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Chapter 8; Health Information Management: Electronic and Manual

Terms in this set (98)

Medical records have a vital role in ensuring quality patient care. The healthcare industry is moving slowly but surely toward the electronic management of patient information. Some studies show that physicians are not making the change to electronic health records as readily as they could. The number of physician practices going paperless is expected to grow, however, as the new technology savvy generation of physicians emerges.

Chances are good that, at some point in your career, you will work with a completely computerized and paperless record system. The outpatient medical facility in today's world may be in any phase of computarization depending on geographic location, availability of funds, and personal preferences of the physicians and owners. Weather information is maintained on paper or in electronic form, proper management of the information requires adherence to certain legal, moral, and ethical standards. If these standards are disregarded, a breach of contract between patient and physician may occur, exposing the patient to potential embarrassment or harm and making the physician vulnerable to fines and/or lawsuits.

A thorough and accurate medical record furnishes documented evidence of the patient's evaluation, treatment, change in condition, and communication with the physician and staff. Medical records have many other uses as well, including research, quality assurance, and patient education. Information gathered from the medical record aids the government in planning for future health care needs and protecting the health of the community.

In 1996, HIPAA 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.
The goal of EHR is to improve patient care while boosting efficiency in the medical office. Some of the key features of electronic health records are:

• Point-of-Care Charting - touch screens make inputtng easy, and drop-down menus take less time than handwritten notes, improving quality and productivity in charting.
• Improved Documentation - problems with illegibility are eliminated, decreasing errors. Physicians can also include drawings to support documentation and use graphing features to transfer numeric data into chart form.
• Data Collection from Multiple Sources - data from the hospital, pharmacy, laboratory, radiology, and other departments are stored in EHR for quick retrieval.
• Medication Management - computerized prescription order entry helps prevent medication errors by providing warnings about patient allergies, contraindictions, or possible interactions. It also avoid problems at the pharmacy due to poor handwriting by the prescriber.
• Assistance with Clinical Decision Making - alerts, reminders, and patient care recommendations give providers valuable information at their fingertips.
• Improved Communication - easy access to information enhances communication among medical office staff, as well as with patients and other health care entities.
• Support for Administrative, Financial, and Operational Functions - electronic health records assist with storage of patient demographic data, appointment scheduling, insurance billing and coding, accounting procedures, and inventory and supply tracking, among other tasks.

Electronic health records do have some disadvantages, however, including cost, potential software or hardware damage for failure, and a need for in-depth staff training. The task off inputting data from hundreds or thousands of charts into the computer is time consuming but must be done before the system can be used.
1. Make sure you know the office policy regarding charting. Find out who is allowed to write in the chart and the procedures for doing so.

2. Make sure you have the correct patient chart. If the patient's name is common, ask for a birth date or social security number as a double check.

3. Document in black ink only.

4. Sign your complete name and credentials.

5. Always record the date of each entry. Some outpatient facilities record the time as well. Using military time will eliminate the need to use AM and PM.

6. Write legibly. Printing is more legible than cursive writing.

7. Check spelling, especially medical terms, before entering them into the chart.

8. Use only abbreviations that are accepted by your facility. Because abbreviations can cause confusion and errors in patient care, the use of certain handwritten abbreviations has been prohibited by The Joint Commission.

9. When charting the patient's statements, use quotation marks to signify the patient's own words.

10. Do not attempt to make a diagnosis. it is not within the scope of your training to diagnose.

11. Document as soon as possible after completing a task to promote accuracy.

12. Document missed appointments in the patient's chart. Chart your attempts to reach the patient to remind him or her of the appointment.

13. Document any telephone conversations with the patient in the patient's chart.

14. Be honest. If you have given a wrong medication or performed the wrong procedure, as soon as the appropriate supervisor is notified, document it, and then complete an incident report. State only the facts, do not draw any conclusions or place blame.

15. Never document for someone else, and never ask someone else to document for you.

16. Never documents false information.

17. Never delete, erase, scribble over, or white out information in the medical record because this can be construed as attempting to cover the truth and tampering with a legal document. If you do make an error, draw a single line through it, initial it, and date it. Then write the word "correction" and document the correct information.
For the purpose of storing records, they may be classified in three categories: active, inactive, or closed.

Active records are those of patients who have been seen within the past few years. The exact amount of time is designated within each practice, it usually ranges from 1 to 5 years. Keep these records in the most accessible storage spot available because you will be using them regularly.

Inactive records are those of patients who have not been treated in the office for a set time. Most offices consider files inactive after 2 to 3 years. You will still keep inactive records in the office, but they do not have to be as accessible as the active files. Usually, they are placed on bottom shelves to eliminate constant bending when reaching for active files, or they may be stored in another room within the office. They can be stored in the office in an out-of-the-way area, such as a basement or attic. They may even be kept in the physician's home. This practice is permitted because the records belong to the physician, but it is not recommended because, at any time, the office staff may need access to these records. Inactive patients have not formally terminated their contract with the physician, but they have either not needed the physician's services or have not informed the office regarding a move, change in physician, or death.

Closed records are those of patients who have terminated their relationship with the physician. Reasons for such termination might include the patient moving, termination of physician-patient relationship by letter, no further treatment necessary, or death of the patient.

Many practices use microfilm or microfiche to store closed records. Microfilm and microfiche are ways to photograph documents and store them in a reduced form.

Microfilm, a popular method for storing large volumes of records, particularly in hospitals and clinics, use a photographic process that develops medical records in miniature on film. Information is stored on cards holding single file frames or in reels or strips for projection on compact electric viewers placed at convenient office locations. The cost of the equipment is declining, making this a more practical method for storing and retrieving inactive files.

Microfiche is a miniature photographic system that stores rows of images in reduced size on cards with clear plastic sleeves rather than on film strips. Information can be handled manually, examined on a viewer that enlarges the record, or produced as hard copy on a high speed photocopier. A standard microfiche card holds more than 60 pages of information. The microfiche process allows 3200 papers to be reduced to fit on a single 4- to 6- inch transparency.
The statute of limitations is the legal time limit set for filing suit against an alleged wrongdoer. The time limit varies from state to state. You must observe the statute of limitations in your particular state to know how long medical and business records should be kept in storage.

It is recommended that medical records be stored permanently because, in some states, malpractice lawsuits can be filed within 2 years of the date of discovery of the alleged malpractice. The statute of limitations for minors is extended until the child reaches legal age in every state, the time given past the legal age varies, however.

When a health care provider's practice ends, either from retirement or death, notice to all patients with records stored in the facility is required. This notice can be in the form of a letter to each patient and/or a newspaper notification advising patients of the closing of the practice and giving them a reasonable length of time in which to pick up their records. Since the facility no longer exists, you may release the original record to the patients.

As discussed previously, the record itself belongs to the facility, but the information in the record belongs to the patient. Since the facility no longer exists, it is felt that the record now belongs to the patient. Retiring physicians or the families of deceased physicians may ask a colleague to maintain storage and any pertinent records that are not claimed. This location should be given to the patient in their written notification.

Of course, the statue of limitations for legal action and the need for these records should be taken into consideration. Most risk management experts advise that the record should be kept in some form forever, but this is not always feasible. At the least, every reasonable attempts should be made to notify patients and disseminate the information maintained by the retiring or deceased physician.