Records Management – MA Book – Chapter 13

Medical Records
Legal documents – spelling counts;
Patient History;
Family history;
Religious beliefs;
Ethnic beliefs;
Cultural beliefs
Charting
Progress notes
EHR
Electronic Health Records
EMR
Electronic Medical Records
Electronic Health Records
Contains insurance and medical history
Electronic Medical Records
Contains medical history (diagnosis, treatment, etc.)
Medicaid and Medicare
Controlled by CMS
CMS
Center for Medicare and Medicaid Services
Meaningful Use
Governed by CMS;
If doctor accepts a patient, at the end of the year the office will receive an “incentive bonus”
Certified MA can
Order labs;
Phone in prescriptions;
Order X-Rays
Parts of a medical record
Administrative data;
Financial and insurance information;
Correspondence;
Referral;
Past medical records;
Clinical data;
Progress notes;
Diagnostic information;
Lab information;
Medications
Subjective Information
What the patient states
Objective Information
What is found
Progress notes
documents the progress of the patient;
contains chief complaint
Chief Complaint (CC)
the main reason for seeking medical care
Two popular charting methods
POMR;
SOAP
Problem-Oriented Medical Record
POMR
POMR
Begins with the standard database information; then lists chronic problems with dates of service for each problem; last medication lists, preventative lists, and education information given to the patient.
Subjective-Objective Assessment Plan
SOAP
SOAP
Subjective impressions;
Objective clinical evidence;
Assessment or diagnosis;
Plans for further studies, treatment, or management
CHEDDAR
Chief Complaint;
History;
Examination;
Details of problems and complaints;
Drugs/Dosages;
Assessment;
Return visit
When to use CHEDDAR
To ensure you’ve charted with needs to be charted
History Physical Impression Plan
HPIP
HPIP
History (subjective findings);
Physical exam (objective findings);
Impression (assessment/diagnosis);
Plan (treatment)
Health Insurance Portability and Accountability Act
HIPAA
HIPAA
Legal requirements regarding patient privacy rights
Steps for proper records
1. Read accurately and spell names correctly
2. Print or write legibly with black ink
3. Record information as soon as possible
4. Make corrections by drawing one line through the error
5. Keep charts neat and file in a timely manner
Filing systems
Chronological
Alphabetically
Numeric
Subject
Steps in filing
1. Inspect
2. Index
3. Code
4. Sort
5. Store
Inspecting
Look for anything abnormal in the reports
Indexing
Categories
Coding
Index identifier
Sorting
After it is coded, put it in order
Storing
Put it away
Outguide
Patient’s Name
Patient’s Address
Patient’s DOB
Who has patient’s record
Purge
To clean out
Unit (when indexing)
One (patient) name
Last name
Surname
Review of Symptoms
ROS
Who do records belong to?
The office