Y khoa - Dược - Chapter 11: Medical records and documentation

11Medical Records and DocumentationLearning Outcomes (cont.)11.1 Explain the importance of patient medical records. 11.2 Identify the documents that comprise a patient medical record. 11.3 Compare SOMR, POMR, SOAP, and CHEDDAR medical record formats.11.4 Identify the six Cs of charting, giving an example of each.Learning Outcomes (cont.)11.5 Describe the need for neatness, timeliness, accuracy, and professional tone in patient records. 11.6 Illustrate the correct procedure for correcting and updating a medical record.11.7 Describe the steps in responding to a written request for release of medical records.IntroductionMedical assistants role regarding patient health recordsDocumentation Maintenance Medical records – critical to patient careEvaluation Management Treatment The Importance of Medical RecordsPast medical history and present conditionCommunication tool for healthcare team Legal documentation Patient and staff education Quality control and research Documentation for billing and codingImportance of Patient Records (cont.) General informationContact informationOccupationMedical historyCurrent complaintHealthcare needsTreatment plan or services providedRadiology and laboratory reportsResponse to careLegal Guidelines for Patient RecordsSupport a malpractice claimSupport defense for a malpractice claimBack up financial recordsDocumentationMedical care, evaluation and instructionsNoncompliant patientStandards for RecordsEvidence of appropriate careCompleteAccurateEveryone who documents in the patient record has a responsibility to the patient and physicianAdditional Uses of Patient RecordsPatient EducationQuality ofTreatmentResearchTest resultsHealth issuesTreatment instructionsPeer reviewTJC reviewHealth-careanalysis andpolicy decisionsSource of dataApply Your KnowledgeWhat is the purpose of documentation in a patient’s medical record?ANSWER: Documentation in the medical record provides evidence of appropriate care. If a procedure is not documented, it is considered not done.Good Job!Contents of Patient Medical RecordsPatient Registration Form Date Patient demographic information Age, DOB Address, phone number SSN Insurance/financial information Emergency contact Contents of Patient Medical Records (cont.)Patient medical historyPast medical historyFamily medical historySocial and occupational historyHistory of present illness (chief complaint)Contents of Patient Medical Records (cont.)Physical examination resultsReview of systemsForm ensures consistencyResults of laboratory and other testsDocuments from Other SourcesContents of Patient Medical Records (cont.)Doctor’s diagnosis and treatment planTreatment options and planInstructions Medication prescribedComments or impressionsOperative reports, follow-up visits, and telephone calls Contents of Patient Medical Records (cont.)Hospital discharge summary formsConsent formsVerify that the patient understands procedures, outcomes, and optionsPatient may withdraw consent at any timeCorrespondence with or about the patientInformation received by fax – request an original copyDate and initial everything you place in the chartContents of Patient Medical Records (cont.)Maintaining ConfidentialityThe right to notice of privacy practices. The right to limit or request restriction on their PHI and its use and disclosure. The right to confidential communications. Maintaining Confidentiality (cont.)4. The right to inspect and obtain a copy of  their PHI.5. The right to request an amendment to  their PHI. 6. The right to know if their PHI has been  disclosed and why.Apply Your KnowledgeWhat section of the patient record contains information about smoking, alcohol use, and occupation?ANSWER: Information about smoking, alcohol use, and occupation is part of the patient’s past medical history.Correct!Types of Medical RecordsSource-Oriented Medical Records Information is arranged according to who supplied the dataProblems and treatments are on the same formDifficult to track progress of specific eventsTypes of Medical Records (cont.)Problem-Oriented Medical Records Data BaseProblem List Each problem numberedSign vs. symptomAn Educational, Diagnostic, and Treatment Plan per each problemProgress NotesTypes of Medical Records (cont.)SOAP documentationOrderly series of steps for dealing with any medical caseLists the followingPatient symptomsDiagnosisSuggested treatmentSOAPInformation the patient tells you What the physician observes during the examinationThe impression of the patient’s problem that leads to diagnosisThe treatment plan to correct the illness or problemSOAP DocumentationSubjective dataObjective dataAssessment PlanCHEDDAR FormatExpands on SOAP formatCChief complaint, presenting problems, subjective statementsHistory – social and physical historyHExaminationDCHEDDAR FormatExpands on SOAP formatDDrugs and dosageAssessment of diagnostic process and diagnosisAReturn visit information or referralRApply Your KnowledgeLabel the following items as either (S) “subjective” or (O) “objective.”____ headache ____ pulse 72____ vomited x 3 ____ nausea____ skin color ____ respirations 16, labored____ chest pain ____ poor appetiteSOSSSOOOExcellent!Documenting and the Six Cs of ChartingUpdating medical formsDocumenting test resultsExamination Preparation and Vital SignsFollow-UpTranscribe notes the doctor dictatesPost results of laboratory tests and examinations Record telephone communication with the client Record all instructions and educationThe Six Cs of ChartingClient’s wordsClarityCompleteness C oncisenessChronological orderconfidentialityCApply Your KnowledgeWhat are the six Cs of charting?ANSWER: The six C’s of charting areClient’s words ConcisenessClarity Chronological orderCompleteness ConfidentialityApply Your KnowledgeIn addition to transcribing notes the doctor dictates and posting lab results, what are two other follow-up tasks the medical assistant might be required to perform as part of follow-up to a patient appointment?ANSWER: The medical assistant may have to record telephone calls with the patient, as well as medical or discharge instructions given to the patient.Right!Appearance, Timeliness, and Accuracy of RecordsNeatness and legibilityMedical transcriptionHandwritten notesBlue inkHighlight specific items such as allergiesMake corrections properlyTimelinessRecord all findings as soon as they are available For late entries, record both original date and current dateRecord date and time of telephone calls and information discussedRetrieve file quickly in event of an emergency Check information carefully Never guess or assume Double-check accuracy findings and instructions Make sure most recent information is recordedAccuracyProfessional Attitude and ToneRecord patient commentsDo not record personal or subjective comments, judgments, opinions, or speculationsYou may call attention to problems or observations by attaching a note to the chart, but do not make such comments part of medical record.Apply Your KnowledgeWhat is important to remember when you are documenting in the medical records?ANSWER: It is important that medical records be neat and legible, timely, accurate, and maintain a professional tone.Very Good!Correcting and Updating Medical RecordsMedical records are created in “due course”Information is entered at the time of occurrenceUntimely submissions may be regarded as “convenient” Using Care with CorrectionsCorrect mistakes immediatelyDraw a line through the original informationInsert correct informationDocument why correction was madeDate, time, and initial correctionHave a witness, if possibleerorm/d/yyyy 00:00pm misspelled JHCerror/chjUpdating Patient RecordsAdditions should not appear deceptiveDocument why late entry is madeDate and initial added items May have a third party witness additionAddition made to record because patient called back with additional information.Mm/dd/yyyy – JHC/ chjApply Your KnowledgeWhat is the appropriate way to correct an error in a patient’s medical record?ANSWER: To correct an error in a patient’s medical record: Draw a line through the original informationIt must remain legible Insert correct information above or below original line or in marginDocument why correction was madeDate, time, and initial correctionSuper Job!Responding to Release of Records RequestRecords are property of the practiceContain confidential PHI which belongs to the patientMust have patient’s written consent to releaseRelease of Informationto HMO Insurance CompanyI authorize Dr. J. Jones to release my health-care information to the above-named insurance company.Christopher Hansen mm/dd/yyyyPatient Signature DateProcedures for Releasing RecordsNew authorization to transfer records Verbal consent is not validFile in medical recordCopy original materials – only information requestedCall to confirm receipt of materialsProcedures for Releasing Records (cont.)Special casesNot always clear who can authorize releaseIf unsure, ask your supervisorConfidentiality18 years oldEmancipated minorMature minorLegal and ethical principle: Protect the patient’s right to privacy at all times.Auditing Medical RecordsExamination and review CompletenessAccuracyTypes Internal External Apply Your KnowledgeThe medical assistant receives phone call authorizing transfer of medical record information for a client to another physician’s office. What would you do in this situation?ANSWER: Never release information based on telephone authorization. You cannot be sure who the caller is. Tell them you need a written and signed release of information. In Summary11.1 Medical records are legal documents that give a complete, concise, chronological history of a patient’s past medical history, current medical issues, treatment plan, and treatment outcome. Additionally, they act as a communication tool between care providers. The patient medical record provides physicians and other healthcare providers with all the important information, observations, and opinions that have been recorded about a patient.In Summary11.2 The records that comprise the patient medical record include, but are not limited to the following: patient registration formmedical history formphysical exam formlaboratory and other test resultsrecords from physicians or hospitals, physician diagnosis and treatment planoperative reportshospital discharge summariesfollow-up notesrecords of telephone callssigned informed consentscorrespondence with or about the patientIn Summary (cont.)11.3 SOMR files documents in the medical record in strict chronological order. POMR files the same documents according to numbered problems found on the patient problem list. SOAP notes organize medical record documentation according to subjective, objective, assessment and plan. The CHEDDAR format breaks down this information even further into chief complaint, history, exam, details, drugs, assessment, and return visit plan.In Summary (cont.)11.4 The six Cs of charting are client’s words, clarity, completeness, conciseness, chronological order, and confidentiality. 11.5 Neatness, legibility, accuracy, and professional tone are musts in maintaining medical records. Remember that patient medical records are legal documents. Personal thoughts and observations should never be a permanent part of the patient medical record.In Summary (cont.)11.6 The proper way to make corrections in a medical record is to draw a single line through the error so that the original entry is still legible. Any additions to a medical record should also be made as soon as the need for the addition is noted, and the reason for the addition or change should also be clearly documented.11.7 In order to release any confidential medical information, express written permission from the patient must be received. Only release records that are expressly requested and authorized by the patient.Organization is the power of the day; without it, nothing is accomplished.~ Sophia PalmerFrom A Daybook for Nurses: Making a Difference Each DayEnd of Chapter 11