CHAPTER
9
Maintaining Patient
Records
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9-2
Learning Outcomes
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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-3
Learning Outcomes (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.
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9-4
Learning Outcomes (cont.)
9.8 Explain how to update a medical record.
9.9 Identify when and how a medical record may
be released.
9.10 Discuss the advantages and disadvantages
of the electronic medical record, also known
as the electronic health record.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-5
Introduction
• Medical records document the evaluation and
treatment of patients
– Critical to patient care
– Sectioned to describe various aspects of patient
information and care
– Legal documents
• Medical assistant has a major role in
documenting in and maintaining patient records
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9-6
Importance of Patient Records
• The patient’s chart
– Past and present medical conditions

– Communication tool for health-care team
• Plan to provide for continuity of care
– Documentation for billing and coding
– Patient education and research
– Legal document admissible in court
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9-7
Importance of Patient Records (cont.)
• Information included in patient record
– Name and address
– Insurance coverage and
person responsible
for payment
– Occupation
– Medical history

– Current complaint
– Health-care needs
– Medical treatment
plan
– Response to care
– Lab and radiology
reports
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9-8
Legal Guidelines for Patient Records

Proof of event or procedure


No documentation – no proof that care was
done
Legal document


Must document complete information about
patient care
Document if patient is noncompliant
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9-9
Standards for Records
• Complete, accurate, and well-documented
records are evidence of appropriate care
• Incomplete, inaccurate, altered, or illegible
records may imply a poor standard of care
• Everyone who documents in the patient
record has a responsibility to the patient
and employing physician
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9-10
Patient Records
Patient
Education
• Test results
• Health issues
• Treatment
instructions
Additional Uses of
Patient Records
Research
Quality of
Treatment
• Peer review
• TJC review
• Source of data
• Health-care
analysis and
policy decisions
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-11
Apply Your Knowledge
What 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.
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9-12
Standard Chart Information
Patient Registration Form

Date

Patient demographic information
 Age,
DOB
Address

SSN

Insurance/financial information

Emergency contact
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9-13
Standard Chart Information (cont.)
• Patient medical history
– Illnesses, surgeries, allergies, and current
medications
– Family medical history
– Social history (diet, exercise, smoking, use of
drugs and alcohol)
– Occupational history
– Current patient complaint recorded in patient’s
own words
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9-14
Standard Chart Information (cont.)
• Physical examination results
• Results of laboratory and other
tests
• Records from other physicians
or hospitals
– Include a copy of the patient
consent authorizing release of
information
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9-15
Standard Chart Information (cont.)
• Doctor’s diagnosis and treatment plan
–
–
–
–
Treatment options and final treatment list
Instructions to patient
Medication prescribed
Comments or impressions
• Operative reports, follow-up visits, and
telephone calls
– These are part of the continuous patient record
– Document calls made to and from the patient
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9-16
Standard Chart Information (cont.)
• Informed consent forms
– Verify that the patient understands
procedures, outcomes, and options
– Patient may withdraw consent at any time
• Hospital discharge summary forms
– Information summarizing the patient’s
hospitalization
– Instructions for follow-up care
– Physician signature
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9-17
Standard Chart Information (cont.)
• Correspondence with or about the patient
– All written correspondence regarding the
patient
– Record date item was received on the actual
form
• Information received by fax – request an
original copy
• Date and initial everything you place in the
chart
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-18
Apply Your Knowledge
What 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.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-19
Initiating and Maintaining Patient Records
Completing medical
history forms
Documenting
test results
Initial
Interview
Examination,
preparation,
and vital signs
Documenting
patient
statements
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9-20
Initiating and Maintaining Patient Records
(cont.)
• Follow-up
– Transcribe notes the doctor dictates
– Post results of laboratory tests and
examinations
– Record all telephone communication with the
client
– Record all medical or discharge instructions
given to the client
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9-21
Apply Your Knowledge
In addition to transcribing notes the doctor dictates
and posting lab results, what are two other followup 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!
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9-22
The Six Cs of Charting
Client’s words – Do not interpret patient’s words
Clarity –
Precise descriptions/medical terminology
Completeness – Fill
C out forms completely
onciseness – To the point/approved abbreviations
Chronological order – Legal issues
confidentiality –
Follow HIPAA guidelines
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-23
Apply Your Knowledge
What are the six Cs of charting?
ANSWER: The six C’s of charting are
Client’s words
Conciseness
Clarity
Chronological order
Completeness
Confidentiality
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9-24
Types of Medical Records
Source-Oriented Medical
Records
• Conventional approach
• Information is arranged
according to who supplied
the data
• Problems and treatments are
on the same form
• Difficult to track progress of
specific events
Problem-Oriented
Medical Records
• POMR records make it
easier to track specific
illnesses
• Information included
– Database
– Problem list
– Educational, diagnostic,
and
treatment plans
– Progress notes
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9-25
Types of Medical Records (cont.)
• SOAP documentation
– Orderly series of steps for dealing with any
medical case
– Lists the following
• Patient symptoms
• Diagnosis
• Suggested treatment
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9-26
SOAP Documentation
The treatment plan to correct the illness or problem
The impression of the patient’s problem
that leads to diagnosis
What the physician observes
during the examination
Information
the patient
tells you
lan
ssessment
bjective data
ubjective data
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9-27
CHEDDAR Format
• Expands on SOAP format
C
Chief complaint, presenting problems, subjective statements
H
History: social and physical history
E
Examination
D
D
A
R
Details of problem and complaints
Drugs and dosage
Assessment of diagnostic process and diagnosis
Return visit information or referral
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9-28
Apply Your Knowledge
Label the following items as either (S) “subjective” or
(O) “objective.”
____
S headache
____
O pulse 72
O vomited x 3
____
____
S nausea
____
O skin color
____
O respirations 16, labored
____
S chest pain
____
S poor appetite
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-29
Apply Your Knowledge
What type of documentation expands on the SOAP
format?
ANSWER: CHEDDAR format of documentation.
GOOD!
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9-30
Appearance, Timeliness, and Accuracy of
Records
Neatness and legibility
–
Use a good-quality pen
–
Blue ink is preferred (differentiates original
from copy)
–
Highlight critical items such as allergies
–
Handwriting must be legible
–
Make corrections properly
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9-31
Appearance, Timeliness, and Accuracy of
Records (cont.)
 Timeliness
–
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 information discussed
–
Retrieve file quickly in event of an
emergency
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9-32
Appearance, Timeliness, and Accuracy of
Records (cont.)
Accuracy
 Check information carefully
 Never guess or assume

Double-check accuracy findings and
instructions

Make sure most recent information is
recorded
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9-33
Appearance, Timeliness, and Accuracy of
Records (cont.)
• Professional attitude and tone
– Record patient comments in his or her own
words
– Do not record your personal or subjective
comments, judgments, opinions, or
speculations
You may call attention to problems or observations by
attaching a note to the chart, but do not make such
comments part of medical record.
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9-34
Electronic Health Records
• Advantages
• Disadvantages
– Fewer lost records
– Costly
– Reduced transcription
costs
– Retraining of staff
– Readability/legibility
– IT staff may be needed
– Chart access after hours
– Possible damage to
software and system
– Easier access to patient
education materials
– Improved billing

Essential to quality of health care and patient safety
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9-35
Electronic Health Records (cont.)
• Advantages of computer records
– Can be accessed by more than one
person at a time
– Can be used in teleconferences
– Useful for tickler files
• Security concerns – protect patient
confidentiality
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-36
Apply Your Knowledge
What 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.
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9-37
Medical Transcription
• Transcription means transforming
spoken words into written format
• Dictated information is part of the medical
record and must be kept confidential
• Date and initial each transcription page
• Strive for ultimate accuracy and
completeness of transcribed information
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9-38
Medical Transcription (cont.)
• Transcribing direct dictation
– Use a writing pad and pen that will not smear
– Use incomplete sentences and phrases to keep up
with physician’s pace
– Use abbreviations accurately
– Ask for clarification immediately if something is
unclear
– Read the dictation back to verify accuracy
– Enter notes into patient record, date, and initial
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9-39
Medical Transcription (cont.)
Transcription
reference books
Medical
terminology books
Transcription
Aids
Secretarial
books
Medical reference
books
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9-40
Apply Your Knowledge
When taking direct dictation, when should you
clarify information if you do not understand
something?
ANSWER: You should immediately clarify
information that you do not understand when taking
direct dictation.
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9-41
Correcting and Updating Patient Records
• Medical records are created in “due
course”
– Legal term meaning information is to be
entered at the time of occurrence
– Information corrected or added after patient’s
visit is regarded as “convenient”
• Make corrections as soon as possible after
the original entry was made
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9-42
Correcting Patient Records
• When mistakes happen, correct them
immediately
– Draw a line through the original information
• It must remain legible
– Insert correct information above
or below original line or in margin
– Document why correction was made
– Date, time, and initial correction
– Have a witness, if possible
m/d/yyyy 00:00pm
misspelled JHC /chj
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9-43
Updating Patient Records
• Additions to record
should not appear
deceptive
– Document why late
entry is made
– Date and initial added
items
– May have a third party
witness addition
Addition made to record
because patient called back
with additional
information.
Mm/dd/yyyy – JHC
/ chj
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-44
Apply Your Knowledge
What 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 information
• It must remain legible
• Insert correct information above or below original
line or in margin
• Document why correction was made
• Date, time, and initial correction
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9-45
Release of Records
• Records are property of
the practice
– Contain confidential patient
health information
– Must have patient’s written
consent to release
– Exceptions: cases of
contagious disease or court
order
Release of
Information
to HMO Insurance
Company
I authorize Dr. J. Jones to release my healthcare information to the above-named
insurance company.
Christopher Hansen
Patient Signature
mm/dd/yyyy
Date
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9-46
Release of Records
(cont.)
• Procedures for releasing records
– Obtain a signed and newly dated release form
authorizing the transfer of information, and place
it in the patient’s record
– Make photocopies of original materials
• Copy and send only documents covered in the release
authorization
– Call to confirm receipt of materials
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9-47
Release of Records
• Special cases
– Divorce – legal
guardian of children
(may be one or both
parents)
– Death – next of kin or
legally authorized
representative
– If unsure, ask
supervisor
(cont.)
• Confidentiality
– 18-year-olds are
considered adults in
most states
Legal and ethical
principle:
Protect patient’s right to
privacy at all times.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-48
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?
ANSWER: 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 based on a fax
request and release of information form. Request the
original form.
Nice Job!
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
9-49
In Summary
9.1 Patients’ records should be compiled
because they serve as legal documents,
and may be used in medical malpractice
cases and lawsuits.
9.2 The content of a patient record consists
of standard chart information; information
received by fax; dating and initialing of
patients’ charts.
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9-50
In Summary (cont.)
• Include
• Maintain the charts
properly
– Registration form
– Medical history
–
– Exam results, lab and other
tests
– Records from other physicians
and hospitals
– Diagnosis and treatment plans
– Operative reports, consent
forms, discharge summaries
– Correspondence with or about patients.
Documenting detailed
notes about the contact
with the patient, patient
responses and progress,
and treatment outcomes.
9.3 To create and maintain patient records forms
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9-51
In Summary (cont.)
9.4 The most common approaches in
documenting information into medical records
is through Conventional or Source Oriented
records, Problem-Oriented Medical Records
(POMR), SOAP, and CHEDDAR.
9.5 Neatness, legibility, accuracy, and professional
tone are musts in maintaining medical records.
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9-52
In Summary (cont.)
9.6 When performing accurate transcription:
– Use incomplete sentences or phrases to keep up with
the physician’s pace
– Use abbreviations whenever possible
– If physician speaks fast, ask him or her to speak
slower and more clearly
– Read dictation back to physician for clarity
– Enter notes into patient record.
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9-53
In Summary (cont.)
9.7 When correcting medical records, make sure
you correct as soon as possible. Use
appropriate procedure to make corrections.
9.8 Each item that is added to the patient record as
an update should be dated and initialed. If the
information is extremely important, get a third
party to witness and initial and date as well.
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9-54
In Summary (cont.)
9.9 Medical records can only be released with
patient’s written consent or subpoena by the
courts. Consent form must be on file.
9.10 The advantages of the electronic medical
record outweigh the disadvantages. Evaluate
software before purchasing. Maintain
sensitivity to patient needs.
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9-55
End of Chapter 9
Organization is the
power of the day;
without it, nothing is
accomplished.
~ Sophia Palmer
From A Daybook for Nurses:
Making a Difference Each Day
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.