MA 40 Ch. 14 Med Record Ch. 16 Med Docs

AHDI

Association for healthcare documentation integrity

As MT you can not divulge information to whom without consulting risk management personnel

Attorney or insurance rep.

Steps for filing

Inspect, index, code, sort, file

Steps for filing medical documentation

Inspect, index, code, sort, file.

POMR is most commonly used amongst what practitioners?

Internest, family practice, pediatrics because see patients for a long period of time.

Titles are considered as what indexing units

Separate indexing units. If title appears with first and last name, it is then the last indexing unit. Example: Dr. Marlene Elaine Smith Example: Unit 1 Smith, Unit 2 Marlene, unit 3 Elaine, Unit 4 Dr.

Filing Chart Data

Types of reports: Clinical notes, correspondence, laboratory reports, misc.

Three types of primary file cabinets

Vertical, lateral and movable.

Microscopic examinations

Viewing a specimen with the aid of a microscope, results are put in pathology report.

Permanently kept files

X-Ray, laboratory, personal & professional records. Appointment books. insurance records,

Alphabetic Card File

card that contains name, address and file number. any cross-reference is here. manual filing system.

Source-Oriented Medical Record (SOMR)

chart system that groups information according to its source, such as laboratory reports, pathology reports, and progress notes.

History of the present illness (HPI)

chronological description of patient illness.

Active files

current patient

Forms included in patient records are

demographics, social and family medical history, previous surgeries, HIPPA guidelines, release of information form.

HIPAA

determines who can have access to your records.

Movable file units

easy access to large record systems and require less space than vertical or lateral files. Can be electronically or manually moved.

Manual record Advantages

established and understood. easier to protect. no worry computer malfunction.

Straight numeric filing

filing places charts in exact chronological order according to assigned number. Example. 10,11,12

Key Unit

first indexing unit of the filing segment

What is miscellaneous numeric file section used for

for records that have not been assigned a number yet. placed in front of all numeric numbers.

Inactive files

haven't been seen for 3 years or more

Steps for cross referencing

identify primary filing label. make proper primary location file. identify alternatives for finding file. make cross-reference card.

Discharge Summaries TAT

if patient dies, it is called a death summary. must be filed within 48 to 72 hours.

Accession Record

is a journal (or computer listing) where numbers are preassigned. each entry will have a number.

If there is no record of treatment then,

it did not happen

Office equipment keep time

kept until warranties are no longer valid.

Patients are allowed access to their medical records and can ask for certain information to be added or excluded

True

True or false. POMR associates symptoms and problems with a number.

True

risk management personnel should be considered first before divulging files to an attorney or insurance representative. true or false

True

Out Guide

card stock or plastic sheet kept in place when chart is removed. has record of who has and when chart was removed, where it can be located.

Transcribing radiology or imaging reports

date must be of date of service, not date of dictation.

Health Insurance Portability and Accountability Act (HIPAA)

law that put in place policies and actions to protect all patient information.

Subject filing is used when

research, specific diseases, frequently used services.

Double Caption Alphabetizing

Ab - Cd

What is the most essential to patient care records

Accuracy

What is used when names are identical

Address is used, and alphabetizing by name or person or store, then name of street. alphabetize by store or person, then street name, then city, then state. if all above is same, order by street number.

Checkout System

A record of when the chart was removed or Where the chart can be located

Guides

Described by the position of tab, and location. Used in the vertical and lateral filing system.

Electronic Medical Record (EMR)

Electronic medical records are used to store e files of patient documents within a single facility, office, pharmacy and so on.

Release Marks

Date stamp, initials, check mark on every document so it can be filed.

History of present illness

HPI. chronological description of patients illness, past medical and surgical, family, social history.

H& P Report

History and physical report. documents information relating to the patient's main reason for the treatment and encounter as well as synopsis of previous medical information. Is divided into two sections; History and ROS. Needs to be filed within 24 hours.

Chart notes/ Progress notes

concise description of the patients encounter with the medical clinic. present problems, findings, and treatment plan. should be filed within 24 hours. They are chronologically listed and may include in-person visits to inquiries.

Outsourcing

contracting with a service outside of the clinic or hospital to a company where the task can be accomplished at a lower cost and with a faster turnaround time

Tickler date is

date when action should be taken.

Closed file

deceased or 7 years plus absence

Before any information is released from patients medical record, the patient must be

the patient be notified and written approval received. Includes the reason for release and what specific information is requested.

What does medicare and joint commission guidelines require for signature on medical reports

they need to be completed by provider dictating the information and not delegated to anyone else.

Problem-Oriented Medical Record (POMR)

type of patient chart where patient medical problems are identified by a number that corresponds to the charting; for example, bronchitis is #1, a broken wrist is #2, and so forth

Authentication

type of signature that may use various computer key entries as identification. when provider signs it to indicate that all is accurate and complete.

Tickler File

A reminder note added to a file to notify that there is still a remaining task to be done. Should be reviewed daily or weekly.

Old or aged reports TAT

48 to 72 hours or less.

Requesting medical records TAT from facility

7 to 10 business days

TAT reports

7 to 10 business days. If pt needs immunization or whole medical records.

Unit

Identifies each part of a name. First, middle, last. Last Unit 1. First Unit 2. Middle Unit 3. Surnames unit 4. Hyphenated or ethnic is one unit.

which of the following best describes the primary use of cross reference filing

Identifying the location of a file

Single Caption Alphabetizing

A, B, C

AHDI accredits what credentials

CMT & RMT

What is the most common filing system used

Color Coding ??

STAT Report time line

within 2-4 hours Biopsy results.

Common transcribed reports

1. Chart notes and progress notes. 2. History and physical. examination reports. 3. Radiology reports. 4. Operative reports. 5. Pathology reports. 6. Consultations. 7. Discharge summaries. 8. Autopsy reports. 9. Correspondence

Radiology or imaging reports TAT

4 to 8 hours

File Folder cuts

1/5, 1/3, 1/2, full cuts.

A digital dictation system allows one to measure

10th or 100th of a minute

Inactive files are sent to outside storage within

2 to 3 years of being inactive

STAT reports TAT

2 to 4 hours

Case history of Minor records keep time

20 + years, must be kept until age of majority

ARRA

2009 American Reinvestment and recovery act. Incentives for physicians and hospitals to make transition to EMR

Current Reports TAT

24 hours or less. These are radiology, pathology, laboratory reports

Pathology report must be completed within how many hours

24 hours turn around, with copies given to provider

Closed files are kept until

3 to 6 years beyond statute of limitations

How many indexing units are in the name

3, First Middle Last. depending on the name.

Operative Reports

All surgery reports and notes.

Common filing techniques used in ambulatory care setting

Alphabetic, numeric, and subject

What is the Key to Organizing all files and charts

Alphabetizing filing system.

Transcribed reports include

Chart, progress notes. History and physical exams. Radiology, operative, pathology, Autopsy reports. consultations. discharge summaries. Correspondence.

common filing systems

Color coding, numeric, alphabetic

Old Reports or aged

Complete 48 to 72 hours or less last seen patient within 3 years or more

key Unit

First indexing unit of filing segment

Company name filing units

Kelso Medical Supply would be unitized by, 1. Kelso 2. Medical 3. Supply

Medical Transcriptionist Qualifications

MT needs 2 years minimum experience. CMT needs voluntary examination from AHDI. RMT needs graduation from CMT, MT with less than 2 years can apply.

Caption

Method of designating major sections of file folders. These are marked on tabs of guides. These are what sit in-between a file system. IE) A, B, Ab-Be

If a single letter is used as first name, you should

Put that single letter as the first name area. Example, J. Larson Unit 1: Larson Unit 2: J Unit 3: nothing.

Lateral Open shelf

Most popular manual patient record system. make quick retrieval files possible. used most often with color coded filing. locking capability.

a filing system that maintains patient anonymity is

Numeric filing system

What are the most popular manual patient record filing system.

Open Lateral filing system.

Risk management

Practices that keep the practice, its environment, and its procedures as safe for the patient as possible

The Purpose of Medical records are to

Provide Base management care. inter/intra office communication. patterns of patient needs. basis for legal information to protect. clinical data research.

Current Reports are defined as

Reports such as history and physical examinations that should be completed within 24 hours.

Difference between POMR and SOMR

SOMR groups info to source. quickly accessible, and chronological. POMR associates a problem source with a number per visit. Used for general medicine because they see their patients more often and longer. Difference: SOMR does not have a problem list

Operative Reports TAT

STAT

Turn Around Time for Reports

STAT Report. 2 to 4 hours. Current reports. 24 hours. Old reports or DS reports 48 to 72 hours.

Indexing Units

Selecting name, subject or number to file a record and determining the order of units and how they should be filed.

Types of numeric filing systems

Straight numeric, terminal digit, middle digit

SOAP/ SOAPER

Subjective Objective Assessment Plan Education Response

Vertical files

These are likely used for business records and document, and should include a locking device.

Medicare and the joint commission address the issue of electronic signatures on medical documents, that they must be signed only by provider. true or false?

True

Cross-Reference

a note in a file that directs to a specific record that may be filed under more than one name, subject or number.

Joint commission

accredits and regulates all policies, procedures of hospitals and clinics owned by hospital orgs.

When indexing identical names what is next used

address

What is reasonable period after death or closure of practice to get rid of files.

after notification to patient, 3 to 6 months determined by state regulation. destroy by burning or shredding.

Progress Note

aka chart note. A concise description of patients encounter with medical clinic. providers formal or informal notes about presenting problem, findings, assessment or plan for treatment.

Chart Note

aka progress notes. these are notes about presenting problem, findings and plan. similar to SOAP note

hyphenated, Ethnic or foreign languages are indexed as one unit. what rule is included

all spacing, punctuation and capitalizations are ignored. Example: Carlo Del Rio. Unit 1: Delrio Unit 2: carlo

Three major filing systems are commonly used in the ambulatory care setting

alphabetic, numeric, and subject, color coding, geometric

An electronic signature may be done through

alphanumeric computer key entries as ID. electronic writing device. Biometric system.

Autopsy reports TAT

also called autopsy protocol, necropsy report or medical examiner report. to determine the cause of death or to ascertain and confirm presence of disease Certain states require military time be used. must be placed in file within 72 hours and in report within 60 days.

Chief complaint

also known as present problem. a description of symptoms, problems or conditions that brought patient to clinic.

Pathology reports

any path reports that get sent to the pathologist and come back with results.

What can a patient ask for their medical record

ask for notes or information to be added to their files, and request that certain information be taken out.

What does AMRA do?

association of medical records administration. facilitate the alphabetic process in maintaining files in the medical clinic.

Vertical Files

cabinets that have pullout drawers, up and out. Used for business records and documents. should have locking device.

Purging

maintaining order in files by separating active from non active and closed files.

Open-shelf lateral file cabinets

make quick retrieval of files possible. most .popular manual patient record system

Respondeat Superior

meaning the provider-director or clinic manager is responsible for the wrongful acts of the MT working under his supervision

Confidentiality

means treating the patients medical information as private and not for publication

Pathology Report

medical report that tells of pathology findings during surgical procedure

Operative Report (OR)

medical report that tells of surgical procedure

Discharge Summary (DS)

medical reports that document hospitalization history, illness and plan of action for a patient.

Strict Chronological Arrangement

most recently charted materials to the top of the folder. Con: makes it difficult to access patient information from the past. Best for practices that see patients on a short term. Dietician, radiologist or PT.

Tickler file should include

name, tickler date, required action, additional info.

Reports must be

neat, accurate, complete

Electronic Medical Records Disadvantages

needs protection. Expensive to maintain. on site assistance IT. 12 wees staff training.

Manual record Disadvantage

one person use only. easily misplaced. storage space required. more error.

When are seniority or professional, academic listed.

only to distinguish identical names. Example: James Edward Brown Jr./ Sr.

Once you sign the release of information these third parties do not have to re ask for release if referred.

other doctors, insurance companies,

Miscellaneous

paperwork not related to direct treatment

Auditor

person responsible for determining the final content

Filing Letters

personal letter with hotel Letterhead need to index signature. Company Letter head and president signature, index company name. letter with no letterhead, no firm and material not relevant to patient. Index signature. Letter with firm and not related to patient. index company name.

medical transcriber

responsible for transforming written or dictated medical information into an accurate, permanent document that is legible and uniform in format

document stored in the medical record are stored in

reverse chronological order, most recent first.

Review of systems (ROS)

review of systems directly related to the problems from history of present illness.

Advantage for Numeric filing

preserves patient information. most commonly used numeric are straight and terminal digit system.

Quality Assurance (QA)

process to provide accurate, complete, consistent health care documentation in timely manner while minimizing errors.

Medical documents may be reviewed by

providers, attorneys, insurance companies, court, military

Retention and Purging

record purging, active files, inactive files, closed files.

Tickler Files

reminder files that are a reminder that something needs to be fulfilled in the future. Info needed: Patient name Tickler date (when action should be taken) Required action (e.g., schedule surgery or mail reminder) Additional relevant information (telephone number)

Indexing

selecting the name, subject, or number to file a record and determining the order

the purpose of the medical record is to

serve as a legal record documenting the planning and care that a patient receives

Correction of a document looks like

single line drawn with red ink, write Corr above area and initial with date.

Terminal digit filing

six digit number used with hyphens. primary unit is last two numbers. secondary unit is middle numbers. third unit is first units.

When is tab alpha system used

small clinics that use vertical files and all charts are visible. only full cut folders are used.

Chief Complaint

specific symptoms or problems for which the patient is seeing provider.

Turn around time

specific time period in which document is expected to be completed from received to transcript and in record.

Voice Recognition software

speech recognition, automatic speech recognition (ASR), or natural language recognition software, converts voice to text using a computer

Voice Recognition software is also known as

speech recognition, automatic speech recognition or natural language recognition software.

confidentiality agreement

stating that you will comply with the established procedures. Your contracts, together with the protocols, become a part of the institution's documentation.

Pathology report is generated to describe

the gross an microscopic examinations performed on organs, lesions, tissue and fluid removed during surgery.

Married Names rule for indexing units is

the name is always indexed by the legal name. example: Amy Sue Sung (Mrs. John) Example: unit 1 sung, unit 2 amy, unit 3 sue, unit 4 mrs john.

When are exact names filed when one has numeric and one has seniority name

the numeric is filed before seniority.

What is privileged information

this may only be communicated with the patients permission or by court order.

Who's property are medical records

those who create them, but the information inside belongs to the patient and it must be protected.

clinical notes

track patients course of treatment

Medical records are governed by the laws and may be subpoena for review by courts true or false

true

Financial records keep time

up to 3 years then placed in inactive storage permanetly

When is alpha Z system used

used with open lateral or vertical files. these are used as primary guides. 13 colors are used. typed name, color block for first letter of first unit. then color block to second and third letters of last name.

Gross Examination

viewing specimen with the naked eye. Part of the pathology report that describes the size and shape of a biopsy specimen.

POMR

vital identification data, immunizations, allergies, medications, problems. used by internist, family practitioners, peds.

Flag indicated

when MT cannot interpret or something can't be referenced, has question. section of document needs to be corrected or resolved.

Consultation Report TAT

when one provider request the service of another provider for treatment of a patient. Filed within 24 hours.

Current Reports

within 24 hours or less progress notes, lab reports, current.

Chart Notes/Progress notes TAT

within 24 hours.

Patient Charts Include

Demographics. social medical and family history. previous surgeries. Hippa Guidelines and signatures. Release of information details.