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Health Information Management: Electronic and Manual Medical Records

EMR (Electronic Medical Records)

By 2015, all medical records must be electronic.

Records Management

*Medical Records Have a Vital Role In Ensuring Quality Patient Care
*The Number of Physician Practices Going Paperless is Expected to Grow
*Proper Management of Health Information is Very Important

Records Management: Standards

If standards are disregarded, a breach of contract between patient and physician may occur, exposing the patient to embarrassment or harm, making the physician vulnerable to fines and or lawsuits.

Records Management: Accuracy

A thorough and accurate medical record furnishes documented evidence of the patient's evaluation, treatment, change in condition, and the communication with the physician and staff.

Records Management: Government

Information that is gathered from the medical records aids the government in planning for future health care needs and protecting the health of the public.


Health Insurance Portability and Accountability Act of 1996 was enacted to provide consumers with greater access to health care insurance, to protect the privacy of health care data, and to promote more standardization and efficiency in the health care industry.

5 Goals of HIPAA

1. Simplify the health insurance claims process and speeding up the process of reimbursement.
2. Proving greater access to health care insurance when an individual changes employers.
3. Addressing issues dealing with funds set up by employers to pay for health care costs.
4. Requiring ease of electronic transmission by establishing a Standard Unique Identifier, which provides complete but coded information about the holder of the code.
5. Protection of communication of health information between physicians.


Protected Health Information

Records Management: Confidentiality

Confidentiality has always been required in the medical field, but each state has its own laws regarding the exchange of information.

Records Management: Regulations

Physicians offices must also take appropriate steps to ensure that any company they are associated with follows HIPAA regulations. Contracts among physicians and their business partners should reflect that the business adheres to HIPAA regulations.

Records Management: Compliance

*All health care providers must have certain policies in place to comply with HIPAA.
*Health care providers are considered compliant if reasonable care is taken to comply and if the effort is documented.
*HIPAA requires that at least one employee be designated as the HIPAA Officer and one as Privacy Officer.

HIPAA Officer

Coordinates and oversees the various aspects of compliance.

Privacy Officer

Keeps track of who has access to protected health information. Monitors the access of health information. Makes sure human resources are changing or adjusting employees passwords and access.

Releasing Medical Records

*The protection of personal information is crucial to the privacy of patients. Although the physical records legally belongs to the physician, the information belongs to the patient.

Who May Request Medical Records?

*Insurance Companies
*Other Health Care Practitioners
All requests should be made in writing, stating the patient's name, address, and social security number, and must contain the patient's original signature authorizing the release of records. Never release information over the telephone !!!

HIPAA's Privacy Rule

*HIPPA provides protection of the sharing of what is referred to as (PHI) Protected Health Information.
*PHI is any information that can be linked to a specific person.
*The privacy rule established safeguards to protect confidentiality of medical records.

Releasing Records to Patients:

*The doctor makes the decision about what to copy (release to the patient).
*Patients under the age of 17 cannot get copies of their own medical records without a signed consent from a parent or legal guardian, except emancipated minors.

Proper Authorization:

*You must follow certain guidelines, even with a signed release form.
*The authorization form must give the patient the opportunity to limit the information to be released.
*Patients may release only information relating to a specific disorder, or they may specify a time limit.
*Patients may not ask the physician to leave out information pertinent to the situation.

Legally Required Disclosures

Information that is released without the permission of the patient.
*Vital Statistics
*Child or Elder Abuse or Maltreatment
*Emergency Circumstances
*Cause of Death
*Communicable Diseases
*Violent Crime Activities

Standard Medical Records:

There are a variety of options for standard or manual medical record keeping.
*Paper Charts, Files

Maintaining Medical Records:

No matter how the records are stored, make sure that the information contained within is:
*Easily Retrievable
*Orderly Manner

Contents of the Medical Record:

A paper medical record in an outpatient facility, is referred to as a chart or a file.
*Confidential Clinical Information
*Billing and Insurance Information
*General Information
This information should never be intermingled with the clinical information.

Contents of the Medical Record Cont.

Every Visit:
*Chief Complaint
*Present Illness
*Family and Personal History
*Review of Systems
*Progress Notes
*Radiographic Reports (X-Rays)
*Laboratory Reports (Blood Tests)
*Consultation Reports (Dr. to Dr.)
Medication Administration
*Documented Advance Directives (Living Will)
*Correspondences Pertaining to the Patient

Provider Encounters

Whether the patient is new or established or seen by a Physicians Assistant or the Physician, the visit must be documented:
*Computer Generated
**The most common formats used to document:
*Narrative (oldest, least structured, paragraph format)


Subjective (what the patient says)
Objective (what is observed by the M.A. and the Dr.)
Assessment (diagnosis)
Plan (treatment)


Problem Oriented Medical Record
Lists each problem of the patient at the beginning, references each problem with a number throughout the file. Easier to track patient treatment and progress.

Medical History Forms

Used to gather information from the patient before the visit with the physician.

Flow Sheet

Allows for information to be recorded in either graphic or table form.

Progress Notes

Statements about various aspects of patient care.

Medical Record Entries

Proper medical record entries are necessary for efficient communication and for legal considerations. The medical record is a legal document that can be subpoenaed in a malpractice suit. If the documentation is accurate, timely, and legible, it can help win a lawsuit or prevent one altogether.

Filing Procedures

To ensure efficient and speedy filing and document retrieval:
*Condition (prepare the files, remove paperclips)
*Index (organize, separate, and order)
*Sort (alphabetically or numeric)
*Store (filing and storing in a safe place)

Filing Systems

The two main filing systems:

Other filing systems:

Storing Health Information:

Electronic Data Storage
*Back up copies of computerized records must be made daily and stored in a safe, fire proof location.
*HIPAA mandates that offices establish a disaster plan that includes emergency storage of data and security and safety of that data.

Medical Record Storage

Standard Medical Records
*Shelf Filing
*Shelving Units
*Drawer Filing
*Rotary Circular or Lateral Filing Systems

Classification of Medical Records

Medical records may be classified in three categories:
*Active (current patient)
*Inactive (2-3 years ago)
*Closed (transferred or deceased)

Medical Record Retention

Statue of Limitations
*Legal time set for filing suit against an alleged wrongdoer
*Time limit varies from state to state
*Recommend that medical records be stored permanently, because in some states, malpractice law suits can be filed within 2 years of the date of discovery of the alleged malpractice.
*Minors are extended until the child reaches legal age, this is in every state.

Providers Practice Ends

Patient must be notified by letter or newspaper. If the facility no longer exists, the original records can be released to the patient.

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