Download Maintaining Patient Records - McGraw Hill Higher Education

PowerPoint® to accompany
Chapter 9
Medical Assisting
Chapter 9
Second Edition
Ramutkowski  Booth  Pugh  Thompson  Whicker
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
1
Maintaining Patient Records
Objectives
9-1 Explain the purpose of compiling patient medical
records.
9-2 Describe the contents of patient record forms.
9-3 Describe how to create and maintain a patient
record.
9-4 Identify and describe common approaches to
documenting information in medical records.
2
Maintaining Patient Records
Objectives (cont.)
9-5 Discuss the need for neatness, timeliness, accuracy,
and professional tone in patient records.
9-6 Discuss tips for performing accurate transcription.
9-7 Explain how to correct a medical record.
9-8 Explain how to update a medical record.
9-9 Identify when and how a medical record may be
released.
3
Maintaining Patient Records
Patient Records
Also known as charts
containing:
• Past and present
medical conditions
• Communications
between health
team members

• Name and address
• Insurance coverage
• Occupation
• Medical treatment plan
• Health-care needs
• Response to care
• Lab and radiology reports
The chart is a legal document and can play a role in patient and staff
education. It may also be used for quality control and research.
4
Importance of Patient Records
Legal Guidelines for
Patient Records
 As a general rule, if
information is not
documented, there is
no proof it was ever
done.
 Charts are used in
court.
Standards for Records
 Complete, accurate,
and well-documented
records can serve as
convincing evidence
that the doctor
provided appropriate
care.
 Incomplete, inaccurate,
altered, or illegible
records may imply
poor standards.
5
Importance of Patient Records
Patient Education
Quality of Treatment
Additional Uses of
Patient Records
Research
6
Contents of Patient Charts
Standard Chart Information

Patient Registration Form






Date of current visit
Demographic data (age, date of birth, SS#,
address, telephone number, marital status, etc.)
Medical insurance information
Emergency contact person
Family medical history
List of medical problems
7
Contents of Patient Charts
Standard Chart Information (cont.)

Past Medical History





Illnesses, surgeries, allergies, and current
medications
Family medical history
Social history (use of drugs and alcohol, cigarette
smoker, etc.)
Occupational history
Statement of current patient complaint recorded
in patient’s own words
8
Contents of Patient Charts
Standard Chart Information (cont.)

Physical Examination Results


Results of Laboratory and other Tests


Containing results of a general physical exam
Results from lab tests performed on patient
Records from other Physicians or Hospitals

Include along with these records a copy of the
patient consent authorizing release of information
9
Contents of Patient Charts
Standard Chart Information (cont.)

Doctor’s Diagnosis and Treatment Plan


Lists doctor’s diagnosis, medications prescribed,
and overall treatment plan
Operative Reports, Follow-Up Visits, and
Telephone Calls


A continuous record of all care provided to the
patient while under the doctor’s care
Also document calls made to and from the patient
10
Contents of Patient Charts
Standard Chart Information (cont.)

Informed Consent Forms



Signed consent forms show that the patient
understands procedure, outcomes, and options
Patient may still change his/her mind even after
signing the consent form
Hospital Discharge Summary Forms


Includes information summarizing the patient’s
hospitalization
Follow-up care after discharge is also included
and the physician signs it
11
Contents of Patient Charts
Standard Chart Information (cont.)

Correspondence With or About the Patient


All written correspondences regarding the patient
should be included
Be sure to record date each was received on the
actual form
Information Received by Fax
Dating and Initialing
Request an original copy, if not
available make a photocopy of
the fax.
Be sure to date and place
your initials on everything
you place in the chart.
12
Initiating and Maintaining
Patient Records
Completing Medical
History Forms
Documenting Test
Results
Initial
Interview
Examination Preparation
& Vital Signs
Documenting Patient
Statements
13
Initiating and Maintaining
Patient Records (cont.)

Follow-Up Duties




Transcribe notes the doctor dictates
Post results of laboratory and examinations
on summary sheet
Record all telephone communication with
the client
Record all medical or discharge
instructions given to the client
14
Apply Your Knowledge
The medical assistant is obtaining the initial
information from a patient. The patient informs
the medical assistant that he/she has used
intravenous drugs for the past 3 years. Which
section of the chart will this be recorded in?
15
Apply Your Knowledge -Answer
The medical assistant is obtaining the initial
information from a patient. The patient informs
the medical assistant that he/she has used
intravenous drugs for the past 3 years. Which
section of the chart will this be recorded in?
This should be recorded in the past medical history section. More
specifically under the social history section.
16
The Six Cs of Charting
hronological
lient’s wordsorder
larity
ompleteness
onciseness
onfidentiality
Be
and
use
accepted
medical
Fill
out
all
inthe
thethe
patient
Beprecise
asentries
brief
and
to
point
as
Date
in
order
they
Be
sure
toforms
record
the
client’s
exact
terminology
when
describing
a
record
completely
so
others
will
possible.
Use
medical
words
and
do
not
rephrase
his/her
All information
in consistency
patient record
occur.
This shows
with
patient’s
condition.
understand
your confidential
notations
and to
statements.
abbreviations
to
save
time.
must
be
kept
accurate documentation.
entries.
protect patient privacy.
17
Types of Medical Records
Source-Oriented
Medical Records




Also called conventional
Information is arranged
according to who supplied the
data
Problems and treatments are
described on the same form
Presents some difficulty with
tracking progress of specific
events
Problem-Oriented
Medical Records






(POMR) makes it easier to
track specific illnesses
Consists of:
Data base
Problem list
Educational, diagnostic, and
treatment plan
Progress notes
18
SOAP Documentation



Incorporated with POMR
Utilizes an orderly series of steps for dealing
with any medical case
Lists the following:



Patient symptoms
Diagnosis
Suggested treatment
19
SOAP Documentation
Plan of action consists of the treatment plan to correct the illness or problem.
Assessment is the impression of the patient’s problem that
leads to a diagnosis.
Objective data is data observed by the
physician during the examination.
Subjective data is
information the
patient tells you
about their
symptoms.
lan
ssessment
bjective data
20
ubjective data
Appearance, Timeliness, and
Accuracy of Records

• Use a good quality pen, black ink preferably.
• Make all writing legible.
• Never use white out in charts.

• Check information carefully
• Double check accuracy of
information
• Make sure most recent
information is recorded
• Follow correct procedure for
correcting errors
• Record all findings as soon
as they are available
• For late entries, record both
original date and current
date
• Record date and time of
telephone calls and
21
information discussed
Professional Attitude and Tone

Maintain a professional tone with your
writing by:


Recording patient comments in his/her own
words
Not recording your personal, subjective
comments, judgments, opinions, or speculations
You may call attention to a problem by attaching a note to the
chart, but do not make such comments part of the chart.
22
Computer Records

Advantages




Can be accessed by more than one person at a
time
Can be used in teleconferences
Useful for tickler files
Security Concerns

Protecting patient confidentiality is a major area
of concern
23
Medical Transcription




Transcription means transforming spoken
words into written format.
Dictated information is part of the medical
record and must be kept confidential.
Always date and initial each transcription
page.
Strive for ultimate accuracy and completeness
of transcribed information.
24
Medical Transcription (cont.)

Transcribing Recorded Dictation







Organize your work area
Adjust transcription machine speed, tone, and volume as
needed
Listen initially to entire recording before transcribing and
document areas with difficult interpretations
Listen to voice tones to determine correct punctuation
Never try to guess at meanings
Re-read for accuracy and correct spelling and punctuation
Physicians should initial all transcribed doctor’s notes
25
Medical Transcription (cont.)

Transcribing Direct Dictation





Use a writing pad and good pen that will not
smear
Use incomplete sentences and phrases to keep up
with physicians pace
Use abbreviations
Ask for clarification immediately if something is
unclear
Read the dictation back to verify accuracy
26
Medical Transcription (cont.)
Transcription
Reference Books
Medical
Terminology Books
Transcription
Aids
Secretarial
Books
Medical Reference
Books
27
Apply Your Knowledge
Label the following items as either (S) “subjective” or
(O)“objective”.
headache
vomiting
or
nausea
chest pain
respirations = 22 and non-labored
skin color
28
Apply Your Knowledge -Answer
Label the following items as either (S) “subjective” or
(O)“objective”.
headache
vomiting
nausea
chest pain
skin color
respirations = 22 and non-labored
29
Correcting and Updating
Patient Records



Medical records in legal terms are regarded as
“due course,” meaning information is to be
entered at the time of occurrence and not
“conveniently” later.
Use care with corrections because it is more
difficult to explain a chart that has been
altered after something was documented.
Date and initial each addition to the medical
record.
30
Release of Records

Procedures for Releasing Records




Special Cases


Obtain a signed and newly dated release form authorizing
the transfer of their information, and place in file.
Make photocopies of original materials.
Copy and send only documents covered in the release
authorization.
Divorce and death
Confidentiality

Children age 18 in many states are to be treated as adults,
and their parents do not have the right to see their records
31
without authorization.
Apply Your Knowledge
The medical assistant receives a fax
transmittal authorizing transfer of medical
record information for a client to another
physician’s office. What would you do in
this situation?
32
Apply Your Knowledge -Answer
The medical assistant receives a fax
transmittal authorizing transfer of medical
record information for a client to another
fax number. What would you do in this
situation?
It is difficult to know the actual originator of a fax transmittal and
to verify the signature. The safest solution would be not to release
any information ever via fax.
33
End of Chapter
34