CHAPTER
11
Medical Records
and Documentation
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11-2
Learning Outcomes (cont.)
11.1 Explain the importance of patient medical
records.
11.2 Identify the documents that comprise a
patient medical record.
11.3 Compare SOMR, POMR, SOAP, and
CHEDDAR medical record formats.
11.4 Identify the six Cs of charting, giving an
example of each.
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11-3
Learning Outcomes (cont.)
11.5 Describe the need for neatness, timeliness,
accuracy, and professional tone in patient
records.
11.6 Illustrate the correct procedure for correcting
and updating a medical record.
11.7 Describe the steps in responding to a written
request for release of medical records.
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11-4
Introduction
• Medical assistants role regarding patient
health records
– Documentation
– Maintenance
• Medical records – critical to patient care
– Evaluation
– Management
– Treatment
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11-5
The Importance of Medical Records
• Past medical history and present condition
• Communication tool for healthcare team
• Legal documentation
• Patient and staff education
• Quality control and
research
• Documentation for
billing and coding
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11-6
Importance of Patient Records (cont.)
• General information
– Contact information
– Occupation
– Medical history
– Current complaint
– Healthcare needs
– Treatment plan or services provided
– Radiology and laboratory reports
– Response to care
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11-7
Legal Guidelines for Patient Records
• Support a malpractice claim
• Support defense for a malpractice claim
• Back up financial records
• Documentation
– Medical care, evaluation and instructions
– Noncompliant patient
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11-8
Standards for Records
• Evidence of appropriate care
– Complete
– Accurate
• Everyone who documents in the patient
record has a responsibility to the patient
and physician
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11-9
Additional Uses of Patient Records
Patient
Education
• Test results
• Health issues
• Treatment
instructions
Quality of
Treatment
Research
Source of data
• Peer review
• TJC review
• Health-care
analysis and
policy decisions
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11-10
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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11-11
Contents of Patient Medical Records
Patient Registration Form

Date

Patient demographic information

Age, DOB

Address, phone number

SSN

Insurance/financial information

Emergency contact
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11-12
Contents of Patient Medical Records (cont.)
• Patient medical history
– Past medical history
– Family medical history
– Social and occupational history
– History of present illness (chief complaint)
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11-13
Contents of Patient Medical Records (cont.)
• Physical examination results
– Review of systems
– Form ensures consistency
• Results of laboratory and other tests
• Documents from
Other Sources
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11-14
Contents of Patient Medical Records (cont.)
• Doctor’s diagnosis and treatment plan
– Treatment options and plan
– Instructions
– Medication prescribed
– Comments or impressions
• Operative reports, follow-up visits, and
telephone calls
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11-15
Contents of Patient Medical Records (cont.)
• Hospital discharge summary forms
• Consent forms
– Verify that the patient understands
procedures, outcomes, and options
– Patient may withdraw consent at any time
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11-16
Contents of Patient Medical Records (cont.)
• Correspondence with or about the patient
• Information received by fax – request an
original copy
• Date and initial everything you place in the
chart
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11-17
Maintaining Confidentiality
1. The right to notice of privacy practices.
2. The right to limit or request restriction on
their PHI and its use and disclosure.
3. The right to confidential communications.
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11-18
Maintaining Confidentiality (cont.)
4. The right to inspect and obtain a copy of
their PHI.
5. The right to request an amendment to
their PHI.
6. The right to know if their PHI has been
disclosed and why.
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11-19
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.
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11-20
Types of Medical Records
• Source-Oriented Medical Records
– Information is arranged according to who
supplied the data
– Problems and treatments are on the same
form
– Difficult to track progress of specific events
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11-21
Types of Medical Records (cont.)
• Problem-Oriented Medical Records
– Data Base
– Problem List
• Each problem numbered
• Sign vs. symptom
– An Educational, Diagnostic, and Treatment
Plan per each problem
– Progress Notes
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11-22
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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11-23
SOAP Documentation
Information the patient tells you
ubjective data
bjective data
ssessment
lan
What the physician observes during
the examination
The impression of the patient’s
problem that leads to diagnosis
The treatment plan to correct the
illness or problem
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11-24
CHEDDAR Format
• Expands on SOAP format
C
Chief complaint, presenting problems, subjective
statements
H
History – social and physical history
D
Examination
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11-25
CHEDDAR Format
• Expands on SOAP format
D
Drugs and dosage
A
Assessment of diagnostic process and diagnosis
R
Return visit information or referral
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11-26
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
Excellent!
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11-27
Documenting and the Six Cs of Charting
• Updating medical forms
• Documenting test results
• Examination Preparation and Vital Signs
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11-28
Follow-Up
• Transcribe notes the doctor dictates
• Post results of laboratory tests and
examinations
• Record telephone communication with the
client
• Record all instructions and education
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11-29
The Six Cs of Charting
Client’s words
Clarity
Completeness C
onciseness
Chronological order
confidentiality
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11-30
Apply Your Knowledge
1. 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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11-31
Apply Your Knowledge
2. In addition to transcribing notes the doctor
dictates and posting lab results, what are two
other follow-up tasks the medical assistant
might be required to perform as part of followup 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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11-32
Appearance, Timeliness, and Accuracy of
Records
Neatness and legibility
– Medical transcription
– Handwritten notes
• Blue ink
• Highlight specific items such as allergies
• Make corrections properly
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11-33
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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11-34
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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11-35
Professional Attitude and Tone
• Record patient comments
• Do not record 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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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
11-36
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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11-37
Correcting and Updating Medical Records
• Medical records are created in “due
course”
– Information is entered at the time of
occurrence
– Untimely submissions may be regarded as
“convenient”
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11-38
Using Care with Corrections
• Correct mistakes immediately
– Draw a line through the original information
– Insert correct information
– 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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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
11-39
Updating Patient Records
• Additions 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
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11-40
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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11-41
Responding to Release of Records
Request
• Records are property
of the practice
• Contain confidential
PHI which belongs to
the patient
• Must have patient’s
written consent to
release
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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11-42
Procedures for Releasing Records
• New authorization to transfer records
– Verbal consent is not valid
– File in medical record
• Copy original materials – only information
requested
• Call to confirm receipt of materials
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11-43
Procedures for Releasing
Records (cont.)
• Special cases
• Confidentiality
– Not always clear who
can authorize release
– If unsure, ask your
supervisor
– 18 years old
– Emancipated minor
– Mature minor
Legal and ethical
principle: Protect the
patient’s right to privacy at
all times.
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11-44
Auditing Medical Records
• Examination and review
– Completeness
– Accuracy
• Types
– Internal
– External
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11-45
Apply Your Knowledge
The medical assistant receives phone call
authorizing transfer of medical record information
for a client to another physician’s office. What
would you do in this situation?
ANSWER: Never release information based on
telephone authorization. You cannot be sure
who the caller is. Tell them you need a written
and signed release of information.
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11-46
In Summary
11.1
Medical records are legal documents that give a
complete, concise, chronological history of a
patient’s past medical history, current medical
issues, treatment plan, and treatment outcome.
Additionally, they act as a communication tool
between care providers.
The patient medical record provides physicians and
other healthcare providers with all the important
information, observations, and opinions that have
been recorded about a patient.
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11-47
In Summary
11.2
•
•
•
•
The records that comprise the patient medical
record include, but are not limited to the following:
patient registration form
medical history form
physical exam form
laboratory and other test
results
• records from physicians
or hospitals,
• physician diagnosis and
treatment plan
• operative reports
• hospital discharge
summaries
• follow-up notes
• records of telephone calls
• signed informed consents
• correspondence with or
about the patient
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11-48
In Summary (cont.)
11.3
SOMR files documents in the medical record in strict
chronological order.
POMR files the same documents according to
numbered problems found on the patient problem
list.
SOAP notes organize medical record documentation
according to subjective, objective, assessment and
plan.
The CHEDDAR format breaks down this information
even further into chief complaint, history, exam,
details, drugs, assessment, and return visit plan.
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
11-49
In Summary (cont.)
11.4
The six Cs of charting are client’s words, clarity,
completeness, conciseness, chronological order,
and confidentiality.
11.5
Neatness, legibility, accuracy, and professional tone
are musts in maintaining medical records.
Remember that patient medical records are legal
documents.
Personal thoughts and observations should never be
a permanent part of the patient medical record.
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
11-50
In Summary (cont.)
11.6
The proper way to make corrections in a medical
record is to draw a single line through the error so
that the original entry is still legible.
Any additions to a medical record should also be
made as soon as the need for the addition is noted,
and the reason for the addition or change should
also be clearly documented.
11.7
In order to release any confidential medical
information, express written permission from the
patient must be received. Only release records that
are expressly requested and authorized by the
patient.
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11-51
End of Chapter 11
Organization is the
power of the day;
without it, nothing is
accomplished.
~ Sophia Palmer
From A Daybook for Nurses:
Making a Difference Each Day
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