Chapter 8 Medical Records Management

OWNERSHIP OF MEDICAL RECORDS
Information belong to the patient and is protected with privacy and confidentially; Medical facilities generated large amount of information, greatest bulk info is from medical records
PURPOSE OF ACCURATE MEDICAL RECORDS
Are essential for patient cause:
• Maintain conscientious record of patient care
• Assist in controlling cost of medical care
• They are needed to provide referral for specialty care
• Cannot be released without patient’s knowledge. Patient has to have a signed released information.
AUTHORIZATION TO RELEASE INFORMATION
Even release of information required for a subpoena requires notification of patient
• Patient must sign a release form if information is given to others.
• May be yearly, when accepting insurance coverage, case-by-case basis
• Should be very specific in what information is and what information is NOT to be release
CORRECTING MEDICAL RECORDS-MANUAL RECORDS
Draw a single line using red pen through the error; the use of red pen may vary from office to office.
If it’s not in the chart, it never happened.
ELECTRONIC MEDICAL RECORDS
Likely to be used by solo practioners
POMR (PROBLEM-ORIENTED MEDICAL RECORDS)
Identifies problems numerically as listed by patients;
readily identifies frequency of recurring problems
NEAR USED SOAP/SOAPER
Soap – Subject Objective Assessment Plan
Soaper – Education for patient response at patient to education and care given
MOVEABLE FILE UNITS
Moveable units electronically powered;
used for offices with large record system
OUTGUIDES
Primary use is to indicate a chart has been removed;
filing tool used to tack a patient’s chart that has been removed from the storage area;
primary information is who has possession of the chart
FILING IDENTICAL NAMES
Names have Jr. Sr. II or III;
II or III is filed before Jr. or Sr.
NUMERIC
It is used in very large ambulatory care and hospital systems
ALPHABETIC FILING
One of the most simplest methods;
Used when a limited number of is accessed
NUMERIC FILING
Preserves patient confidentiality;
Has a straight terminal systems (chronological order);
Equally distributed files
CROSS-REFERENCING
Helps store files for quick and accurate retrieval; helps identify location of file
TICKLER FILES IN MANUAL SYSTEM OR CALENDAR IN EMRs
A reminder that actions needs to be taken;
Should contain: Patient’s name, Tickler date when action should be taken, required action, additional relevant information
FILING CHART DATA
• Most common document/types of reports
• Clinical notes
• Correspondence
• Laboratory reports
• Misc.
RECORD PURGING
Sorting through records and removing those not actively used
ACTIVE FILES
Current patient files that need to be readily accessible
PROGRESS NOTES
Documentation for each patient’s encounter
SHINGLING
taping the paper across the top to a regular-size sheet