1 copyright © 2011, 2007, 2003, 1999 by saunders, an imprint of elsevier inc. all rights reserved....

1Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Paper Medical RecordThe Paper Medical Record

Chapter 14


IntroductionIntroduction

Medical records management systems are only as Medical records management systems are only as good as the ease of retrieval of the data in the good as the ease of retrieval of the data in the files.files.

Organization and adherence to set routines will Organization and adherence to set routines will help to ensure that medical records are accessible help to ensure that medical records are accessible when they are needed.when they are needed.


This chapter will examine:This chapter will examine:

Reasons for keeping accurate recordsReasons for keeping accurate records Ownership of recordsOwnership of records Differences among types of recordsDifferences among types of records Differences among types of informationDifferences among types of information Making corrections in the recordMaking corrections in the record Filing procedures and systemsFiling procedures and systems Forms found in medical recordsForms found in medical records


Why Medical Records Are ImportantWhy Medical Records Are Important

Assist the physician in providing the best Assist the physician in providing the best possible care to the patientpossible care to the patient

Offer legal protection to those who provide care Offer legal protection to those who provide care to the patientto the patient

Provide statistical information that is helpful to Provide statistical information that is helpful to researchersresearchers

Vital for financial reimbursementVital for financial reimbursement


Ownership of the Medical RecordOwnership of the Medical Record

The maker, who initiated and developed the The maker, who initiated and developed the record, owns the physical medical record.record, owns the physical medical record.

The maker can be a physician or a medical The maker can be a physician or a medical facility.facility.

Patients have a right of access to the Patients have a right of access to the information in the record.information in the record.


Medical records must be kept confidential and Medical records must be kept confidential and in a secured, locked location. in a secured, locked location.

The record should never leave the medical The record should never leave the medical facility in which it originated. facility in which it originated.

Points to RememberPoints to Remember


Creating an Efficient Medical Creating an Efficient Medical Record SystemRecord System

The system should:The system should: provide for easy retrievalprovide for easy retrieval be organized and orderlybe organized and orderly contain information that is completely legiblecontain information that is completely legible contain accurate informationcontain accurate information show information that is easily understood and show information that is easily understood and

grammatically correctgrammatically correct


Types of RecordsTypes of Records

Paper-based medical recordsPaper-based medical records Computer-based medical recordsComputer-based medical records


Disadvantages of Paper-Based Disadvantages of Paper-Based Medical RecordsMedical Records

Only one person can use the record at a time, Only one person can use the record at a time, unless multiple people are crowding around the unless multiple people are crowding around the same record.same record.

Items can be easily lost or misfiled or can slip Items can be easily lost or misfiled or can slip out of the record if not securely fastened.out of the record if not securely fastened.

The record itself can be misplaced or be in a The record itself can be misplaced or be in a different area of the facility when needed.different area of the facility when needed.


Advantages of Computer-Based Advantages of Computer-Based Medical RecordsMedical Records

More than one person can use the record at a More than one person can use the record at a time.time.

Information can be accessed in a variety of Information can be accessed in a variety of physical locations.physical locations.

Records can often be accessed from another Records can often be accessed from another city or state.city or state.

Complete information is often available in Complete information is often available in emergency situations.emergency situations.


Organization of the Medical RecordOrganization of the Medical Record

Source-oriented recordsSource-oriented records Problem-oriented recordsProblem-oriented records


Source-Oriented Medical RecordsSource-Oriented Medical Records

Traditional method of keeping patient recordsTraditional method of keeping patient records Observations and data are cataloged according Observations and data are cataloged according

to their sourcesto their sources Forms and progress notes are filed in reverse Forms and progress notes are filed in reverse

chronological orderchronological order Separate sections are established for laboratory Separate sections are established for laboratory

reports, x-ray films, radiology reports, etc.reports, x-ray films, radiology reports, etc.


Problem-Oriented Medical RecordsProblem-Oriented Medical Records

Divides records into four bases:Divides records into four bases:1.1. DatabaseDatabase2.2. Problem listProblem list3.3. Treatment planTreatment plan4.4. Progress notesProgress notes

Courtesy Bibbero Systems, Petaluma, Calif.


DatabaseDatabase

Includes:Includes: Chief complaintChief complaint Present illnessPresent illness Patient profilePatient profile Review of systemsReview of systems Physical examinationPhysical examination Laboratory reportsLaboratory reports


Problem ListProblem List

Numbered and titled list of every problem the Numbered and titled list of every problem the patient has that requires treatmentpatient has that requires treatment

May include social and demographic troubles May include social and demographic troubles as well as medical and/or surgical notesas well as medical and/or surgical notes


Treatment PlanTreatment Plan

Includes:Includes: ManagementManagement Additional workups neededAdditional workups needed TherapyTherapy

Each plan is titled and numbered with respect to Each plan is titled and numbered with respect to the problem.the problem.


Progress NotesProgress Notes

Structured notes are numbered to correspond Structured notes are numbered to correspond with each problem number.with each problem number.

Progress notes follow the SOAP approach.Progress notes follow the SOAP approach.


SOAP Approach to Progress NotesSOAP Approach to Progress Notes

SOAP acronymSOAP acronym

S—Subjective impressionsS—Subjective impressions

O—Objective clinical evidenceO—Objective clinical evidence

A—Assessment or diagnosisA—Assessment or diagnosis

P—Plans for further studies, treatment, or P—Plans for further studies, treatment, or managementmanagement

Optional E—Evaluation or educationOptional E—Evaluation or education

R—ResponseR—Response


CHEDDARCHEDDAR

C—Chief complaintC—Chief complaint H—HistoryH—History E—ExaminationE—Examination D—Details (of problem and complaints)D—Details (of problem and complaints) D—Drugs and dosagesD—Drugs and dosages A—AssessmentA—Assessment R—Return visit R—Return visit


Contents of the Complete Case HistoryContents of the Complete Case HistorySubjective InformationSubjective Information

Patient’s full namePatient’s full name Parents’ names, if a childParents’ names, if a child SexSex Date of birthDate of birth Marital statusMarital status Spouse’s nameSpouse’s name Number of childrenNumber of children Social Security numberSocial Security number Driver’s license numberDriver’s license number

Home address and Home address and phonephone

Email addressEmail address Occupation and employerOccupation and employer Business address and Business address and

phonephone Healthcare insurance Healthcare insurance

informationinformation Spouse’s employment Spouse’s employment

informationinformation Source of referralSource of referral


Personal and Medical HistoryPersonal and Medical History

Often obtained by patient questionnaireOften obtained by patient questionnaire Provides information about any past illnesses or Provides information about any past illnesses or

surgical operationssurgical operations Explains injuries or physical defectsExplains injuries or physical defects Information about the patient’s daily health Information about the patient’s daily health

habitshabits Information about allergies, advance directives, Information about allergies, advance directives,

living wills, and so onliving wills, and so on


Patient’s Family HistoryPatient’s Family History

Physical condition of members of the patient’s Physical condition of members of the patient’s familyfamily

Past illnesses and diseases family members Past illnesses and diseases family members may have experiencedmay have experienced

Record of causes of family members’ deathsRecord of causes of family members’ deaths


Patient Information FormPatient Information Form


Patient’s Social HistoryPatient’s Social History

Information about the patient’s lifestyleInformation about the patient’s lifestyle Alcohol, tobacco, and drug use historyAlcohol, tobacco, and drug use history Marital informationMarital information Psychological informationPsychological information Emotional information, if pertinentEmotional information, if pertinent


Patient’s Chief ComplaintPatient’s Chief Complaint

Nature and duration of pain, if anyNature and duration of pain, if any Time when the patient first noticed symptomsTime when the patient first noticed symptoms Patient’s opinion as to the possible causes of Patient’s opinion as to the possible causes of

the difficultiesthe difficulties Remedies that the patient may have applied or Remedies that the patient may have applied or

triedtried Whether the patient has had the same or similar Whether the patient has had the same or similar

condition in the pastcondition in the past Past medical treatment for the same conditionPast medical treatment for the same condition


Pain ScalePain Scale

““How bad is your pain on a scale of 1 to 10, How bad is your pain on a scale of 1 to 10, with “1” being like a mosquito bite and “10” with “1” being like a mosquito bite and “10” being the worst pain you have ever being the worst pain you have ever experienced?”experienced?”


Objective InformationObjective Information

Objective findings, often called Objective findings, often called signs,signs, are are gained from the physician’s examination of the gained from the physician’s examination of the patient.patient.


Objective InformationObjective Information

Physical examination and findingsPhysical examination and findings Laboratory and radiology reportsLaboratory and radiology reports DiagnosisDiagnosis Treatment prescribed Treatment prescribed Progress notesProgress notes Condition at the time of termination of treatmentCondition at the time of termination of treatment


DiagnosisDiagnosis

ProvisionalProvisional DifferentialDifferential FinalFinal


Obtaining the HistoryObtaining the History

Histories may be obtained by:Histories may be obtained by: Patient questionnairePatient questionnaire Medical assistant asking the patient questionsMedical assistant asking the patient questions Physician asking the patient questionsPhysician asking the patient questions Combination of questionnaire and questionsCombination of questionnaire and questions


Medical Assistant’s Role When Medical Assistant’s Role When Taking the Patient HistoryTaking the Patient History

Take the history in a physical location that Take the history in a physical location that ensures patient confidentiality.ensures patient confidentiality.

Ask open-ended questions.Ask open-ended questions. Obtain details of the patient’s condition and Obtain details of the patient’s condition and

symptoms.symptoms. Keep all information about the patient Keep all information about the patient

confidential.confidential.


AuthenticationAuthentication

For a chart to be admissible as evidence in court, For a chart to be admissible as evidence in court, the person dictating or writing the entries must be the person dictating or writing the entries must be able to attest that they were true and correct at able to attest that they were true and correct at the time they were written.the time they were written.

This is “authentication” and is best done by This is “authentication” and is best done by initialing entries made to the medical record.initialing entries made to the medical record.


Making Additions to the RecordMaking Additions to the Record

Place the most recent information on top.Place the most recent information on top. Physicians should read and initial reports before Physicians should read and initial reports before

they are filed.they are filed. Some offices direct only abnormal reports to the Some offices direct only abnormal reports to the

physician.physician. Follow the office policy as to which method is Follow the office policy as to which method is

used in that particular office.used in that particular office.


Laboratory ReportsLaboratory Reports

Often on different colors of paper for easy Often on different colors of paper for easy reference.reference.

May need to be attached to standard-sized May need to be attached to standard-sized paper.paper.

Reports may be shingled, if necessary.Reports may be shingled, if necessary.


Laboratory Reports Laboratory Reports



Radiology ReportsRadiology Reports

Usually typed on standard-sized stationery.Usually typed on standard-sized stationery. Place in reverse chronological order, with the Place in reverse chronological order, with the

most recent report on top.most recent report on top. Medical records often have a separate section Medical records often have a separate section

for laboratory and radiology reports.for laboratory and radiology reports.


Progress NotesProgress Notes

Continually added to the medical record.Continually added to the medical record. Must list each patient visit and any notations Must list each patient visit and any notations

about the visit.about the visit. Instructions, prescriptions, and telephone calls Instructions, prescriptions, and telephone calls

for advice should be noted in the progress for advice should be noted in the progress notes.notes.

Always initial entries in progress notes.Always initial entries in progress notes.


Making Corrections and Making Corrections and Alterations to Medical RecordsAlterations to Medical Records

First, verify the correct procedure as detailed in First, verify the correct procedure as detailed in the policy and procedure manual.the policy and procedure manual.

Never use correction fluid, erasers, or any other Never use correction fluid, erasers, or any other type of obliteration methods.type of obliteration methods.

Do not mark through information to obliterate it.Do not mark through information to obliterate it. Do not hide errors.Do not hide errors. If errors could affect the health and well-being of If errors could affect the health and well-being of

the patient, bring it to the physician’s attention the patient, bring it to the physician’s attention immediately.immediately.


Correcting an ErrorCorrecting an Error

Three StepsThree Steps1.1. Draw one line through the error.Draw one line through the error.

2.2. Insert the correction above or immediately after the Insert the correction above or immediately after the error.error.

3.3. In the margin, write “correction” or “corr” and initial the In the margin, write “correction” or “corr” and initial the entry, if indicated by the office policy and procedure entry, if indicated by the office policy and procedure manual.manual.


Correcting Electronic RecordsCorrecting Electronic Records

If an error is made while typing, simply If an error is made while typing, simply backspace and correct the error.backspace and correct the error.

If the error is discovered later, make an If the error is discovered later, make an additional entry (addendum) with corrected additional entry (addendum) with corrected information. information.

Do not delete or change previous entries on Do not delete or change previous entries on electronic records.electronic records.


Keeping Records CurrentKeeping Records Current

Records must be methodically kept current.Records must be methodically kept current. Do not allow histories and reports to accumulate Do not allow histories and reports to accumulate

for long before filing them.for long before filing them. The patient’s health is jeopardized when The patient’s health is jeopardized when

current, accurate records are not available to current, accurate records are not available to the physician.the physician.

Remember that the physician bases his or her Remember that the physician bases his or her decisions on the information in the patient’s decisions on the information in the patient’s medical record.medical record.


PrescriptionsPrescriptions

Some prescription pads are printed on NCR Some prescription pads are printed on NCR paper, which automatically makes a copy for the paper, which automatically makes a copy for the medical record.medical record.

All prescriptions must be noted in the medical All prescriptions must be noted in the medical record, including refills called in to the patient’s record, including refills called in to the patient’s pharmacy.pharmacy.


Classifications of Records in the Classifications of Records in the Physician’s OfficePhysician’s Office

Active filesActive files patients currently receiving treatmentpatients currently receiving treatment

Inactive filesInactive files patients who have not been seen for about 6 months patients who have not been seen for about 6 months

to a year.to a year. Closed filesClosed files

patients who have died, moved away, or otherwise patients who have died, moved away, or otherwise discontinued treatmentdiscontinued treatment


Transfer of RecordsTransfer of Records

Follow office policies regarding transferring Follow office policies regarding transferring medical records from active to inactive or closed medical records from active to inactive or closed categories.categories.

This process is called “purging.” This process is called “purging.”

Files may need to be physically rearranged to Files may need to be physically rearranged to accommodate transfers.accommodate transfers.


Retention and DestructionRetention and Destruction

Most physicians keep medical records for 10 Most physicians keep medical records for 10 years at a minimum.years at a minimum.

Some records may warrant longer retention Some records may warrant longer retention periods.periods.

Records for minor patients should be kept for at Records for minor patients should be kept for at least 3 years after he or she reaches legal age.least 3 years after he or she reaches legal age.

Use year stickers on patient files.Use year stickers on patient files.



Follow local, state, and federal guidelines for Follow local, state, and federal guidelines for retention and destruction of records.retention and destruction of records.

HIPAA does not specify medical record HIPAA does not specify medical record retention requirements.retention requirements.

In most cases, keep medical records at least as In most cases, keep medical records at least as long as the length of time of the statute of long as the length of time of the statute of limitations for medical professional liability limitations for medical professional liability claims.claims.



Medicare and Medicaid patient records must be Medicare and Medicaid patient records must be kept for at least 6 years.kept for at least 6 years.

Keep records on patients who are deceased for Keep records on patients who are deceased for at least 2 years.at least 2 years.

Follow office policies for record retention and Follow office policies for record retention and destruction.destruction.


Releasing Medical Record InformationReleasing Medical Record Information

Requests must be made in writing for release of Requests must be made in writing for release of records.records.

Patients must sign an authorization for release Patients must sign an authorization for release of medical records.of medical records.

Patients can revoke previously signed Patients can revoke previously signed authorizations for release of records.authorizations for release of records.

Release only records that are specified on the Release only records that are specified on the request.request.


Releasing Medical Record Information Releasing Medical Record Information



Filing EquipmentFiling Equipment

Various types of equipment are available for Various types of equipment are available for storing medical records in today’s medical storing medical records in today’s medical offices.offices.


Considerations in Choosing Considerations in Choosing Filing EquipmentFiling Equipment

Office space availabilityOffice space availability Structural considerationsStructural considerations Cost of space and equipmentCost of space and equipment Size, type, and volume of recordsSize, type, and volume of records Confidentiality requirementsConfidentiality requirements Retrieval speedRetrieval speed Fire protectionFire protection


Types of Filing SystemsTypes of Filing Systems

Drawer filesDrawer files Shelf filesShelf files Rotary circular filesRotary circular files Lateral filesLateral files Compactable filesCompactable files Automated filesAutomated files Card filesCard files


Filing SuppliesFiling Supplies

Divider guidesDivider guides OUTguidesOUTguides OUTfoldersOUTfolders Files and foldersFiles and folders LabelsLabels



Filing ProceduresFiling Procedures

ConditioningConditioning ReleasingReleasing Indexing and codingIndexing and coding SortingSorting Storing and filingStoring and filing


Indexing RulesIndexing Rules

Last name first, then first name, then middle Last name first, then first name, then middle name or initial.name or initial.

Initials precede names beginning with the same Initials precede names beginning with the same letter.letter.

Hyphenated names are treated as one unit.Hyphenated names are treated as one unit. Apostrophes are disregarded.Apostrophes are disregarded.



Index each part of foreign names if confused as Index each part of foreign names if confused as to first and last names.to first and last names.

Names with prefixes are filed in regular Names with prefixes are filed in regular alphabetic order.alphabetic order.

Abbreviated parts of a name are indexed as Abbreviated parts of a name are indexed as written.written.



Name of a married woman is indexed by legal Name of a married woman is indexed by legal name.name.

Titles may be used as the last filing unit if Titles may be used as the last filing unit if needed to distinguish from another identical needed to distinguish from another identical name.name.

Terms of seniority are indexed only to Terms of seniority are indexed only to distinguish from an identical name.distinguish from an identical name.


Filing MethodsFiling Methods

AlphabeticAlphabetic NumericNumeric AlphanumericAlphanumeric SubjectSubject


Color-CodingColor-Coding

Almost all medical offices use some sort of Almost all medical offices use some sort of color-coding in their filing systems.color-coding in their filing systems.

Numeric color-coding provides a high degree of Numeric color-coding provides a high degree of patient confidentiality. patient confidentiality.


Color-Coding Color-Coding



Transitory or Temporary FilesTransitory or Temporary Files

Transitory or temporary files are used for Transitory or temporary files are used for materials having no permanent value.materials having no permanent value.

Materials in these files are kept there Materials in these files are kept there temporarily, usually until the document is dealt temporarily, usually until the document is dealt with and is no longer needed.with and is no longer needed.

Useful when seeing patients from another Useful when seeing patients from another geographic area who are not expected to return geographic area who are not expected to return to the office.to the office.


Summary of ScenarioSummary of Scenario

All duties performed in the practice are All duties performed in the practice are learning opportunities.learning opportunities.

Ask for additional responsibilities.Ask for additional responsibilities. Always be ready to assist a co-worker.Always be ready to assist a co-worker. Earn the trust of patients.Earn the trust of patients.


Closing CommentsClosing Comments

Advances in medical records occur rapidly.Advances in medical records occur rapidly. Be willing to learn.Be willing to learn. Adapt to changes.Adapt to changes. Keep a positive attitude.Keep a positive attitude.

1 copyright © 2011, 2007, 2003, 1999 by saunders, an imprint of elsevier inc. all rights reserved....

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