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Transcript of Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. UNIT 4 SEMINAR Hello Students. The...
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
UNIT 4 SEMINAR
Hello Students.
The seminar will begin shortly.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Questions
Do you have any questions about the course?
Only the students that have questions should be typing for the next few minutes.
Keep in mind that certain questions might require research; thus don’t be offended if I ask you to email the question to me.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
The information in this Seminar was designed for Gerald Burke’s students. Contact your instructor for clarifications if you are not in Gerald Burke’s class. Your instructor might have different course expectations.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
QUESTION 1Which of the following are not needed when describing a patient’s chief complaint?
a. Remedies the patient has tried to relieve symptoms
b. Duration of painc. Time when symptoms were first noticedd. How many family members are healthy
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
ANSWER QUESTION 1
D
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
QUESTION 2Continuity of care means:
a. an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries
b. a formal examination of an organization’s or individual’s accounts
c. that which continues smoothly from one provider to another, so that the patient receives the most benefit
d. granted or endowed with a particular authority
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
ANSWER QUESTION 2
C
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
QUESTION 3Which of the following is not objective
information?
a. Progress notes
b. Family history
c. Diagnosis
d. Physical examination and findings
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
ANSWER QUESTION 3
B
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
QUESTION 4 A filing system in which an intermediary source
of reference, such as a file card, must be consulted to locate specific files is called a(n) _____ system.
a. shelf filing
b. indirect filing
c. direct filing
d. Shingling
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
ANSWER QUESTION 4
B
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
QUESTION 5 Medical facilities should keep records on minors
for how long?
a. Indefinitely
b. Until the minor is deceased
c. For 10 years
d. Until the minor reaches the age of majority, plus 3 years
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
ANSWER QUESTION 5
D
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Career Tip #3 – Read publications that will enhance your career.
Why should you read publications that will enhance your career?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Which career related publications do you read?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
WSJ Online
Wall Street Journal Online
http://online.wsj.com/home-page
Look around and save it to your favorites or make it your home page.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
WSJ Online
The WSJ Online contains a tremendous amount of career guidance and a wide range of information.
Most of the articles are free.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
WSJ Online
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
WSJ Online
The WSJ Online helps you stay a step or two ahead.
Learn about it before it happens.
Learn from the mistakes and successes of other professionals and job hunters.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
WSJ Online
Learn how to manage your career.– Job search strategy.
– Increase salary.
– Change careers, switch industries, reinvent yourself, etc.
– Stand out from the competition.
– Overcome career obstacles.
– Deal with difficult peers and managers.
– Find out what employers want and need.
– Learn about industry trends.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
WSJ Online
Learn which organizations are going to hire more employees.
Learn which organizations are going to layoff part of their staff.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
WSJ Online
WSJ Online’s other features– Education
– Personal Finance
– Small Business
– Real Estate
– World News
– US News
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
WSJ Online
– Financial Markets
– Technology
– Life & Style
– Opinion
– Health Industry
– Economy
– Law
– Management
– Media and Marketing
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
WSJ Online
Arts & Entertainment
Autos
Books
Fashion
Sports
Travel
And More!
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
WSJ Online
The WSJ Online provides world-class caliber career guidance. Find out for yourself.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Career Tips
Remember Career Tip #1? – Consider signing up with one or more employment agencies that specialize in your chosen profession(s).
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
More Employment Agency Strategy
Why should you consider registering with employment agencies in different industries?
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More Employment Agency Strategy
Why should you contact the agencies and let them know when you are not available for work(due to a current work assignment, etc.)?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
More Employment Agency Strategy
Why should you consider giving a gift to the employment agency/recruiter that has been sending you on the best work assignments?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Introduction
Medical records management systems are only as good as the ease of retrieval of the data in the files.
Organization and adherence to set routines will help to ensure that medical records are accessible when they are needed.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Why Medical Records Are Important
Assist the physician in providing the best possible care to the patient
Offer legal protection to those who provide care to the patient
Provide statistical information that is helpful to researchers
Vital for financial reimbursement
Can you think of other reasons why medical records are important?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Medical records must be kept confidential and in a secured, locked location.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
An efficient medical record system should:
provide for easy retrieval
be organized and orderly
contain information that is completely legible
contain accurate information
show information that is easily understood and grammatically correct
What are some other attributes of an efficient medical record system?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Types of Records
Name some disadvantages of paper-based medical records?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Disadvantages of Paper-Based Medical Records
Only one person can use the record at a time, unless multiple people are crowding around the same record.
Items can be easily lost or misfiled or can slip out of the record if not securely fastened.
The record itself can be misplaced or be in a different area of the facility when needed.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Organization of the Medical Record
What are source-oriented records?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Source-Oriented Medical Records
Traditional method of keeping patient records.
Observations and data are cataloged according to their sources.
Forms and progress notes are filed in reverse chronologic order.
Separate sections are established for laboratory reports, x-ray films, radiology reports, and so on.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Organization of the Medical Record
What are problem-oriented records?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Problem-Oriented Medical Records
Divides records into four bases:
1. Database
2. Problem list
3. Treatment plan
4. Progress notes
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Problem-Oriented Medical Records
Database Includes:– Chief complaint
– Present illness
– Patient profile
– Review of systems
– Physical examination
– Laboratory reports
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Problem-Oriented Medical Records
Problem List– Numbered and titled list of every problem the patient
has that requires treatment
– May include social and demographic troubles as well as medical and/or surgical notes
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Problem-Oriented Medical Records
Treatment Plan Includes:– Management
– Additional workups needed
– Therapy
Each plan is titled and numbered with respect to the problem.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Problem-Oriented Medical Records
Progress Notes– Structured notes are numbered to correspond with
each problem number.
– Progress notes follow the SOAP approach.
What does the acronym SOAP stand for?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
SOAP Approach to Progress Notes
SOAP acronym
S—Subjective impressions
O—Objective clinical evidence
A—Assessment or diagnosis
P—Plans for further studies, treatment, or management
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Obtaining the History
There are different ways to obtain a patient’s medical history. What are some of those ways?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Obtaining the History
Histories may be obtained by:
Patient questionnaire
Medical assistant asking the patient questions
Physician asking the patient questions
Combination of questionnaire and questions
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
What is “authentication” as it pertains to medical records?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Authentication
For a chart to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written.
This is “authentication” and is best done by initialing entries (or the equivalent) made to the medical record.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Progress Notes
Have you ever seen or worked with progress notes?
Continually added to the medical record.
Must list each patient visit and any notations about the visit.
Instructions, prescriptions, and telephone calls for advice should be noted in the progress notes.
Always initial entries in progress notes.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Corrections and Alterations to Medical Records
How do you correct an error in a paper based medical record?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Correcting an Error
Three Steps
1. Draw one line through the error.
2. Insert the correction above or immediately after the error.
3. In the margin, write “correction” or “corr” and initial the entry.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Corrections and Alterations to Medical Records
Never use correction fluid, erasers, or any other type of obliteration methods.
Do not mark through information to obliterate it.
Do not hide errors.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Correcting Electronic Records
An electronic medical record contains an error. How do you correct the error?
Four
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Correcting Electronic Records
If an error is made while typing, simply backspace and correct the error.
If the error is discovered later, make an additional entry with corrected information.
Most of the time you will not have the computer authority to delete or change previous entries on electronic medical records.
Why will most health care organizations not permit the deletion or alteration of electronic medical record entries?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Keeping Records Current
Records must be methodically kept current.
The patient’s health is jeopardized when current, accurate records are not available to the physician.
Remember that the physician bases his decisions on the information in the patient medical record.
Do not allow paper-based histories and reports to accumulate for a long time before filing them. In your opinion, how long is too long?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Classifications of Records in the Physician’s Office
Active files– patients currently receiving treatment
Inactive files– patients who have not been seen for about 6 months to
a year.
Closed files– patients who have died, moved away, or otherwise
discontinued treatment
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Transfer of Records
Follow office policies regarding transferring medical records from active to inactive or closed categories.
Files may need to be physically rearranged to accommodate transfers.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Retention and Destruction
Most physicians keep medical records for 10 years at a minimum.
Some records may warrant longer retention periods.
Follow local, state, and federal guidelines for retention and destruction of records.
In most cases, keep medical records at least as long as the length of time of the statute of limitations for medical professional liability claims.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Retention and Destruction
Medicare and Medicaid patient records must be kept for at least 6 years.
Follow office policies for record retention and destruction.
How long should you keep records on patients who are deceased?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Keep records on patients who are deceased for at least 2 years.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Releasing Medical Record Information
Requests must be made in writing for release of records.
Patients must sign an authorization for release of medical records.
Patients can revoke previously signed authorizations for release of records.
Release only records that are specified on the request.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
SAMPLE
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Filing Equipment
Various types of equipment are available for storing medical records in today’s medical offices.
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
What does your office need to consider before it purchases filing equipment?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
Considerations in Choosing Filing Equipment
Office space availability
Structural considerations
Cost of space and equipment
Size, type, and volume of records
Confidentiality requirements
Retrieval speed
Fire protection
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Color-Coding
Almost all medical offices use some sort of color-coding in their filing systems.
Numeric color-coding provides a high degree of patient confidentiality. Why is this statement true?
Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.
QUESTIONS?