Best possible medical care (continuity of care, legal protection for those who provide care for the patient, statistical information that is helpful to researchers, Financial reimbursements.
The four basic reasons medical records are kept.
The provider , the physician, or medical center, often called "The Maker."
Who owns the medical record?
Paper medical records, and electronic medical records.
The two major types of medical records.
Source oriented, observations and the data are cataloged according to their source-physician, lab-nurse, radiology, etc-no recording of logical relationship among them.
The traditional patient record.
Forms and progress notes are filed most recent on time.
Reverse chronological order
Created by Dr Weed, a record of clinical practice that divides medical action into four bases: The database which includes the chief complaint and present illness, the problem list which is a numbered titled list of every problem the patient has, The treatment plan which includes management and therapy, and the progress notes
POMR, Problem oriented medical records.
Progess notes follow this approach, subjective impressions, objective clinical evidence, assessment or diagnosis, plans for further studies, treatment, or management
The SOAP approach.
This method of medical records has the advantage of imposing order and organization on the information added to a patients record. The records are easily reviewed and the likelihood of overlooking a problem is greatly reduced.
The POMR method
Provided by the patient
Observed by the Physician
Name, gender, DOB, marital status, spouse, home address, phone #, employer information, insurance are examples of what?
Examples of personal demographics
Past illnesses and surgeries, injuries, daily health habits are examples of what?
Personal and medical history
Disease and illness of family members, their causes of death are examples of what?
Patients family history
Information about the patients lifestyle, drinking, smoking are examples of what?
Patients Social History
Why the patient is seeing the physician, a concise account of their symptoms in their own words.
The Chief Complaint
Based on all the evidence in the file, the examination, and supplementary tests, the physician notes their diagnosis of the patients condition.What is the type of diagnosis if there is some doubt?
Provisional or Preliminary diagnosis
What is the diagnosis called when weighing the possibility of one disease causing the patients illness against the possibility that other diseases are causative.
When the treatment of a patient is terminated, what does the physician record?
The condition of the patient at the time of termination of treatment
A method of filing in which a report is laid on top of the older report, about a half inch above the 1st report, allowing the date to show on the 1st report, with this method the latest report always appears on top
When you make a mistake, it is ok to use correcting fluid
False, you should not obliterate the entry, put a single line through the error, insert the correction, put "correction" and your name and date
Files of patients currently seeing the Doctor
Files of patients who have not seen the Doctor for 6 months or longer, when the patient returns to the Doctor, the file is put back to active
Patients who have died, moved away, or have terminated their relationship with the Doctor
The process of moving a file from active to inactive status.
Purging the file.
When no rules specify the retention of medical records, what course should you folow?
Keep the records for 10 years. For Minors its the age of majority plus 3 years. HIPAA does not include requirements, Medicare and Medicaid is 10 years
On the very rare occasion that original medical records are out of the office (subpoenaed by court, case history to a colleague) what is inserted in place of the regular folder
OUTfolder and notation made of the date, name, and to whom the record was released to.
Conditioning, releasing, indexing and coding, sorting, and storing and filing
Five basic steps of filing procedures
Alphabetic by name, Numeric, Subject filing Alphanumeric
Three basic filing methods
What type of system is Alphabetic by name?
Direct filing system in that the person only needs to know the name to find the desired file
The correct spelling of the name must be known, as the number of files increases, more space is needed for each section of the alphabet, as the files expand, more time is required for filing because of the greater number of folders involved in the search
Drawbacks of Alphabetic filing
What type of filing is numeric filing?
Indirect filing system, requires the use of an alphabetic cross-reference to find a given file, which is an extra step.
It allows unlimited expansion without periodic shifting of folders, and shelves usually are filed evenly. It provides confidentialty to the chart. It saves time in retrieving and refiling records quickly. One knows that 978 falls between 977 and 979
Advantages of numeric filing. There is the straight or consecutive numeric system, terminal digit system, middle digit filing, some practices use last 4 digits of SSN
It can be Alphabetic, or Alphanumeric (a 1-3)
Subject filing, the main problem is indexing, or classifying, deciding where to file a document, many papers require cross-referencing
A heading, title, or subtitle under which records are filed
Patients Address, email address, insurance information,complaint of pain, headache
Bruises on arm, blood pressure, yellowed eyes, vitals that the MA measures (weight, BP etc)
Patient signs this if they no longer want their medical records released. Form is kept in their file
Removing all staples, paper clips, stapling related papers together, attaching smaller items to regular sized sheets of paper
Some maek is placed on the paper indicating that it is ready to file, MA initials or a file stamp
Deciding where to file the letter or paper, and placing some indication of this decision on the paper
Indexing and Coding
Arranging papers in filing sequence
Place items face up, top edge to the left, with most recent date at the front of the folder
Storing and Filing
Last name is considered first in filing, then the given name(first) is 2nd and the middle name or initial is 3rd. Initials precede a name. Hyphenated names are considered one unit. On a foreign name where you cannot distinguish the difference, index in the order it was written. MC and MAC are filed in their regular place in the alphabet
Examples of Indexing Rules
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