CH. 13The Medical Record,

Documentation, and Filing

BEGINNING THE PATIENT’S RECORD Patient’s personal information

Demographic informationMarital status, children, and living

arrangementsSocial habitsOccupation information

Medical history and family historyMedicationsTesting performed

PURPOSE OF MEDICAL RECORDS

Maintains and documents the course of patient careProvider’s evaluationPrescribed treatmentResponses to treatment

Provides for a continuity of care Eliminates incompatible therapies, duplication

of efforts, or unnecessary expenses Provides legal protection Maximizes reimbursement Helps conduct research

HIPAA AND THE MEDICAL RECORD HIPAA Privacy Rule HIPAA Security Rule

Ensures confidentiality of patient’s medical record

Protects against use or disclosure of information without the patient’s consent

All employees must comply with HIPAA

EMR EMR

Electronic medical recordElectronic record of health-related

information for an individual that is created, gathered, managed, and consulted by licensed clinicians and staff that is maintained through a single organization

EHR EHR

Electronic health recordAggregate electronic record of health-

related information on an individual that is created and gathered cumulatively across more than one health care organization

Often used interchangeably with “EMR”

PHR PHR

Personal health recordCollection of medical records compiled and

maintained by the individual

ADVANTAGES OF EHRS Searchable databases Results can be transmitted to different

providers and departments immediately Legible prescriptions sent to pharmacy

immediately Reminder systems for routine

maintenance and testing

Encourages coordination of care between providers and departments

Plug-ins for voice recognition software to decrease transcribing needs

Automatic CPT/ICD code assignment Photo upload capabilities to ensure

correct patient is selected

ADVANTAGES OF EHRS

PARTS OF THE MEDICAL RECORD Administrative

data Financial and

insurance information

Correspondence Referrals Past medical

records

Clinical data Progress notes Diagnostic

information Lab information Medications

INFORMATION IN THE RECORD Subjective

Provided by the patient

Routine information about the patient

Chief complaint

ObjectiveProvided by the

provider and health care team

Vital signsExam findingsDiagnostic tests

ADMINISTRATIVE, FINANCIAL, AND INSURANCE INFORMATION Demographics HIPAA Notice of Privacy Practices Insurance information

CORRESPONDENCE AND REFERRALS All correspondence received by the

medical office Referral or follow-up letters from

specialists In an EHR, these are scanned and

uploaded into the patient record

PAST MEDICAL HISTORY Records from previous providers or

facilitiesRelease of information formEnsures continuity of care

PROGRESS NOTES Arranged chronologically

Most recent note on top Each entry is timed, dated, and signed Medical office or provider will indicate

preferred format for progress notes

DIAGNOSTIC AND LAB INFORMATION Imaging information

X-rays, MRIs, and many others Lab reports

Critical values should be highlighted and presented to the provider for review

MEDICATIONS Medications administered in the office

Complete documentation Prescriptions

CHARTING IN THE PATIENT RECORD

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Problem-oriented medical record (POMR) SOAP

Subjective, objective, assessment, plan HPIP

History, physical exam, impression, plan CHEDDAR

Chief complain, history, examination, details, drugs/dosages, assessment, return visit

FILING MEDICAL RECORDSGenerally the medical assistant

files three types of items:

New patientrecordfolders

Individualdocuments

forexistingfolders

Previouslyfiled

patientrecordfolders

5 STEPS TO FILING

Place files in order to save time when storing Add an identifying mark to ensure that the file is put in the correct place

Coding

Name the file using the office classification system

Make sure document is ready to

be filed

Indexing

Sorting

Place the files in the appropriate location for easy retrieval when needed

Inspecting

Storing

FILING SYSTEMS Alphabetic Numeric Subject Geographic Chonologic

ALPHABETICAL With alphabetic filing systems

Each letter is assigned a colorThe first two letters of the last name are

color-coded with colored tabsCan easily tell if files are filed correctly

File these in the correct order:Allen, E.S.Allen, William C.Allard, Wm.Allens, M.R.Allen, Edna

NUMERIC With numeric filing systems

Numbers 1 to 9 assigned a distinct colorHelps identify numeric files that are out of

place

File these in the correct order:02-17-2512-25-3508-17-3510-07-25

SUBJECT Inventory Copies of orders Financial Records Tax records

TICKLER Tickler files

Reminder files

Check on a regular basis

Organized by month, week of month or day of week

Computers systems offer tickler files in the form of a calendar Reminders set to alert prior to event

FILING Take a close look at the contents of patient

records each time you pull or file them

Keep files neat Do not overstuff file folders Papers should not extend beyond edge of

folder

Remove file from drawer when adding documents Prevents damage to documents

LOCATING MISPLACED FILES Determine where the file was when last seen or used

Look for the file while retracing steps from that location

Check filing cabinet where it belongs Check neighboring files

Check underneath files in drawer or on shelf Check items to be filed Check with other staff members Check other file locations

Similar indexes Under patient’s first name Misfiled chart color

LOCATING MISPLACED FILES Ask if someone inadvertently picked up

the file with other materials

Have another person complete the steps to double-check your search

Straighten the office, carefully checking all piles of information

ACTIVE VS. INACTIVE FILES Active files are files that you use

frequently

Inactive files are files that you use infrequently

Closed filesFiles of patients that no longer consult the

officeThe physician determines when a file is

deemed inactive or closed

Certain records have legal criteria for the length they must be maintained in the office, such as ImmunizationsEmployee health recordsMedical office financial records

Criteria from IRS – financial recordsAMA, American Hospital AssociationHIPAA lawFederal and state laws

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INACTIVE AND CLOSED FILE STORAGE

BasicStorageOptions

Computer Storage

Microfilm Paper Storage

Files remain in their original format Labeled boxes with lids to allow even stacking

If the paper becomes brittle, transfer documents to another storage medium.

Patient records can be scanned and saved on computer tapes, recordable CDs or DVDs, flash drives, or external hard drives.

Microfilm, microfiche and film cartridges offer a paperless way of storing records.

Some offices have extra storage space on-site

Smaller offices require the use of off-site storageUse a facility that takes precautions against fires

and floodsMaintain a list of all files stored at off-site locations Inactive and closed files must remain safe and secure

Evaluate storage sites carefully

Preferably place files in fireproof and waterproof containers

The storage site should be safe fromFire and floodsVandalism and theftExtremes of temperature