ALLIED HEALTH ASSISTING
CHAPTER 13: THE MEDICAL RECORD, DOCUMENTATION, AND FILING
THE PURPOSE OF RECORDS
 A complete accurate medical record is necessary

Personal information

Medical history

Family history

Social habits

Medications

Occupational exposures

Different types of testing performed
THE PURPOSE OF RECORDS
 Personal information includes

Gender

Ethnicity

Religion

Age

Marital status

Living arrangements

Children

Occupation

Insurance information
THE PURPOSE OF RECORDS
 Medical record serves as a way to maintain and document the course of medical evaluations, treatments, and
changes in condition
 Charting

Lays out a chronological account of the patient reports, providers evaluation, prescribed treatment, and responses to
treatment
 Provides legal protection for both the patient and provider
 Used for insurance purposes
 Conducting research
HIPAA AND THE MEDICAL RECORD
 Health Insurance Portability and Accountability Act

Established in 1996

Privacy of patient information is main focus

Pertain primarily to records management

Maintaining the privacy of health information

Establishing standards for any electronic transmission of health information and related claims

Ensuring the security of all electronic health information
HIPAA AND THE MEDICAL RECORD
 HIPAA privacy rule for all medical data

Effective in 2003

Provides standards for patients’ confidential, personal information

Medical facilities need to limit what information was released and who it was released to

HIPAA is more lenient than most realize


The privacy rule allows each organization to do what it feels is reasonable within the maintained guidelines
Most institutions employ a HIPAA office

Understand the rulings

Train the staff

Keep up with changes
HIPAA AND THE MEDICAL RECORD
 HIPAA security rule

Ensure confidentiality, integrity, and availability of all electronic protected health information (PHI) the providers compose,
receive, or maintain, or send out

Have policies and procedures in place to protect against use or disclosures of the electronic information that is not
required or permitted under the Privacy Ruling

Have policies and procedures in place to protect against threats or hazards to the PHI records

Demonstrate compliance with the Security Ruling within the workplace
HIPAA AND THE MEDICAL RECORD
 Centers for Medicare and Medicaid Services (CMS) can audit and ask for documentation of compliance with the
Security Rule

Administrative safeguards

Physical safeguards

Technical safeguards

Organizational requirements

Documentation
 New employee orientation and periodic updates should include training in maintaining security of records
ELECTRONIC HEALTH RECORDS
 National Alliance for Health Information Technology (NAHIT) has established definitions for:

Electronic Medical Records (EMR)


Electronic Health Record (EHR)


Electronic record of health-related information for an individual that is created, gathered, managed, and consulted by licensed clinicians as
staff that is maintained through a single organization
Differs from EMR is that is it the aggregate electronic record of health-related information that is created and gathered cumulatively
across more that one organization
Personal Health Records (PHR)

Collection of medical records compiled and maintained by the individual
ELECTRONIC HEALTH RECORDS
 EHRs provide improved management of patient records
 Facilitate more efficient billing services
 Federal government provides incentives for practices to convert to EHRs

Provider must satisfy meaningful use

Practice must actually use the system, not just have it in place

40% of prescriptions must be submitted electronically

Provide patients with copies of their health information within 3 days more than 50% of the time

Obtain patient demographic data a minimum of 50% of the time
ELECTRONIC HEALTH RECORDS
 Advantages of EHRs

Availability of a searchable database that records patients’ demographics, allergies, lab results, and improved accessibility of
the record to health care providers

Radiology and laboratory departments that can transmit results directly to the provider, reducing the time to treatment and
notification of critical values

Electronically entered prescriptions that minimize errors related to illegible handwriting and reduce the time for
prescriptions to be available to the patient. Software also screens medications for interactions and allergies

Aiding in reminding the health care provider when routine testing should occur, such as mammography, vaccinations, and
cardiovascular procedures

In a multi-specialty facility or practice, facilitating coordination of care among providers and elimination duplicate or
incomplete testing and treatment
ELECTRONIC HEALTH RECORDS
 Advantages of EHRs

Chart notes that can be available immediately when a patient needs a referral or consultation with another provider

Voice recognition software that improves availability of printed records and decreases costs by eliminating the need for
transcribing dictated notes

Assigning the CPT and ICD codes at the time of the visit, streamlining the process of insurance filing

A photograph of the patient, which can be included in some software applications to ensure the correct record has been
selected

Trending that might help identify problems that might not be identified as early when using traditional paper records
 Does not completely eliminate the need for paper records
PARTS OF THE MEDICAL RECORD
 Divided into the following sections

Administrative data

Financial and insurance information

Correspondence

Referral

Past medical records

Clinical data

Progress notes

Diagnostic information

Lab information

medications
PARTS OF THE MEDICAL RECORD
 Subjective vs. Objective Information


Subjective

Supplied by the patient

Signs

Symptoms

Complaints
Objective

Can be measured

Seen

touched
PARTS OF THE MEDICAL RECORD
 Administrative, financial, and insurance information

Demographic and insurance information should be verified every visit

Good idea to post a sign saying, “Do we have your current address and phone number?”

Maintain accurate documentation of insurance and payment information
PARTS OF THE MEDICAL RECORD
 Correspondence and referrals

All correspondence received, whether medical or financial, should be maintained in the record

Referral or follow up letters from specialists

Letters from insurance

Correspondence from the patient

In the EHR, correspondence is scanned and uploaded in the patients chart
PARTS OF THE MEDICAL RECORD
 Progress Notes

Documents the progress of each patient

Entered in chronological order

Provider’s “Journal”

Chief Complaint

Brief description of why the patient came in

In the patient’s own words
 Diagnostic Imaging Information

Results from X-rays, CT scans, MRI’s, Ultrasounds, etc

Dictated by Radiologist

CD, DVD, Film copies

Must request electronic format, if not just dictated report will be sent
PARTS OF THE MEDICAL RECORD
 Lab Information

Any critical values should be highlighted

Placed in chronological order with most current first

Separated into groups
PARTS OF THE MEDICAL RECORD
 Medications

All medications administered are documented

Entry includes:


Prescriber

Medication name

Dose

Frequency

Route

Time given

Observation period
Copies of prescriptions
CHARTING IN THE PATIENT RECORD
 Problem-Oriented medical record (POMR)

Developed by Lawrence L. Weed M.D. in early 1970’s

Progress notes are organized based on the source from which they come

Works well in group settings

Promotes continuity of patient care

Same system incorporated into the EHR’s of today
CHARTING IN THE PATIENT RECORD
 SOAP
Subjective impressions
Objective Clinical Evidence
Assessment or diagnosis
Plans for further studies, treatment, management
CHARTING IN THE PATIENT RECORD
 SOAP

Process makes the chart easier to review and helps in follow-up

Example:
Pt complains of two days of sever high epigastric pain and burning, radiating through the back. Pain accentuated after eating
On examination there is extreme guarding and tenderness, high epigastric region, no rebound. Bowel sounds normal. BP 110/7, P 66, R 18
R/O gastric ulcer, pylorospasm
Pt to have upper gastrointestinal series, Start on Cimetidine 300mg daily. Eliminate coffee, alcohol, ASA, and return in two days.
CHARTING IN THE PATIENT RECORD
 HPIP
History
Physical exam
Impression
Plan
CHARTING IN THE PATIENT RECORD
 HPIP

Similar system to SOAP

Example:

C/O severe H/A Rt side of his head lasting several hours to up to 3 days; has had 4 in the past 6 wks, pain is increasing each time; takes
ASA for pain. Neurologic exam shows slight tremor in both hands. R/O encephaloma. CAT scan o cranium. Refer to Clearbrook
Neurological Associates
CHARTING IN THE PATIENT RECORD
 CHEDDAR

Another method for charting that encourages providers to include greater detail than SOAP or HPIP

Chief Complaint:


Presenting problem. Should be recorded in the patients words

Any unusual descriptions should be put in quotes

As much subjective information should be obtained as possible
History

A list of patient’s prior medical history

Social history

Relevant family history
CHARTING IN THE PATIENT RECORD
 CHEDDAR

Examination


Details of problems and complaints



Objective findings by the examiner
Results of additional testing
Drugs and dosages

Complete list of ALL medications, both prescription and OTC

Vitamins and supplements too
Assessment

Diagnosis

Appropriate treatment

Further testing
CHARTING IN THE PATIENT RECORD
 CHEDDAR

Return visit

Indicate if a return or follow-up visit is required
DATING, CORRECTING, AND MAINTAINING THE CHART
 Date and time should always be notes when making any entry in the chart
 Always use military time
 In EHR’s date and time is automatically stamped
 Any entries in the chart must be signed by the person who made them
 Corrections and late entries

Single line through incorrect entry

Correct above or following

Initial

Time and date
DATING, CORRECTING, AND MAINTAINING THE CHART
 Only use BLACK pen
 When you are finished with the chart, straighten and tidy the forms
 File the chart appropriately ASAP
 Transcribe dictated notes ASAP
DATING, CORRECTING, AND MAINTAINING THE CHART
 Use the following 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 them in a timely manner
DATING, CORRECTING, AND MAINTAINING THE CHART
 Tracking Medical Records

Every office has a system to track outstanding work

This work must be completed before releasing the chart to be filed

EHR’s may have prompts to show what records are waiting
FILING MEDICAL RECORDS
 Even with the use of electronic resources, proper filing is necessary
 Include staff needs and limitations in determining what filing system is needed
 Safety is an important consideration when working with filing cabinets

Place files in bottom drawers first
FILING MEDICAL RECORDS
 Steps in filing

Step one: Inspecting

CMAA is usually first one to inspect reports

Divided into negative/normal and positive/abnormal for provider to read

Provider should review all reports

Provider makes check mark in upper right corner and circles any abnormal findings in red

Makes notation about follow up
FILING MEDICAL RECORDS
 Steps in filing

Step two: Indexing

Requires you to make a decision about the name, subject, or other identifier under which you file the material

Materials for patients should be filed under patient name

Research papers can be filed under illness, procedure, treatment, medication, or author

A cross-reference can be helpful in finding things later
FILING MEDICAL RECORDS
 Steps in filing

Step three: Coding

Done by marking the index identifier on the papers to be filed

If the name, subject, or a number appears on the paper, underline it, or circle it, or highlight it

If it does not appear, write in the upper right corner
FILING MEDICAL RECORDS
 Steps in filing

Step four: Sorting

Place in alphabetical order
FILING MEDICAL RECORDS
 Steps in filing

Step five: Storing

Locate the file drawer or shelf with the appropriate caption

Find the folder where the reports are stored

Place on flat surface before adding any material

Place back in drawer or on shelf IN ORDER!!
FILING MEDICAL RECORDS
 Filing Supplies

Guides

OUTguides

Folders

Vertical pockets

Index tabs

labels
FILING SYSTEMS

Most filing systems are based directly or indirectly on alphabetic arrangement




Numeric Filing

Material is arranged in numeric order in the main file

Main file is supplemented by an alphabetically arranged card index
Subject filing

Based on an outline or classification of the subject matter

Reference materials
Geographic


Simplest and most common method of filing
Arranged alphabetically by political or geographic subdivisions
Chronologic

Filed according to the date, with the most current first
RULES FOR ALPHABETIC FILING
 Rule 1

In filing the names of persons, the surname is considered first, the first name or initial second, and the middle name or initial
third

Ex.

John E. Brown is filed as Brown, John E.
RULES FOR ALPHABETIC FILING
 Rule 2

Names are filed alphabetically in an A-to-Z sequence from the first to the last letter, considering each letter in the same
separately and each unit separately

When the surnames of two persons are spelled differently, the first and middle names or initials are not considered

When a shorter surname is identical with the first part of a longer surname, the shorter names is listed first. The rule is
sometimes states as “nothing before something”

When the surnames are alike, the order in filing is determined by the first names or initials. When surnames and first names
are alike, the middle name is used
RULES FOR ALPHABETIC FILING
 Rule 2

An initial is listed before a name beginning with the same letter. This again is an example of “nothing before something”

An abbreviated first or middle name is treated as if it were spelled out in full.
RULES FOR ALPHABETIC FILING
 Rule 2

Examples:
Allard, Wm.
Allen, E.S.
Allen, Edna
Allen, Wm. A.
Allen, William C.
Allens, M.R.
RULES FOR ALPHABETIC FILING
 Rule 3

A prefix, such as Mc, Mac, De, Le, and Von, is considered as part of the surname

Example:

MacAdams, Bruce

McAdams, Helen
RULES FOR ALPHABETIC FILING
 Rule 4

Most firm names are filed as they are written. The apostrophe is disregarded in filing.

Example:

Herb’s Auto Service

Walters Printing Company
RULES FOR ALPHABETIC FILING
 Rule 5

Firm names that include the full name of an individual are filed with the name of the individual transposed

Example:

Edward Wenger Company is filed as Wegner, Edward Company
RULES FOR ALPHABETIC FILING
 Rule 6

When the article the is part of a title, it is placed in parentheses and disregarded in filing

Example:

Sam the Barber is filed as Sam (the) Barber

The Family Steakhouse is filed as Family Steakhouse (The)
RULES FOR ALPHABETIC FILING
 Rule 7

And, for, of, and so on are disregarded in filing but are not omitted

Example:

Adams & Smith Pharmacy is filed as Adams (&) Smith Pharmacy
RULES FOR ALPHABETIC FILING
 Rule 8

Abbreviations such as Co., Inc., or Ltd., in a firm name are indexed as though spelled out

Example:

Frank Smith Co. is filed as Smith, Frank Company
RULES FOR ALPHABETIC FILING
 Rule 9

Hyphenated surnames and hyphenated firm names are indexed as one unit

Example:

Dunning-Lathrop & Assoc. Inc. is filed as Dunning-Lathrop (&) Associates, Incorporated

Lester Smith-Mayes is files as Smith-Mayes, Lester
RULES FOR ALPHABETIC FILING
 Rule 10

Numbers are usually filed as spelled out

Example:

5th Avenue Store is filed as Fifth Avenue Store
RULES FOR ALPHABETIC FILING
 Rule 11

Professional or honorary titles are not considered in filing but should be written in parentheses at the end of the name for
identification purposes

Example:


Dr. Anne Lewis is filed as Lewis, Anne (Dr.)
Titles are filed as written when they are part of a firm name. Foreign or religious titles followed by one name are also filed
as they are written

Dr. Scholl’s Foot Powder

Prince Phillip
RULES FOR ALPHABETIC FILING
 Rule 12

Terms of seniority, such as Junior, Senior, Second, or Third, are not considered in filing. If two names are otherwise identical,
the address is used to make the decision

Example:

Keir, Willard, Sr. (Cleveland, Ohio)

Keir, Willard, Jr. (Columbus, Ohio)
RULES FOR ALPHABETIC FILING
 Rule 13

File the names of federal, state, or local government departments first by political division and then by the name of the
department

Example:

Drug Enforcement Administration, Cincinnati, Ohio, is files as Cincinnati, Drug Enforcement Administration, Cincinnati, Ohio