Medical Records Management

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Medical Records Management
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Why are Medical Records important?

• Assist physician in providing best possible care.
• Provides a complete history.
• Provides critical information for others.
• Provides continuity of care.

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Why are Medical Records important?

• Offer legal protection for those who are
  providing care.
• Remember If it isnt documented, it didnt
  happen.

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Why are Medical Records important?

• Provide statistical information.
• Provides information about medications taken and
  reactions to them.
• Evaluate effectiveness of treatment.
• Track drug effectiveness and side effects.

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Why are Medical Records important?

• Vital for financial reimbursement.
• Usually required by third-party payors.
• Supports medical necessity for billing and
  payment.

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Who Owns the Medical Record?

• The physician or medical facility owns it.
• They are the maker of the record.
• The patient has the right to demand access to the
  information contained in the record, but does not
  own it.

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Security

• Originals should never leave the premises.
• Should an original leave the premises, a copy
  should be retained in the record and marked as
  such until the original is returned.
• Records should be kept in a locked cabinet or
  locked room.

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So tell me what you know

• Why are medical records important?
• Who owns the medical record?
• How should medical records be kept secure?
• Who knows how to complete this statement If it
  isnt documented, ____.
• Why is this statement important?

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Management of Records

• Files should be organized at all times.
• Adding documents to a chart should be able to be
  done efficiently.
• A physician or provider should always have the
  most up-to-date information.
• Above all, the system must work for the facility.

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Types of Records

• Paper based
• Electronic based/Computer-based

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Paper based

• Only one person can use the record at a time.
• Not readily available for use by others.
• Misfiled information is common.
• Entire record can be misfiled or misplaced.
• Data is difficult to retrieve for statistical and
  quality control purposes.
• It is good evidence of patient care.

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Paper based

• If you have patients who stay for a period of
  time and discharge (nursing home or hospital)
• It is generally a good idea to have a different
  color chart for each calendar year to allow for
  rapid year location.
• 2008 green
• 2009 blue
• 2010 red
• 2011 yellow

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Paper based

• Master Card File This is a master file of all
  charts and storage location.
• Master Card Files are often a 3x5 cardex type
  file and includes identifying patient
  information, dates of service, medical record
  number, etc.
• Master file is to be updated as files are
  relocated (closed files, relocated to make more
  room for current files).
• Master Card is to be noted with date of chart
  destruction.

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Computer based

• Differs from Electronic based
• The bulk of the record is computerized but may
  not include everything, such as x-rays or lab
  reports.
• Guarding patient confidentiality is difficult.
• Computer malfunctions may limit access to the
  record.
• Access to records will be available even if the
  patient is not in his/her home town.

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Electronic based

• All records are stored electronically.
• Includes x-rays, MRIs, etc.
• Anything not provided in an electronic format is
  scanned into the record.

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So tell me what you know

• What are the pros/cons of a paper-based record
  system?
• What are the pros/cons of a computer-based record
  system?
• What are the pros/cons of an electronic-based
  record system?
• How do you know which one is best for your
  office/hospital?
• What is the purpose of a Master Cardex?

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Chart Order

• Forms are filed in Reverse Chronological Order
• This means the most recent document is on top.
• All like documents are kept together.
• All physician's orders are together, all lab
  reports, all nurses notes and so on.

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SOAP / SOAPE (SOAPIE)

• Many doctors (or Nurse Practitioners) use the
  SOAP or the SOAPE (SOAPIE) approach to their
  progress notes.
• This essentially forces a rational approach to
  patient problems and assist in formulating a
  logical and orderly plan of patient care.

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SOAP

• S Subjective Impressions
• O Objective Clinical Evidence
• A Assessment or Diagnosis
• P plans for further studies or treatment

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SOAPE (SOAPIE)

• S Subjective Impressions
• O Objective Clinical Evidence
• A Assessment or Diagnosis
• P plans for further studies or treatment
• (I Intervention)
• E Evaluation

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So tell me what you know

• Explain what reverse chronological order means.
• What does each letter of SOAP mean and give an
  example of information that would be written for
  each.

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Demographic Information

• Personal Demographics
• Full name (spelled correctly)
• Name of parents (if a child)
• Patients sex
• Date of Birth (DOB)
• Marital Status
• Name of spouse, if married
• Number of Children, if any
• Home address, telephone number and email

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Demographic Information

• Occupation
• Name of employer
• Business Address and telephone number
• Employment information for spouse
• Healthcare Insurance Information
• Source of Referral
• Social Security Number

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So tell me what you know

• Why is demographic information important?
• How many examples of demographic information can
  you name? (Hint You were just given 15 no
  peeking!)

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Personal and Medical History

• Often obtained by completing a questionnaire
• Past illnesses and surgeries
• Physical defects (congenital or acquired)
• Allergies
• Daily habits
• Advanced Directives
• Anything that needs to be in the forefront of the
  providers mind while providing care.

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Family History

• Illnesses or diseases
• Causes of death for immediate family members
• Many diseases and illnesses have hereditary
  patterns.

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Social History

• Information about a patients lifestyle
• Do they consume alcohol? How much?
• Do they smoke? How much?
• Do they use drugs? How often?
• Do they wear a seat belt?
• Married? Single? Sexually active?

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So tell me what you know

• Why is a patients personal and medical history
  important?
• Why is their family history important?
• How much of an impact does a patients social
  history have on their medical care?
• What if the patient does not tell the truth?

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Chief Complaint

• General information may be taken by a Medical
  Assistant, but should be reviewed in detail by
  the Physician/Nurse Practitioner.
• Concise account of patients symptoms, explained
  in the patients own words.
• Should include
• Nature and duration of the pain, if any
• Time when patient first noticed the symptoms
• Patients opinion as to the cause of the
  difficulty
• Remedies patient tried before coming to see the
  doctor
• Other medical treatment recd for the same
  condition in the past

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Objective Information

• Signs that become evident from the physicians
  examination of the patient.
• Physical findings
• Test results or requests for tests
• Diagnosis can be made.
• If some doubt remains, a provisional diagnosis
  can be made.
• Treatment is prescribed.
• Timeframe for follow-up is noted.

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Obtaining the History

• Can be done orally, if privacy allows, to become
  better acquainted with the patient.
• Can be done in writing.
• If the records are kept electronically or the
  questionnaire is lengthy the form may be mailed
  prior to the appointment to allow for time to
  enter the information prior to the visit.
• Will the office provide return postage?

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Forms

• Often different colors are used to make forms
  easy to locate within a paper record.
• Such as yellow for urinalysis, pink for blood
  counts, etc.
• Shingling Small forms taped to a 8 ½ by 11 sheet
  of paper one on top of another approximately ½
  inch above each another starting from the bottom.
  This method allows for the most recent form to
  always be on top.
• Shingle small forms such as half sheets,
  messages, post it notes, etc.

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Keeping Records Current

• Never Procrastinate!!!
• File Daily!!!
• Make certain the physician has received all
  abnormal lab reports and urgent messages.

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So tell me what you know

• Why is the chief complaint significant to the
  physician?
• When you are responsible for maintaining records,
  why is consistent color coding important?
• Why do you shingle records?
• Can you think of records that would be beneficial
  to shingle?

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Transfer, Destruction and Retention of Files

• Active files Patients currently receiving care
• Inactive files Patients the doctor has not seen
  in six months or longer
• Closed files Patients who have died, moved away,
  or otherwise terminated their relationship with
  the doctor.

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Transfer, Destruction and Retention of Files

• No nationwide standard for retention
• Medicare and Medicaid have their own guidelines.
• When no restrictions exist it is best to keep
  records for ten years.
• Applies to Adult Charts
• Minor Charts should be kept until minor is age
  18, plus several more years according to state
  law.
• In all cases, records should be kept for at least
  as long as the statute of limitations for medical
  malpractice claims.

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Releasing Medical Record Information

• The patient must sign a release for information
  to be given to any third party (except insurance
  companies).
• All medical records requests should be in writing
  and retained with the record.

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Releasing Medical Record Information

• Take extreme care with telephone calls.
• Just because I say I am Am I really???

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So tell me what you know

• What kind of patients have active files?
• What kind of patients have inactive files?
• What kind of patients have closed files?
• How long should a medical record be maintained?
• When is it okay to release a copy of the medical
  record?
• Where should record of the release be stored?

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Have questions? Still unclear?