Medical Records and Documentation

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CHAPTER

11Medical Records

and Documentation


11-2

Learning Outcomes (cont.)

11.1 Explain the importance of patient medical records.

11.2 Identify the documents that comprise a patient medical record.

11.3 Compare SOMR, POMR, SOAP, and CHEDDAR medical record formats.

11.4 Identify the six Cs of charting, giving an example of each.


11-3

Learning Outcomes (cont.)

11.5 Describe the need for neatness, timeliness, accuracy, and professional tone in patient records.

11.6 Illustrate the correct procedure for correcting and updating a medical record.

11.7 Describe the steps in responding to a written request for release of medical records.


11-4

Introduction

• Medical assistants role regarding patient health records– Documentation – Maintenance

• Medical records – critical to patient care– Evaluation – Management – Treatment


11-5

The Importance of Medical Records

• Past medical history and present condition

• Communication tool for healthcare team

• Legal documentation

• Patient and staff education

• Quality control and research

• Documentation for billing and coding


11-6

Importance of Patient Records (cont.)

• General information– Contact information– Occupation– Medical history– Current complaint– Healthcare needs– Treatment plan or services provided– Radiology and laboratory reports– Response to care


11-7

Legal Guidelines for Patient Records

• Support a malpractice claim

• Support defense for a malpractice claim

• Back up financial records

• Documentation– Medical care, evaluation and instructions– Noncompliant patient


11-8

Standards for Records

• Evidence of appropriate care– Complete– Accurate

• Everyone who documents in the patient record has a responsibility to the patient and physician


11-9

Additional Uses of Patient Records

Patient Education

Quality ofTreatment

Research• Test results

• Health issues

• Treatment instructions

• Peer review

• TJC review

• Health-careanalysis andpolicy decisions

Source of data


11-10

Apply Your Knowledge

What is the purpose of documentation in a patient’s medical record?

ANSWER: Documentation in the medical record provides evidence of appropriate care. If a procedure is not documented, it is considered not done.


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Contents of Patient Medical Records

Patient Registration Form

Date

Patient demographic information Age, DOB Address, phone number SSN

Insurance/financial information

Emergency contact


11-12

Contents of Patient Medical Records (cont.)

• Patient medical history

– Past medical history

– Family medical history

– Social and occupational history

– History of present illness (chief complaint)


11-13


• Physical examination results– Review of systems– Form ensures consistency

• Results of laboratory and other tests

• Documents from Other Sources


11-14


• Doctor’s diagnosis and treatment plan

– Treatment options and plan

– Instructions

– Medication prescribed

– Comments or impressions

• Operative reports, follow-up visits, and telephone calls


11-15


• Hospital discharge summary forms

• Consent forms– Verify that the patient understands

procedures, outcomes, and options

– Patient may withdraw consent at any time


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• Correspondence with or about the patient

• Information received by fax – request an original copy

• Date and initial everything you place in the chart



11-17

Maintaining Confidentiality

1. The right to notice of privacy practices.

2. The right to limit or request restriction on their PHI and its use and disclosure.

3. The right to confidential communications.


11-18

Maintaining Confidentiality (cont.)

4. The right to inspect and obtain a copy of

their PHI.

5. The right to request an amendment to their PHI.

6. The right to know if their PHI has been disclosed and why.


11-19


What section of the patient record contains information about smoking, alcohol use, and occupation?

ANSWER: Information about smoking, alcohol use, and occupation is part of the patient’s past medical history.


11-20

Types of Medical Records

• Source-Oriented Medical Records

– Information is arranged according to who supplied the data

– Problems and treatments are on the same form

– Difficult to track progress of specific events


11-21

Types of Medical Records (cont.)

• Problem-Oriented Medical Records – Data Base

– Problem List • Each problem numbered• Sign vs. symptom

– An Educational, Diagnostic, and Treatment Plan per each problem

– Progress Notes


11-22

Types of Medical Records (cont.)

• SOAP documentation– Orderly series of steps for dealing with any

medical case

– Lists the following• Patient symptoms• Diagnosis• Suggested treatment


11-23

Information the patient tells you

What the physician observes during the examination

The impression of the patient’s problem that leads to diagnosis

The treatment plan to correct the illness or problem

SOAP Documentation

ubjective data

bjective data

ssessment

lan


11-24

CHEDDAR Format

• Expands on SOAP format

C Chief complaint, presenting problems, subjective statements

History – social and physical historyH

ExaminationD


11-25

CHEDDAR Format

• Expands on SOAP format

D Drugs and dosage

Assessment of diagnostic process and diagnosisA

Return visit information or referralR


11-26


Label the following items as either (S) “subjective” or (O) “objective.”

____ headache ____ pulse 72

____ vomited x 3 ____ nausea

____ skin color ____ respirations 16, labored

____ chest pain ____ poor appetite

S O

S

S S

OO

O

Excellent!Excellent!


11-27

Documenting and the Six Cs of Charting

• Updating medical forms

• Documenting test results

• Examination Preparation and Vital Signs


11-28

Follow-Up

• Transcribe notes the doctor dictates

• Post results of laboratory tests and examinations

• Record telephone communication with the client

• Record all instructions and education


11-29

The Six Cs of Charting

Client’s words

Clarity

Completeness C

onciseness

Chronological order

confidentiality


11-30


1. What are the six Cs of charting?

ANSWER: The six C’s of charting are

Client’s words Conciseness

Clarity Chronological order

Completeness Confidentiality


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2. In addition to transcribing notes the doctor dictates and posting lab results, what are two other follow-up tasks the medical assistant might be required to perform as part of follow-up to a patient appointment?

ANSWER: The medical assistant may have to record telephone calls with the patient, as well as medical or discharge instructions given to the patient.

Right!


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Appearance, Timeliness, and Accuracy of Records

Neatness and legibility

–Medical transcription

–Handwritten notes• Blue ink

• Highlight specific items such as allergies

• Make corrections properly


11-33

Timeliness

Record all findings as soon as they are available

For late entries, record both original date and current date

Record date and time of telephone calls and information discussed

Retrieve file quickly in event of an emergency


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Check information carefully

Never guess or assume

Double-check accuracy findings and instructions

Make sure most recent information is recorded

Accuracy


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Professional Attitude and Tone

• Record patient comments

• Do not record personal or subjective comments, judgments, opinions, or speculations

You may call attention to problems or observations by attaching a note to the chart, but do not make such comments part of medical record.


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What is important to remember when you are documenting in the medical records?

ANSWER: It is important that medical records be neat and legible, timely, accurate, and maintain a professional tone.


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Correcting and Updating Medical Records

• Medical records are created in “due course”

– Information is entered at the time of occurrence

– Untimely submissions may be regarded as “convenient”


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Using Care with Corrections

• Correct mistakes immediately

– Draw a line through the original information

– Insert correct information

– Document why correction was made

– Date, time, and initial correction

– Have a witness, if possible

m/d/yyyy 00:00pm misspelled JHC /chj


11-39

Updating Patient Records

• Additions should not appear deceptive

• Document why late entry is made

• Date and initial added items

• May have a third party witness addition

Addition made to record because patient called back with additional information.

Mm/dd/yyyy – JHC/ chj


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What is the appropriate way to correct an error in a patient’s medical record?

ANSWER: To correct an error in a patient’s medical record:

• Draw a line through the original information• It must remain legible • Insert correct information above or below

original line or in margin• Document why correction was made• Date, time, and initial correction


11-41

Responding to Release of Records Request

• Records are property of the practice

• Contain confidential PHI which belongs to the patient

• Must have patient’s written consent to release

Release of Information

to HMO Insurance Company

I authorize Dr. J. Jones to release my health-care information to the above-named insurance company.

Christopher Hansen mm/dd/yyyyPatient Signature Date


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Procedures for Releasing Records

• New authorization to transfer records – Verbal consent is not valid– File in medical record

• Copy original materials – only information requested

• Call to confirm receipt of materials


11-43

Procedures for Releasing Records (cont.)

• Special cases– Not always clear who

can authorize release

– If unsure, ask your supervisor

• Confidentiality– 18 years old– Emancipated minor– Mature minor

Legal and ethical principle: Protect the patient’s right to privacy at all times.


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Auditing Medical Records

• Examination and review – Completeness– Accuracy

• Types – Internal – External


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The medical assistant receives phone call authorizing transfer of medical record information for a client to another physician’s office. What would you do in this situation?

ANSWER: Never release information based on telephone authorization. You cannot be sure who the caller is. Tell them you need a written and signed release of information.


11-46

In Summary

11.1 Medical records are legal documents that give a complete, concise, chronological history of a

patient’s past medical history, current medical issues, treatment plan, and treatment outcome.

Additionally, they act as a communication tool between care providers.

The patient medical record provides physicians and other healthcare providers with all the important information, observations, and opinions that have been recorded about a patient.


11-47

In Summary

11.2 The records that comprise the patient medical record include, but are not limited to the following:

• patient registration form• medical history form• physical exam form• laboratory and other test

results• records from physicians

or hospitals, • physician diagnosis and

treatment plan

• operative reports• hospital discharge

summaries• follow-up notes• records of telephone calls• signed informed consents• correspondence with or

about the patient


11-48

In Summary (cont.)

11.3 SOMR files documents in the medical record in strict chronological order.

POMR files the same documents according to numbered problems found on the patient problem list.

SOAP notes organize medical record documentation according to subjective, objective, assessment and plan.

The CHEDDAR format breaks down this information even further into chief complaint, history, exam, details, drugs, assessment, and return visit plan.


11-49

In Summary (cont.)

11.4 The six Cs of charting are client’s words, clarity, completeness, conciseness, chronological order, and confidentiality.

11.5 Neatness, legibility, accuracy, and professional tone are musts in maintaining medical records.

Remember that patient medical records are legal documents.

Personal thoughts and observations should never be a permanent part of the patient medical record.


11-50

In Summary (cont.)

11.6 The proper way to make corrections in a medical record is to draw a single line through the error so that the original entry is still legible.

Any additions to a medical record should also be made as soon as the need for the addition is noted, and the reason for the addition or change should also be clearly documented.

11.7 In order to release any confidential medical information, express written permission from the patient must be received. Only release records that are expressly requested and authorized by the patient.


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Organization is the power of the day; without it, nothing is accomplished.

~ Sophia Palmer

From A Daybook for Nurses: Making a Difference Each Day

End of Chapter 11

Medical Records and Documentation

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