Med Records Management- Med Records Basics

Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) codes

-EHR software often links to databases of clinical vocabularies -both be used for reimbursement and tracking purposes.

Filing Systems

-File Storage -Filing -Alphabetic -Numeric -Shingling Items for Medical Records -Electronic Records

Forms of Charting

-The Narrative Style -Charting with SOAP -Problem-Oriented Medical Record Charting -Inserting Flow Charts and Growth Charts in Medical Records -Progress Notes

Progress notes

-any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes -daily chart notes made during patient visits to document patients' progress or status with certain conditions. Assume a patient arrives for an appointment complaining of fatigue. On the patient's subsequent visits, progress notes would outline the patient's current condition, any treatment recommendations, and outcomes. Depending on the office, progress notes may be made in SOAP, POMR, or narrative format. The notes may also be handwritten or electronic.

Problem-Oriented Medical Record (POMR) charting

Charting that focuses on patient status, emphasizes the problem-solving approach to patient care, and provides a method for communicating what, when, and how things are to be done in order to meet the patient's needs. -Tracks a patient's problems throughout medical care. Each problem is assigned a number, and that number is referenced when the patient comes in for care. Advocates for POMR charting believe that charting according to patients' problems makes healthcare providers less likely to overlook previous problems. Once a condition is resolved, a notation is made so the doctor need not reference the problem on subsequent visits. As new problems arise, new numbers are assigned, and new pages are allotted for tracking the problems.

structure and content standards

Common elements and definitions to be included in an electronic health record.

Charting Patient Communication

Communication with patients outside of office visits must be documented in patient charts when it is medically relevant. Such communications include telephone calls or e-mails from patients that relate to their medical care, missed or cancelled appointments, or pharmacy requests to refill prescriptions. It is important to accurately chart all such exchanges in patient medical records. Each office should have a policy regarding the type of communication that requires charting, and all members of the healthcare team should closely follow that policy

Medical charting must adhere to the following "Five Cs rule," which means patient charts must be:

Concise: Patient charts must be to the point and contain no entries that fail to relate to the patient's healthcare in some way. Complete: Medical records must be complete and objective. All pertinent information must be included while opinions and judgments are excluded. Clear: When handwritten, patient information should be printed, not written in cursive, and delivered in a clear, easy-to-read manner. With the use of EHR software, all information in the patient record is displayed as standard print. Correct: Medical records must be error-free. Errors include both improper additions and omissions. When errors are made, their creators must correct them as soon as possible. Chronologic: Medical records should be in chronologic order, with the latest entries on top.

Which of the following is NOT true about privacy laws and HIPAA compliance? -The software can track entries or deletions and who made them. -Computer screens should not be viewable by other patients while private patient information is displayed. -Each station must be logged off when the user is away from their desk. -All computer users in a medical office have the same password to make accessibility to patient medical records more convenient.

All computer users in a medical office have the same password to make accessibility to patient medical records more convenient.

uniformity and standardization

An EHR benefit in which health record systems adhere to structure and content standards.

collaboration

An EHR benefit wherein information sharing is made easier.

reduction in medical errors

An EHR benefit wherein the opportunities for patient care errors are reduced.

Signing Off on Medical Records

Any entry in a patient's medical record must have an identifying mark indicating the person who made the entry. Policies on this will vary from one medical office to the next, but the minimum should be no less than the initials and credentials of the person making the entry. Some medical offices require a complete signature along with credentials; others allow a first initial, last name, and credentials.

Accessibility

Authorized users can access EHR information from on-site or remote computers. If a healthcare provider needs information, they no longer have to go physically to a record storage area or request a file clerk retrieve documents from a physical record in a records room. Authorized users have immediate access to information. Information is stored and indexed for easy retrieval on demand

Benefits of EHR Systems

Ease of storage, accessibility, efficiency, searchability, collaboration, uniformity and standardization, reduction in errors.

Efficiency

Easy access leads directly to efficiency. As soon as information is entered, it's accessible. The end user (patient, physician) does not have to wait for the document to travel from healthcare provider to medical transcription editor to medical coder to medical biller before they have access to it. The original document is available and additions can be made efficiently until the document reaches a final form.

Patients should never be allowed to access their own EHRs via the Internet, especially when regarding immunizations and medications.

False

Paper medical charts take up a lot of space, especially in large offices or offices where physicians have been in practice for a long time. Keeping all patient charts in the same filing system can be overwhelming and increases the time it takes to find patient files.

For these reasons, many clinics purge inactive or closed patient files.

electronic health record

Systematic collection of a patient's health care and treatment in a digital format exists entirely in electronic format and can be a compilation of information from a single visit or contain information from multiple healthcare-related visits.

Health Information Exchange (HIE)

The use of information technology to improve the quality, safety, efficiency, and confidentiality of healthcare through simultaneous access to patient health information by multiple healthcare providers.

What does NOT need to be included in a "Late Entry"? -the date of the visit the late entry pertains to -the signature of the person making the entry -the notes originally omitted from the entry -the signature of the physician caring for the patient

the signature of the physician caring for the patient

Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT)

a standardized medical vocabulary used to facilitate the indexing, storage, and retrieval of patient information. The current version includes more than 150,000 terms. The importance of standardized medical language is illustrated in the following simple example: The medical term for a heart attack is a myocardial infarction.

Inactive patient files

files for patients who have not seen the physician for extended periods normally those for patients who have not been in to see the physician for a period between two and five years depending on the type of practice, the number of files the practice must store, and the office policy. Removing inactive patient files leaves room for new patient files and makes it easier to find active patient files.

All healthcare providers use an electronic health record system.

false

An electronic-based record is recorded on an electronic device such as a tape recorder or digital voice system.

false

The United States has a universal electronic health record system. Every provider who uses electronic health records must use the national system.

false

active patient files

files for patients who have appointments or who have been in to see the physician recently

EHR Concerns

-cost -confidentiality -security -computer problems

Discovery Rule

-legal theory that provides that the statute of limitations begins to run at the time the injury is discovered or when the patient should have known of the injury -states that the statute of limitations starts on the day the injury was discovered or should have been discovered.

Correcting medical records procedure

-single red line through error, write corr or correction with date and initials, if chart has been sent else where make copies and send out immediately to them. -When an error is an entire line or several lines in the patient chart, the entire portion of the entry that is in error should be struck with a line. When an entire entry is in error, which can happen if the clinical medical assistant accidentally charts in the wrong patient's chart, the person who made the error should draw a line through the entire entry, make a notation such as "wrong patient's chart," and include the date and their initials and credentials. Only the person who made the error should correct the medical chart.

Place the following list in numerical order from lowest to highest. 1)125142.10 2)125412.10 3)125412.20 4)125410.10

1 4 2 3

Alphabetize the following patient list. Remember, always alphabetize by the last name, then the first name, then middle initial, then title. 1)CHARLIE B. JOHNSON 2)CHARLIE B. JONSON 3)CHARLES B. JOHNSON 4)CHARLIE B. JOHNSON JR

1)Charles B Johnson 2)Charlie B Johnson 3)Charlie B Johnson Jr 4)Charlie B Jonson

Alphabetize the following patient list. Remember, always alphabetize by the last name, then the first name, then middle initial, then title. 1)JASON M. DAVIDSON 2)JAYSON M. DAVIDSON 3)JASON M. DAVIDS 4)JAYSON M. DAVIDSEN

1)Jason M Davids 2)Jayson M Davidsen 3)Jason M Davidson 4)Jayson M Davidson

Alphabetize the following patient list. Remember, always alphabetize by the last name, then the first name, then middle initial, then title. 1)MARIE L. SMITH-GRAVES 2)MARIE L. SMITH-GRAMS 3)MARY L. SMITH-GRAVES 4)MARIE L. SMITH

1)Marie L Smith 2)Marie L Smith-Grams 3)Marie L Smith-Graves 4)Mary L Smith-Graves

Place the following list in numerical order from lowest to highest. 1)241512 2)241436 3)241568 4)241435

4 2 1 3

Patient files fluctuate among active, inactive, and closed status

A file that is considered active today may be closed tomorrow if the patient contacts the office to report an out-of-state move. That same file may return to active status if the patient moves back and resumes care in the medical office.

advance directives

A legal document designed to indicate a person's wishes regarding care in case of a terminal illness or during the dying process documents that outline patients' wishes regarding healthcare should those patients be unable to speak for themselves, a copy of that document should be placed in the patient's medical record.

Numeric filing is far more common overall in most medical offices.

False

Avoiding Medical Mistakes

Electronic health records can be used to alert healthcare providers to possible medication reactions. This is especially helpful when treating patients who are co-treating with several specialists. The EHR software will typically have a safeguard mechanism built in that alerts the prescribing physician to any contraindicated medications a particular patient may have. EHR systems can help to prevent some medical errors. To take the most obvious example, some medical errors are caused by indecipherable handwriting. The EHR eliminates this problem by recording all information in typed form, making the information clear and easy to read. EHR systems also help to reduce other medical errors, through clinical decision support such as drug-drug interaction checks.

As a medical administrative assistant, you will be filling in growth charts, but not flow charts.

False

EHR software can show immediate results within the EHR itself, except in the case of digital x-rays, Holter monitors, and spirometers.

False

Electronic health records do not allow medical staff to easily transmit patient information to patients' health insurance companies when requested.

False

Cost

Healthcare providers must invest dollars to develop or purchase, then install and maintain an EHR system that adequately meets their needs. However, most providers have installed EHR systems, in part because of government incentives that helped them purchase systems. Today, government reimbursement programs require providers to use certified EHR systems and meet goals around quality reporting and other measures.

Computer Problems

Human error can cause many problems with records, but sometimes, despite your best efforts, the computer you are using will get malware or have other technological issues. As you can imagine, having your computer shut down in the middle of updating someone's records or while you have an office full of sick patients would be a problem. Protecting your computer network from malware and other failures is vitally important.

Deleting Information

If a patient wishes for information to be removed, do not argue with them. Simply thank them for bringing the information or error to your attention and explain that you are not allowed to remove anything from the record. Let them know you will notify the clinician and that they can correct it. Some facilities allow patients to add their own entries to the medical record. This allows the record to contain the patient's point of view as well as the clinician's. If this is an option, explain the process to the patient.

Which of the following is NOT true about a medical record? -It documents a patient's treatment plan on paper or in electronic form -It must contain a full account of all patient treatment -It can be changed by its owner (patient) if they think it has an error. -It should never contain opinions or judgments about patients.

It can be changed by its owner (patient) if they think it has an error.

Searchability

It takes less time to search for a specific item in an electronic document than in a paper document. Software tools and features make searching quick and easy. This is a benefit for providing patient care to an individual patient and it is a time saver as well.

Putting Medical Records Online

Many clinics allow patients to view, download, or transfer portions of their electronic health records via a patient portal available on the Internet. Using this password-protected system, patients can access a clinic's record of their lab results, dates of immunizations, or current medications, which can help when patients travel or need to seek emergency care with someone other than their primary care provider. Patient portals offer individuals online storage of medical information, such as clinical summaries, immunizations, allergies, prescriptions, and surgeries.

Cameras

Many facilities use images in their medical records. Some include photos to help staff better recognize the patients; images taken with a microscopic camera during exploratory surgery are another example; still others will use cameras to document physical ailments, such as bruising or burns (this is especially common when abuse or assault is suspected). Images can easily be added to the medical record. If using EHRs, images are uploaded just like attaching files to an email message. The equipment and the images must be kept secure. Cameras should be treated carefully and stored in a locked room with designated access. Images on a computer, camera, paper, or in a medical record should be treated as any other PHI.

Saving Time

Many healthcare providers believe they spend a great deal of time charting, far more time than they spend on actual patient care. With the cost of healthcare rising, it makes sense to free up the healthcare provider's time while decreasing avoidable patient injuries. EHRs allow medical staff to easily transmit patient information to health insurance companies when requested, rather than having to photocopy the paper records and send them via the postal service. It is just as important to follow HIPAA guidelines for releasing medical records electronically as it is for releasing photocopies of the patient's paper medical record.

Marketing Purposes

Many medical clinics send informational flyers to patients on a regular basis. An example would be a flyer that is sent during flu season and describes the signs and symptoms of the flu along with prevention tips. Part of the prevention tips would be to encourage readers to come into the physician's office for a flu vaccine. With EHRs, the administrative staff is also able to create a list of patients according to specific parameters. For example, if the office has recently welcomed a physician who specializes in allergies to the office, the administrative staff can create a list of patients who have been treated for allergies and use that list to send a letter to patients to let them know of the availability of the new physician.

Shingling Items for Medical Records

Many medical offices file such small items in patients' medical records as written telephone messages or half-size sheets containing patient progress notes. To keep these small items from being lost in the records, offices employ shingling, which is the process of simply taping the small items to an 8 1/2 inch x 11 inch sheet of paper and then filing the paper in the patient's chart.

Health Maintenance

Many medical offices send reminder cards or letters to patients regarding the need for upcoming services. These are typically used to remind patients of the need for preventive care, such as a dental exam, a mammogram, a yearly physical, immunizations, or well child check-ups. Using electronic health records, the medical office professional can query the software to generate these reminders.

Charting Conflicting Orders

Medical administrative assistants should follow no orders they feel may harm patients. Instead, they should consult the physicians out of the patient's hearing range. When physicians insist that their orders be followed according to their instructions and they explain why the orders will not cause patient injury, the medical administrative assistant should chart the events, including the fact that they questioned the doctor as to the accuracy of the orders. They should also include the physicians' responses.

paper-based record

Medical record data printed and stored on paper in hard copy format.

electronic-based record

Medical record data stored in an electronic format in a computer system or systems. These are commonly known as either an electronic health record (EHR) or an electronic medical record (EMR).

"Owning" the Medical Record

Medical records belong to the physicians or facilities where they are created. The information inside, however, belongs to the patients. Patients have a right to access their medical records and to correct those records when they feel errors have been made. Patients should not, however, be left alone to peruse their chart. When patients request corrections to their medical records, the healthcare team must determine whether errors exist. If the physician agrees an error has been made, the correction should be made as described earlier in this unit. If the physician feels the entry was not in error, the physician cannot be forced to treat the entry as an error. In this case, patients must be allowed to create their own version of the event, and copies of those written statements must be placed in the medical records. Such statements become permanent parts of the patient medical records.

Confidentiality and Security

Mistakes can happen-as can abuse of access to medical records. Not everyone in the office is as honest as you will be. As a medical administrative assistant, it's your job to make sure that the records you work with are handled properly.

File Storage

Most medical office filing systems consist of metal cabinets that hold paper patient charts in alphabetical order. Old-style filing cabinets were designed in a tower shape with drawers that pulled out to reveal the files within. Other styles of freestanding filing cabinets have drawers that pull out to reveal the sides of files. These cabinets are useful for identifying files by their color-coded alphabetic or numeric tabs.

Filing

Most medical offices use one of two types of filing systems for paper medical records: (1) alphabetic or (2) numeric. While alphabetic is far more common overall, numeric filing is more common in facilities where patient treatment records must be kept extremely confidential, such as in facilities specializing in mental health, HIV or AIDS treatment, or reproductive healthcare.

Electronic Records

One of the advantages of EHRs is the reduced space and time needed to file physical files. If your facility has converted completely to EHRs, you will not have to worry about filing systems.

Which of the following is true? -Patients have the right to access their medical records. -Patients can be left alone when reviewing their charts. -The physician must change an entry if a patient believes there is an error -Patients can never correct their medical records.

Patients have the right to access their medical records.

Narrative notes

Progress notes written in a source oriented record that address routine care, normal findings, and patient problems identified in the plan of care. Simply written descriptions of patient visits. As one of the oldest forms of medical charting, narratives are chronological.

Numeric

Some patient files, such as those in offices devoted to HIV or AIDS-related care, mental health, pregnancy or family planning, or alcohol and drug rehabilitation, may demand a higher level of security. Numeric filing is often used in these types of offices. Because the numeric system masks the identity of patients, it is difficult to retrieve filed information without the proper number. In offices that file with numeric systems, lists of patient names and corresponding numbers must be kept in a secure location for the systems to work.

the steps an office using electronic charting might take:

Step 1A patient calls the office to schedule a new appointment. The medical administrative assistant creates an electronic chart while the patient is on the telephone, adding information about demographics, telephone numbers, insurance information, and symptoms in the EHR. Step 2Sometime before the patient's appointment, the software may be programmed to electronically confirm the patient's health insurance coverage. Step 3The day before the patient's appointment, the software may be programmed to alert the EHR office professional to remind the patient of the appointment via their preferred method of communication, typically by phone or e-mail. Some clinics use an automated service to call and remind the patient of their appointment. EHRs can also save e-mail templates that can be used to easily notify patients of their upcoming appointments. Step 4When the patient arrives in the office, they may be escorted to an examination room, where a medical administrative assistant will fill out the patient information form on the computer while the patient is present to answer any questions. Step 5The EHR office professional will then take the patient's vital signs, entering all gathered information into the EHR as they go. Step 6When the physician comes into the room, they will review the patient's information in the EHR and make their own notes there while interviewing and examining the patient. If a prescription is written, the physician will fill this information out in the EHR and send the prescription electronically to the patient's pharmacy of choice. If any laboratory work or x-rays are ordered, the physician or medical administrative assistant can place the order from within the EHR. If the physician wishes to provide the patient with educational materials, such as information on reducing cholesterol, this information may be quickly printed from within the computer system, including making a notation within the patient's EHR that the information was given. Step 7If laboratory work or x-rays were ordered, the physician will only need to review the results from within the patient's record on the computer, which may be done from any computer terminal within the clinic.

Preparing Medical Charts

Step 1Print the patient's name on a file label, with the last name followed by first name and middle initial. For example, print "Smith, John R." on the file label. Step 2Verify the spelling of the patient's name. Step 3Using color-coded alphabet stickers, place the first two letters of the patient's last name on the file near the file label. In the preceding example, "SM" stickers would appear near the file label. Step 4One space after the stickers in the preceding step, place a color-coded alphabet sticker for the first letter of the patient's first name. Building on the preceding example for John R. Smith, the file stickers would read "SM [space] J." Step 5Add metal file clips to both sides of the file. Step 6Using a two-hole punch, punch holes in the top of the documents to be filed in the patient's chart. These documents include the patient's history form, the HIPAA notification form, and the patient's consent to be examined. Step 7Place the medication record sheet on one side of the chart. Step 8Place the progress report sheet on the other side of the chart. Step 9On the front of the chart in red ink, note any of the patient's known allergies. If the patient believes they have no allergies, write "NKA" (i.e., no known allergies) on the front of the chart.

With paper charting, the patient's chart is only available to one staff member at a time. The following example illustrates the steps an office using paper charting might take:

Step 1The patient telephones the medical office and schedules an appointment to see the physician. The medical administrative assistant writes down the information the patient gives, such as their name, address, telephone numbers, insurance information, and the patient's chief complaint. Step 2Sometime before the patient's appointment, the medical administrative assistant or the billing office may call the patient's insurance carrier to verify the patient's benefits. Step 3The day before the patient's appointment, the medical administrative assistant may call the patient to remind them of their appointment for the next day. The administrative assistant will also prepare the new patient's chart. This is typically done by gathering a paper file folder, color-coded labels to identify the patient's last name, and any other paper forms the patient and the medical staff will fill out on that first visit. Step 4When the patient arrives for their visit, the administrative assistant will give the patient the necessary papers to fill out. Step 5When the patient is taken back to the examination room, the clinical medical assistant will begin taking vital signs, such as blood pressure, pulse, and temperature, and begin noting this information by writing in the patient's medical chart. Step 6When the physician sees the patient, they will review the information the patient has filled out, along with the information the clinical medical assistant has filled out, and will begin making notes of their own into the patient's paper chart. If the physician writes a prescription, they will make a note of this in the patient's chart, along with writing the actual prescription on a paper for the patient to take to the pharmacy. In some offices, the physician does not make written notes in the patient's chart and instead dictates their findings into a recording device. Those notes will be transcribed by a transcriptionist or a transcription service, then added to the patient's chart. Step 7If the physician orders x-rays or laboratory tests, the patient's paper chart will be pulled once those reports are returned to the office in order for the physician to review the results along with the patient's chart.

Here's a common procedure for charting a telephone call from a patient:

Step 1While answering an incoming patient call, determine if the call is medically relevant to the patient's care in the office. Step 2When the call is medically relevant to the patient's care, note the call's time and date, the patient's complete name and telephone number, and the nature of the message. Step 3When the call ends, physically pull the patient's chart or find it in the EHR system. Step 4In the progress notes section of the patient's chart, note the current date and time. Step 5Write or type the medically relevant portion of the call in the patient's medical record, using quotation marks to indicate any direct quotes from the patient. Step 6Sign your name and credentials at the end of the chart entry. Step 7If the call requires the physician's attention, leave the chart on the physician's desk or notify the physician by secure messaging within the EHR. If the call does not require the physician's attention, file the chart. Step 8After transferring all relevant information to the chart, shred any notes from the call that contain personal patient information.

health informatics standards

Structure and content standards that must be maintained in a health record.

Technology and the Medical Record

Technology has enabled exciting breakthroughs for patients and the medical community, such as video conferencing. Video conferencing allows physicians an opportunity to consult "face-to-face" with their patients, other professionals, or both. In some cases, video conferencing has enabled "supervised" medical procedures to be performed in remote areas under the direction of capable clinicians, nurses, or physicians. This technology has also been instrumental in saving lives. information can be instantly transferred via e-mail, CCDAs, fax, Internet sites, voice files, video, and even hand-held mobile devices. These miracles of modern technology have enhanced the opportunities for collaboration because patient information can be shared quickly for the best possible medical care. You can be on vacation virtually anywhere in the world, and your provider can instantly access your records or otherwise exchange vital medical information on you with your hometown doctor. Especially for those with complex medical histories or multiple medical problems, this can mean the difference between life and death.

Ease of storage

The more visits a patient makes to his or her healthcare provider, the larger the patient's medical record becomes. Many healthcare providers see hundreds or even thousands of patients. Record storage can take up a lot of space in any office. Storing patient health information in an EHR simply saves space.

EHR software usually has a safeguard mechanism built in that alerts the prescribing physician to any contraindicated medications a particular patient may have.

True

In offices where medical notes are dictated and printed for patient files, an electronic signature or rubber-stamp signature may replace handwritten signatures.

True

Inactive patient files are normally for patients who have not been in to see the physician for a period between two and five years depending on the type of practice.

True

SNOMED-CT is a standardized medical vocabulary used to facilitate the indexing, storage, and retrieval of patient information.

True

SOAP stands for subjective, objective, assessment, and plan.

True

Documenting Prescription Refill Requests

When a pharmacy calls with a prescription request, you will pull the patient's file and place the request and patient file on the physician's desk for review. If the physician feels the patient should be seen in the office before a prescription refill, you should first call the pharmacy to notify them of the physician's request, and then call the patient to schedule an appointment. If the physician authorizes the refill request, call the pharmacy back with the appropriate information. All information about the refill request, authorized or not, must be charted in the patient's medical record. it may take up to 24 hours for refill requests, giving physicians time to review patients' files.

Using Electronic Health Records with Diagnostic Equipment

With EHR software, the medical office is able to perform many tests in the office and have the results show immediately within the electronic health record. This can also be done with digital x-rays and other medical images, Holter monitors, spirometers, and laboratory test results.

The EHR makes it easier to _____. -read the physician's orders -get information about the patient from other healthcare facilities -get the patient's medical record quickly -all the above

all the above

What should you do when you feel an order may harm a patient? -Consult the physician out of the patients' hearing range. -Chart the events if the physician insists that the orders be followed. -Include the physicians' responses in the patients' chart. -all the above

all the above

Closed patient files

files for patients who will not be returning to the clinic normally reserved for the files of patients who have moved and will not be continuing treatment with the physician or facility. It is also used to describe files for patients who are deceased or files for patients who have stated they will be discontinuing treatment in that facility. normally moved to other storage systems, leaving the space available for active patient files.

Cross-referencing

files with cards that direct staff to proper files can help address such variations. In the case of Smith-Doe, for example, the patient's original medical record would be filed under the correct full name of Smith-Doe and a blank patient file, labeled with the name's other combinations, would be filed under Smith and Doe. Under this system, if the patient called and identified herself as "Mrs. Ann Doe," you would look in the "Doe" file and find a blank file that said "Ann Smith-Doe's file is under Smith-Doe."

Purging involves _____.

inactive patient files

amendment

may be added to a record when adding clarifying details. the date of entry, the signature or initials of the person making the change, and the reason for the change should be included.

Adding to Medical Records

medical records may be incomplete or unacceptable because information is omitted or unclear. If new information that was not available at the time of original documentation needs to be added, an addendum should be created. This is done by inserting the missing information with the title "ADDENDUM to [date of the original visit]." the date of entry, the signature or initials of the person making the change, and the reason for the change should be included.

medical records

must be complete, accurate, organized, concise, timely, and factual—they should never contain opinions or judgments about patients

Objective findings

observations by the clinical medical assistant and the healthcare provider, examination findings, and patient vital signs This section would include the results of any tests performed, such as orthopedic or neurological tests, as well as any visual examination findings made by the physician, such as rashes the patient is exhibiting or the fact that the patient winces when the physician touches a certain body part.

Who should correct a medical chart when there is an error?

only the person who made the error

Alphabetic

patient information is filed alphabetically by last name. Some offices file according to the first two letters of the patient's last name; others use the patient's first and last name initials. Still others use a portion of the patient's last name and the first initial of the first name. Offices that use alphabetic filing place color-coded alphabetic stickers on the outside of patients' charts. Color-coding helps misfiled charts stand out. Patients with hyphenated last names can confuse filing practices in medical offices. When a patient's last name is Smith-Doe, for example, some staff may file the patient's chart under the first part of the hyphenated name, Smith, while other staff may file according to the latter part, which is Doe. To avoid confusion, medical offices should have clear policies for filing the charts of patients with hyphenated names and strictly follow those policies.

subjective findings

patient statements, including any information about the chief complaint.

Whenever medical records are subpoenaed for trials (meaning that a court order demands that a party appear in court, or that copies of the medical record be sent to a third party)

physicians may have to explain notations. A jury who thinks a physician is judgmental or unkind could hand down an unfavorable verdict. In addition, unprofessional notations may predispose other healthcare professionals to treat patients differently. The best way to keep medical charting professional is to write as if the patient will be reading the comments. Anything you would not say to the patient should remain out of the patient's medical record.

Flow charts

show trends in vital signs, blood glucose levels, pain level, and other frequent assessments visual tools that help track certain information in patients' medical records. Although you will not be filling out a flow chart, a patient may call in to ask questions about their chart. Flow charts come in a variety of styles, and you will be trained on how to read them differently depending on the medical office at which you work.

SOAP note charting

subjective, objective, assessment, and plan; a common form of charting in the medical record where clinicians chart information on an easy-to-find format

Assessment

the doctor's diagnosis, possible diagnosis, or the diagnosis that the physician wishes to rule out for that visit. In the event that the diagnosis is one the physician can make at the time of the visit, the assessment will include that information. An example would be an assessment of "eczema" when the physician can clearly see this condition on the patient. If the physician must access certain test results before she can make a definitive diagnosis, the assessment might list "possible pneumonia" while the physician waits to see the patient's chest x-ray to make a definitive diagnosis.

Plan

the healthcare provider's prescribed plan of action, which includes any prescriptions, tests, instructions, or referrals to other providers or therapies. This section will include any information about both prescription and over-the-counter medications, herbal remedies, or diet plans the physician has recommended for the patient.

tradeoff is security

there's a tradeoff to having easily available information. The free flow of information means an increased risk of personal data and medical details being intercepted. As long as the potential risks of electronically transferred data are managed, technology provides enhanced health information management and information sharing.

Electronic health record is a medical record which exists entirely in electronic form.

true

The use of information technology to improve quality, safety, efficiency, and confidentiality of healthcare through simultaneous access to patient health information by multiple healthcare providers is known as health information exchange.

true

electronic signature

typically used as a generic term that encompasses all the ways that that an electronic record can be signed. Depending on the software in use, e-signatures can be entered by clicking on an "I Agree" button, writing one's actual signature on an electronic tablet, or by entering a secret code or PIN when entering documentation. In offices where medical notes are dictated and printed for patient files, an electronic signature or rubber-stamp signature may replace handwritten signatures. In these offices, there must be a permanent record of the signer, as well as an original version of the signature on file.

Risk management departments

use medical records to determine if the standard of care has been met. The standard of care states that a healthcare provider must use reasonable and necessary skills when caring for patients, the same care another provider with the same training would use in the same circumstances. The best defense against malpractice claims is well-kept, accurate medical records. Some civil cases have held healthcare providers liable for their failure to maintain proper records.

Growth charts

used for documenting a child's weight, length, and head circumference. Again, you will not be filling in a growth chart, but be prepared to answer patients' questions regarding them.

Communication Among Staff Members

when one member of the staff needs to communicate with another staff member about a particular patient. An example would be a patient who has an outstanding balance owing in the medical office. The billing staff member may need to see the patient when they come into the office for their visit with the physician. Using the EHR, the billing staff member can post an alert that the medical office professional will see when they check in the patient. The alert allows the billing staff member to have the medical office professional direct the patient to the billing office prior to their visit with the physician.

A late entry into a health record should

would be added to supply additional information that was left out or not documented originally. the date of entry, the signature or initials of the person making the change, and the reason for the change should be included.