record is being used by two difference service areas for two different patients. Service Areas create a second correct patient in RegistrationOCHIN moves all contacts and charges to new patient recordOCHIN removes the incorrect SA MRN type
1881 SW Naito Parkway Portland OR 97201-5195 Phone 503.943.2542 Fax 503.943.2501 Email: [email protected] www.ochin.orgQuestions or Feedback?Lynne Shoemaker, RHIA,CHP,CHC OCHIN Integrity [email protected] Chris York, Technical Lead/Supervisor OCHIN Help Desk and Maintenance [email protected]
1881 SW Naito Parkway Portland OR 97201-5195 Phone 503.943.2542 Fax 503.943.2501 Email: [email protected] www.ochin.org