Medical Records Management

Medical Records

•Where should medical records be kept?

• How long are the records kept?

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

• The record should never leave the medical facility in which it originated, except for legal reasons.

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Points to Remember

Medical Record

• What is placed into the patient’s medical record?

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Ownership of theMedical Record

• Who owns the medical record?

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Ownership of theMedical Record

• Patients own the content and have a right of access to the information in the record.

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Authorization toRelease Information

• Patient must give written permission• 1 year time limit if not otherwise stated

• Only requested information may be released

• Released information never includes insurance or financial information

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Organization of theMedical Record

What are Source-Oriented Medical Records (SOMR)?

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Source-OrientedMedical Records (SOMR)

• Traditional method of keeping patient records.

• Information filed according to their sources– Separate sections for laboratory reports,

x-ray films, radiology reports, and so on.

• Forms and progress notes are filed in reverse chronologic order (newest on top).

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Organization of theMedical Record

What are Problem-Oriented Medical Records (POMR)?

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SOAP Notes

What do these stand for?• S• O• A• P

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SOAP Notes

• S – Subjective – what patient says

• O – Objective – what you see/hear

• A – Assessment – diagnosis

• P – Plan - treatment

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6 C’s of Charting

• Client’s own words• Clarity (Clear) • Completeness• Conciseness• Chronological order• Confidentiality

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Charting

• Can you chart for someone else?

• Why are we conscious of using correct medical terminology when charting?

• Why do we use correct grammar and punctuation?

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Charting

• How do you correct an error that you made while charting?

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Correcting a Medical Record

1. Draw a single line through error2. Make correction in chart above error3. Write “Corr” or “correction” in the

margin4. Date and initial

What is done for electronic records?

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Correcting Electronic Records

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

• If the error is discovered later, make an additional entry with corrected information.

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

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Equipment & Supplies

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Equipment & Supplies

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Outguides

Basic Rules for Filing

Which of these names is filled first in alphabetical order?

Patricia A. McColmPatricia H. McColm

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Basic Rules for Patient Filing

Rule 1: Last name, first name, middle name

Example: 1 2 3 Obama Barack Hussein

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Basic Rules for Filing

Rule 2: Initial used as a legal name is filed as a name

Example: 1 2 3 Eliot, T. S. Elliott T. S.

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Basic Rules for Filing

Rule 3: Foreign prefixes or abbreviations become one unit with the last name

Example: 1 2 3Lisa M. Del Vecchio Delvecchio Lisa MJill A. St. John Stjohn Jill

A

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Basic Rules for Filing

• Rule 4 – Hyphenated names are considered one unit George M. Andrews-Scott becomes

1 2 3Andrews-Scott George M

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3 Major Filing Methods

1. Alphabetic – What is it?2. Numeric – What is it?3. Subject – What is it?

Color Coding (used in all 3 major systems)◦ Each letter is assigned a different color◦ Each folder given a color-coded label◦ Only full-cut folders are used

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Tickler File

• What is it?

• How does a computer do this?

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Project 3

There are two parts to this project.

Part 1 – Due in Unit 6•Medical Records Essay – 40 points • Filing – 15 points

Part 2 – Due in Unit 7• HIPAA Essay – 40 points

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Download the following from the Unit 6 folder of Doc Sharing:• Medical Records Filing Template• Rubric for Project 3

Please be sure to view the instructions for Project 3 in the PowerPoint presentation located in the Unit 6 folder of Doc Sharing.

Project 3

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Use the template! Download the template and rubric from the Unit 6 folder in Doc Sharing.

When you answer each question on the template, • Use APA formatting (double space, size 12 Times

New Roman font)• Add a reference citation • Write a minimum of 300 words total for all three questions.• Do not use contractions (I’ve, can’t).

Please use spell check and make corrections before you submit!

Project 3 – Part 1: Essay

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Project 3 – Part 1: Essay Answer the following questions in essay form (minimum

300 words total):1. Why do medical records exist? (Explain four

reasons. See Chapter 14, page 251 of your text.) 2. Discuss the advantages and disadvantages of establishing and maintaining electronic health records (EHRs). (See Chapter 14, page 252 of your text.)

3. Discuss and explain the five basic filing steps. Include why each is important (conditioning, releasing, indexing, etc.). These are in Chapter 14, pages 271 and 272 of your text.

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Project 3 – Part 1: Filing

Download and use the template!

List the names • in alphabetical filing order• last name, first name, middle

name/initial

Do not change the spelling of the names.

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Project 3 – Part 2: HIPAA Essay

Answer the following question in essay form (minimum 300 words):

Question: Explain how HIPAA Privacy Rules benefits the

healthcare industry, patient, and physician.

This essay is due by midnight Tuesday of Unit 7.

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When you answer this question, • Use APA formatting (double space, size 12 Times

New Roman font).• Add at least two reference citations. (Your text and the HIPAA website) • Write a minimum of 300 words. • Do not use contractions (I’ve, can’t).• Include a title page.• Add a reference page.

Please use spell check and make corrections before you submit!

Project 3 – Part 2: HIPAA Essay

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• You will need to follow the link provided in the course: http://www.dhhs.gov/

• See Chapter 16 of your text for more information.

• Please be sure to state how HIPAA benefits all three of these:• The health care industry• The patient• The physician

Project 3 – Part 2: HIPAA Essay