PATIENT MEDICAL
RECORDS
Types of Records in an Office
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Medical records of the patient’s state of health
Correspondence pertaining to the field of health
care
Documents related to the business and financial
management of the practice
Objectives
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Components that make up medical records
The SOAP format-the most common format used for
recording medical information about patients
The 3 parts of the problem oriented medical record
(POMR) format
Transcribe medical data dictated by a physician, apply
guidelines for grammar
The preservation of medical records
Who actually owns a patient’s medical record
Standards to be used for quality assurance in
maintaining medical records
The Medical Record
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Patient’s medical record=“Patient’s Chart”
 The
source of info about all aspects of a patient’s
health care
 Accurate and up-to-date
 Proper
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health care, financial and legal success
The AMA should be familiar with:
 Why
med. records are regarded as legal documents
 The types of reports and information found in a MR
 The importance of well-maintained MRs for the practice
 The method for making corrections to a MR
MR as Legal Documents
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A patient’s MR constitutes the legal record of the
practice
May have to be produced in court
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Uphold the rights of physician if involved in litigation or as a
witness
Malpractice cases
Content and quality of MR is pivotal, can be more important
than physician’s credentials, personality, or reputation
 If data is incomplete, illegible or poorly maintained, an
attorney can make the Dr. appear negligible
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What is a MR?
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Holds all the data about that patient
MRs include:
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Chart notes
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History and physical
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Copies of all correspondence with patient, including letters, faxes, and notes of phone
conversations
Clinical Forms
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Lab reports, X-ray reports, etc.
Correspondence
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Copies of letters sent to other physicians referring the patient for exams, tests, etc.
Medical Reports
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Patient’s complete medical history(obtained in an interview on 1st visit), initial results of
physical exam
Referral and consultation letters
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Chronological order of ongoing patient care and progress, made by physician, nurse, or other
professional regarding pertinent points of a given visit or communication with patient
Immunization records and pediatric growth and development records
Medication List
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List of the all medications prescribed, including dosage, dispensing instructions, etc.
Reasons for Maintaining MRs
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MRs are used in the following ways:
Main source of info for coordinating and carrying out
patient care among all providers involved with the patient
 Evidence of the course of an illness and a record of the
treatment being used
 A record of the quality of care provided to patients
 A tool for ensuring communication and continuity of care
from one medical facility to another
 The legal record for the practice
 The main record to ensure appropriate reimbursement
 A source of data for research purposes (lecture, bk, article)
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Making Corrections
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Remember: No part of a record should be altered,
removed, deleted, or destroyed
If error or discrepancy occurs, an addendum to the
record must be made
How to make a correction:
 Use
strike-through feature-must be able to read the
incorrect material
 Enter the word “error” next to the deleted statement
 Write your initials and date next to correction
 Enter the correct information into the MR
The Soap Method of Record
Keeping and the POMR Format
SOAP Method
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The most common system for outlining and
structuring chart notes for a MR
Facilitates the creation of uniform and complete
notes in a simple format that is easy to read
SOAP-Subjective, Objective, Assessment, Plan
SOAP: Subjective
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The patient’s description of the problem or complaint,
including symptoms troubling the patient, when they began,
remedies tried, past medical treatment, etc.
Subjective record includes the following headings:
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Chief complaint (CC): Reason for the visit
History of present illness (HPI): Info about symptoms
Past medical history (PMH): list of illnesses and treatments
Family history (FH): facts about family’s health related to you
Social history (SH): Social and marital history (eating, drinking,
smoking, occupation, interests, etc.)
Review of systems (ROS): physician’s review of each body ststem
with the patient (Ex: respiratory system)
SOAP: Objective
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Physician’s examination of the patient
May be dictated under the heading Physical Exam (PE)
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Complete physical exam
Subheadings for a physical exam:
Vital signs (VS)
 General: description of the patient might be
 HEENT: Head, eyes, ears, nose, throat
 Neck
 Heart
 Etc.
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SOAP: Assessment
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Physician's interpretation of the subjective and
objective findings
“Assessment” is used interchangeably with
“Diagnosis (Dx)” and “Impression”
 Gives
a name to the condition from which the patient is
suffering
 Rule out (R/O): The diagnosis is not likely and further
tests must be performed
SOAP: Plan
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Plan-treatment
This section lists the following:
 Prescribed
medications and their exact dosages
 Instructions given to the patient
 Recommendations for hospitalization or surgery
 Any special tests that need to be performed
Problem-Oriented Medical Records
(POMR)
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Another form of record keeping revolves around a list of the
patient’s problems
3 essential components:
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Database
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Initial plan
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Based on the database and initial problems of the patient
Problem list
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Complete history of the patient, problem, history, family, social, etc.
A running account of the patient’s problems
Referred to a updated at each visit
Used for:
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Organizing entries within the problem list
To outline the history and physical for the database section
Transcription Guidelines
Transcription Guidelines
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AMA’s role is to transcribe physicians’ chart notes
and other medical documents
Physician may dictate and then give recording to an
AMA for transcription
Listening Techniques
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Dictation equipment: digital media (CD, analog
media)
Tone, volume, rate of speed can be regulated for
the assistant’s own comfort and rate of transcription
Confidential info-headphones
Foot pedal starts and reverses the machine
Office Policy
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Every office uses its own format for transcribing
chart notes
Include instructions or corrections when transcribing
You may not add anything that is not there
Basic Medical Transcription Guidelines
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Skill in spelling, punctuation, capitalization
Knowledge of medical terminology, guidelines for
medical abbreviations
Areas to Know
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Commas
Semicolons
Colons
Capital letters
Hyphens
Abbreviations
Numbers
Symbols
Memos
Grammar
Document formatting
Record Retention, Ownership, and
Quality Assurance
Preservation of Files
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Patient MRs need to be preserved-importance to
the practice and value as legal document
 Kept
until possible malpractice suit has passed or for
four years after patient has left the practice
 Many
are kept in an inactive file permanently, however
Ownership
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American Medical Association Council on Ethical and Judicial
Affairs-deals with the ownership of MRs
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Notes made by the physician and MRs are physician’s property
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Used for physician’s use in treatment of patients
Info inside belongs to the patient-nature of the diagnosis, etc.
Physician cannot use or withhold the info in the recird according to
his or her own wishes
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Ex: Dr. is ethically obligated to furnish copies of office notes to any
physician who is assuming responsibility for care of the patient (with a
record release form signed and dated by patient)
Patient’s have the right to control the amount and type of info that is
released from the MR
Patient’s alone have the authority to release info to anyone not
directly involved with their care-fee may be charged
Quality Assurance
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Best record of the care given a patient
AMAs job is to make certain the info recorded in the MR is accurate
and up-to-date
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If AMA is unsure of what was dictated, they must flag it for the physician
The AMA should make sure each record contains the following:
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Dated notations describing the service received by the patient
Notations regarding q. procedure performed
Accurate notations. An addendum must be made by physician if a
discrepancy occurs
Justification for hospitalization
If necessary, a discharge summary regarding hospitalization before the
patient arrives for a follow-up visit
Key Terms (Define)
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Assessment-the physician’s interpretation of the subjective and objective findings
Chief complaint (CC)-reason for the visit or why they are seeking medical advice
Diagnosis (Dx)-what the physician determines is the problem with the patient
Family history (FH)-facts about the health of the patient’s siblings, parents, blood relatives
History of present illness (HPI)-info about the symptoms troublign the patient: when they began, what affects
them
Impression objective past medical history (PMH)-listing of any illnesses the patient has had in the past along
with the treatments administered or performed
Physical exam (PE)-a complete physical examination where findings for each of the major areas of the
body are covered
Plan-treatment for patient as directed by the physician
Problem-oriented medical record (POMR)-see PowerPoint
Review of systems (ROS)-physician’s review of each body system (ex: respiratory system)
Rule out (R/O)-the diagnosis is not likely and that further tests will be performed
SOAP-see PowerPoint
Social history (SH)-info regarding the patient’s eating, drinking, smoking habits, occupation, interests
Subjective-the patient’s description of the problem or complaint
Thinking It Through (Answer.)
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How does the use of the SOAP format for record
keeping minimize a provider’s exposure to legal
risk?
Where in the POMR file would you look for
information regarding a patient’s family history of
intestinal cancer?
A former patient calls asking to retrieve x-rays
taken more than five years ago. What do you say?
You are transcribing the physician’s dictation and
cannot understand several words. What do you do?