Chapter 14, The Paper Medical Record
“
The Importance of Accurate
Medical Records”
 Help physician provide the best possible care to patient
 Important for continuity of care with other healthcare professionals
 Offer legal protection to those who provide care to the patient
 Provide statistical information that is helpful to researchers
 Vital for financial reimbursement
Copyright © 2014 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1

Ownership of the Medical Record

Physician or medical facility (the “maker”)
 Patient has right of access to information, but does not own physical record
 Patient has right to demand confidentiality
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Types of Records
 Paper
 Inefficient
 Possibility of misfiled information
 No easy access to data; information difficult to share
 Electronic
 More efficient than paper
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3

Source-Oriented Records
 Observations and data cataloged according to their source
 Forms and progress notes filed in reverse chronologic order
 Separate sections of record
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4

Problem-Oriented Medical Record
 Divides records into four bases:
 Database
 Problem list
 Treatment plan
 Progress notes
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SOAP Notes
 S ubjective impressions
 O bjective clinical evidence
 A ssessment or diagnosis
 P lans for further studies, treatment, or management
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CHEDDAR Method
 C hief complaint
 H istory
 E xamination
 D etails (of problem and complaints)
 D rugs and dosages
 A ssessment
 R eturn visit information, if applicable
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7

Contents of the Complete
Case History

Most important record in a physician’s practice
 Contains subjective and objective information
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Subjective Information
 Personal demographics
 Personal and medical history
 Family history
 Social history
 Chief complaint
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Objective Information
 Physical examination findings and laboratory and radiology reports
 Diagnosis
 Treatment prescribed and progress notes
 Patient consent form required for surgery or other treatment
 Condition at time of termination of treatment
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Medical Assistant’s Role
 Obtaining the history
 Responsible for privacy and confidentiality
 Ask patient to complete questionnaire
 If paper, may be mailed ahead of time or completed in office
 If electronic, may be completed ahead of time
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11

Making Additions to the
Patient’s Record
 Laboratory reports


Different colored paper used for reporting different procedures
Place small lab slips on 8 ½ × 11-inch colored paper
 Radiology reports
 Progress notes
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12

Making Corrections and Alterations to Medical Records
 Correcting a handwritten entry:
 Draw a line through the error
 Insert the correction above or immediately after the error, in a spot where it can be read clearly
 If indicated by the policy and procedures manual, write “Correction” or “Corr.” in the margin
 The person making the correction should write his or her initials or signature below the correction and the date
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13

Keeping Records Current
 Medical assistant responsible for methodically keeping record current
 After last patient, check each history
 Give physician any abnormal reports
 Always adhere to written policy
 Records should never leave office and should not be left out in view at night
 Transcribe any dictated notes
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14

Regular Transfer of Files
 Records filed according to classification:
 Active files
 Inactive files
 Closed files
 Establish system for regular transfer of files from active to inactive or possible destruction
 Purging: process of moving a file from active to inactive status
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15

Retention and Destruction
 Medical considerations are primary basis for deciding length of retention
 Always check state laws before destruction
 At a minimum, keep for at least period of statute of limitations for malpractice claims
 3 years or longer
 Medicare and Medicaid patient records must be kept 10 years
 Contact patient before destruction, and be sure to preserve confidentiality
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16

Protection of Records
 Do not release original case histories to anyone outside the healthcare facility


Prepare summary or photocopy materials needed
Retain the original in the physician’s office
 Fax only required pages
 Use OUTfolder for rare occurrence when records are temp out of office
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17

Long-Term Storage Options
 Microfilm may be used if EMR not currently in use
 For electronic storage, back up regularly
 Transfer of paper records onto optical disks
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Releasing Medical Record
Information
 Patient must sign release form
 Requests for information should be made in writing
 Durable power of attorney often used in medical field
 Special considerations regarding release of minor records
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19

Dictation and Transcription
 Transcription can be done from:
 Handwritten notes, such as shorthand
 Machine dictation, using machine transcription unit or portable transcription unit
 System accessed by telephone
 Voice recognition software may also be used
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20

Filing Equipment
 Drawer files
 Shelf files
 Rotary circular files
 Lateral files
 Automated files
 Card files
 Special items
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Filing Supplies
 Divider guides
 OUTguides
 File folders
 Labels
(Courtesy Bibbero Systems, Petaluma, Calif.)
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22

Filing Procedures
 Conditioning
 Releasing
 Indexing and coding
 Sorting
 Storing and filing
 Locating misplaced files
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Indexing Rules
3)
4)
5)
6)
1)
2)
Last names considered first in filing, first name considered second, and middle name or initial considered third
Initials precede a name beginning with the same letter
Hyphenated elements considered one unit
Apostrophe disregarded in filing
Indistinguishable foreign names
Prefixes considered part of name
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Indexing Rules, cont’d
7)
8)
9)
10)
11)
12)
Abbreviated parts are indexed as written
Mac and Mc are filed in their regular place in the alphabet
The name of a married woman is indexed by her legal name
Titles may be used as the last filing unit if needed
Degrees used only to distinguish from identical name
Articles (e.g., the, a) disregarded in indexing
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Filing Methods: Alphabetic
 Simplest, most commonly used
 Direct filing system
 Requires only a file cabinet or shelf, folders, and divider guides
 Some drawbacks
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Numeric Filing
 Indirect filing system: requires use of alpha cross-reference
 Advantages:
 Allows unlimited expansion
 Provides additional confidentiality
 Saves time in retrieving and filing
 Several types exist
 Requires more training, but fewer errors occur
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Other Filing Systems
 Subject filing
 Color-coding: specific color is selected to identify each letter of alphabet
 Alphabetic color-coding
 Numeric color-coding
 Additional color-coding applications
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28

Organization of Files
 Health-related correspondence
 General correspondence
 Practice management files
 Active accounts
 Paid accounts
 Miscellaneous
 Tickler or follow-up files (chronologic arrangement)
 Transitory or temporary file
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29

Closing Comments
 Advances in medical records occur rapidly
 Be willing to learn
 Adapt to changes
 Keep a positive attitude
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Questions?
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