PATIENT MEDICAL RECORDS

Types of Records in an Office Medical records of the patient’s state of

health Correspondence pertaining to the field of

health care Documents related to the business and

financial management of the practice

Objectives

Components that make up medical records The SOAP format-the most common format used

for recording medical information about patients The 3 parts of the problem oriented medical

record (POMR) format Transcribe medical data dictated by a physician,

apply guidelines for grammar The preservation of medical records Who actually owns a patient’s medical record Standards to be used for quality assurance in

maintaining medical records

The Medical Record

Patient’s medical record=“Patient’s Chart” The source of info about all aspects of a patient’s

health care Accurate and up-to-date

Proper health care, financial and legal success The AMA should be familiar with:

Why med. records are regarded as legal documents The types of reports and information found in a MR The importance of well-maintained MRs for the

practice The method for making corrections to a MR

MR as Legal Documents

A patient’s MR constitutes the legal record of the practice

May have to be produced in court Uphold the rights of physician if involved in

litigation or as a witness Malpractice cases

Content and quality of MR is pivotal, can be more important than physician’s credentials, personality, or reputation

If data is incomplete, illegible or poorly maintained, an attorney can make the Dr. appear negligible

What is a MR? Holds all the data about that patient MRs include:

Chart notes Chronological order of ongoing patient care and progress, made by physician,

nurse, or other professional regarding pertinent points of a given visit or communication with patient

History and physical Patient’s complete medical history(obtained in an interview on 1 st visit), initial

results of physical exam Referral and consultation letters

Copies of letters sent to other physicians referring the patient for exams, tests, etc. Medical Reports

Lab reports, X-ray reports, etc. Correspondence

Copies of all correspondence with patient, including letters, faxes, and notes of phone conversations

Clinical Forms Immunization records and pediatric growth and development records

Medication List List of the all medications prescribed, including dosage, dispensing instructions,

etc.

Reasons for Maintaining MRs MRs are used in the following ways:

Main source of info for coordinating and carrying out patient care among all providers involved with the patient

Evidence of the course of an illness and a record of the treatment being used

A record of the quality of care provided to patients A tool for ensuring communication and continuity of

care from one medical facility to another The legal record for the practice The main record to ensure appropriate reimbursement A source of data for research purposes (lecture, bk,

article)

Making Corrections

Remember: No part of a record should be altered, removed, deleted, or destroyed

If error or discrepancy occurs, an addendum to the record must be made

How to make a correction: Use strike-through feature-must be able to read

the incorrect material Enter the word “error” next to the deleted

statement Write your initials and date next to correction Enter the correct information into the MR

The Soap Method of Record Keeping and the POMR Format

SOAP Method

The most common system for outlining and structuring chart notes for a MR

Facilitates the creation of uniform and complete notes in a simple format that is easy to read

SOAP-Subjective, Objective, Assessment, Plan

SOAP: Subjective

The patient’s description of the problem or complaint, including symptoms troubling the patient, when they began, remedies tried, past medical treatment, etc.

Subjective record includes the following headings: Chief complaint (CC): Reason for the visit History of present illness (HPI): Info about symptoms Past medical history (PMH): list of illnesses and treatments Family history (FH): facts about family’s health related to

you Social history (SH): Social and marital history (eating,

drinking, smoking, occupation, interests, etc.) Review of systems (ROS): physician’s review of each body

ststem with the patient (Ex: respiratory system)

SOAP: Objective

Physician’s examination of the patient May be dictated under the heading Physical

Exam (PE) Complete physical exam

Subheadings for a physical exam: Vital signs (VS) General: description of the patient might be HEENT: Head, eyes, ears, nose, throat Neck Heart Etc.

SOAP: Assessment

Physician's interpretation of the subjective and objective findings

“Assessment” is used interchangeably with “Diagnosis (Dx)” and “Impression” Gives a name to the condition from which

the patient is suffering Rule out (R/O): The diagnosis is not likely

and further tests must be performed

SOAP: Plan

Plan-treatment This section lists the following:

Prescribed medications and their exact dosages

Instructions given to the patient Recommendations for hospitalization or

surgery Any special tests that need to be performed

Problem-Oriented Medical Records (POMR)

Another form of record keeping revolves around a list of the patient’s problems

3 essential components: Database

Complete history of the patient, problem, history, family, social, etc.

Initial plan Based on the database and initial problems of the patient

Problem list A running account of the patient’s problems Referred to a updated at each visit

Used for: Organizing entries within the problem list To outline the history and physical for the database section

Transcription Guidelines

Transcription Guidelines

AMA’s role is to transcribe physicians’ chart notes and other medical documents

Physician may dictate and then give recording to an AMA for transcription

Listening Techniques

Dictation equipment: digital media (CD, analog media)

Tone, volume, rate of speed can be regulated for the assistant’s own comfort and rate of transcription

Confidential info-headphones Foot pedal starts and reverses the

machine

Office Policy

Every office uses its own format for transcribing chart notes

Include instructions or corrections when transcribing

You may not add anything that is not there

Basic Medical Transcription Guidelines

Skill in spelling, punctuation, capitalization

Knowledge of medical terminology, guidelines for medical abbreviations

Areas to Know

Commas Semicolons Colons Capital letters Hyphens Abbreviations Numbers Symbols Memos Grammar Document formatting

Record Retention, Ownership, and Quality Assurance

Preservation of Files

Patient MRs need to be preserved-importance to the practice and value as legal document Kept until possible malpractice suit has

passed or for four years after patient has left the practice Many are kept in an inactive file permanently,

however

Ownership

American Medical Association Council on Ethical and Judicial Affairs-deals with the ownership of MRs Notes made by the physician and MRs are physician’s property

Used for physician’s use in treatment of patients Info inside belongs to the patient-nature of the diagnosis, etc. Physician cannot use or withhold the info in the recird

according to his or her own wishes Ex: Dr. is ethically obligated to furnish copies of office notes to any

physician who is assuming responsibility for care of the patient (with a record release form signed and dated by patient)

Patient’s have the right to control the amount and type of info that is released from the MR

Patient’s alone have the authority to release info to anyone not directly involved with their care-fee may be charged

Quality Assurance

Best record of the care given a patient AMAs job is to make certain the info recorded in the MR is

accurate and up-to-date If AMA is unsure of what was dictated, they must flag it for the

physician The AMA should make sure each record contains the

following: Dated notations describing the service received by the patient Notations regarding q. procedure performed Accurate notations. An addendum must be made by physician if

a discrepancy occurs Justification for hospitalization If necessary, a discharge summary regarding hospitalization

before the patient arrives for a follow-up visit

Key Terms (Define)

Assessment-the physician’s interpretation of the subjective and objective findings Chief complaint (CC)-reason for the visit or why they are seeking medical advice Diagnosis (Dx)-what the physician determines is the problem with the patient Family history (FH)-facts about the health of the patient’s siblings, parents, blood relatives History of present illness (HPI)-info about the symptoms troublign the patient: when they

began, what affects them Impression objective past medical history (PMH)-listing of any illnesses the patient has

had in the past along with the treatments administered or performed Physical exam (PE)-a complete physical examination where findings for each of the major

areas of the body are covered Plan-treatment for patient as directed by the physician Problem-oriented medical record (POMR)-see PowerPoint Review of systems (ROS)-physician’s review of each body system (ex: respiratory system) Rule out (R/O)-the diagnosis is not likely and that further tests will be performed SOAP-see PowerPoint Social history (SH)-info regarding the patient’s eating, drinking, smoking habits,

occupation, interests Subjective-the patient’s description of the problem or complaint

Thinking It Through (Answer.) How does the use of the SOAP format for record

keeping minimize a provider’s exposure to legal risk?

Where in the POMR file would you look for information regarding a patient’s family history of intestinal cancer?

A former patient calls asking to retrieve x-rays taken more than five years ago. What do you say?

You are transcribing the physician’s dictation and cannot understand several words. What do you do?