9-1
Maintaining Patient Records
PowerPoint® presentation to accompany:
Medical Assisting
Third Edition
Booth, Whicker, Wyman, Pugh, Thompson
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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.
© 2009 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.
9.8 Explain how to update a medical record.
9.9 Identify when and how a medical record may be
released.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-4
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-5
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-6
Importance of
Patient Records (cont.)

Information included in patient record


Name and address

Current complaint

Insurance coverage and
person responsible
for payment

Health-care needs

Medical treatment plan

Occupation

Response to care

Medical history

Lab and radiology
reports
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9-7
Patient Records: Legal Guidelines

Proof of event or procedure

No documentation



No proof
Care is considered not done
Legal document


Must document complete information about
patient care
Document if patient is noncompliant
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-8
Patient Records: Standards for Records

Complete, accurate, and well-documented
records are evidence of appropriate care

Incomplete, inaccurate, altered, or illegible
records may imply poor standards

Everyone who documents in the patient
record has a responsibility to the patient and
employing physician
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-9
Patient Records (cont.)
Patient
Education
• Test results
• Health issues
• Treatment
instructions
Additional Uses of
Patient Records
Quality of
Treatment
• Peer review
Research
• JCAHO review
• Source of data
• Health-care
analysis and
policy decisions
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-10
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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-11
Patient Charts: Standard Chart Information
Patient Registration Form

Date

Patient demographic information
 Age,
DOB
Address

SSN

Insurance / financial information

Emergency contact
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-12
Patient Charts:
Standard Chart Information (cont.)

Past 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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-13
Patient Charts:
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-14
Patient Charts:
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-15
Patient Charts:
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-16
Patient Charts:
Standard Chart Information (cont.)

Correspondence with or about the patient



Information received by fax


All written correspondence regarding the patient
Record date item was received on the actual form
Request an original copy; if not available, make a
photocopy of the fax
Dating and initialing

Be sure to date and place your initials on everything
you place in the chart
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-17
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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-18
Initiating and Maintaining
Patient Records
Completing medical
history forms
Documenting
test results
Initial
Interview
Examination,
preparation,
and vital signs
Documenting
patient
statements
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-19
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-20
Apply Your Knowledge
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 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!
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-21
The Six Cs of Charting
Client’s words –
Do not interpret patient’s words
Clarity – Precise descriptions / medical terminology
Completeness – C
Fill out forms completely
onciseness – To the point / approved abbreviations
Chronological order –
Legal issues
confidentiality – Follow HIPAA guidelines
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-22
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-23
Types of Medical Records
Source-Oriented Medical
Records
Problem-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
POMR records make it easier
to track specific illnesses
Information included
Database
 Problem list
 Educational, diagnostic, and
treatment plans
 Progress notes

© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-24
Medical Records:
SOAP Documentation

Orderly series of steps for dealing with any
medical case

Lists the following



Patient symptoms
Diagnosis
Suggested treatment
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-25
SOAP Documentation
The treatment plan to correct the illness or problem
The impression of the patient’s problem that
leads to diagnosis
lan
What the physician observes
during the examination
Information
the patient
tells you
ssessment
bjective data
ubjective data
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-26
Apply Your Knowledge
What type of documentation provides an orderly series of
steps for dealing with any medical case, and what are the
components of this type of documentation?
ANSWER: SOAP documentation provides an orderly series of
steps for dealing with any medical case. The components are
S – Subjective data
A - Assessment
O – Objective date
P - Plan
GOOD!
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-27
Apply Your Knowledge
Label the following items as either (S) “subjective” or
(O) “objective.”
ANSWER:
____
S headache
____
O pulse 72
____
O vomited x 3
____
S nausea
____
O skin color
____
O respirations 16, labored
____
S chest pain
____
S poor appetite
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-28
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-29
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-30
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-31
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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-32
Appearance, Timeliness, and
Accuracy of Records (cont.)

Computer records


Accuracy is also important with electronic
records
Advantages




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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-33
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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-34
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-35
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

Ask for clarification immediately if something is unclear

Read the dictation back to verify accuracy

Enter notes into patient record, date, and initial
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-36
Medical Transcription (cont.)
Transcription
reference books
Medical
terminology books
Transcription
Aids
Secretarial
books
Medical reference
books
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-37
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.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-38
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”
Use care with corrections

It is more difficult to explain a chart that has been
altered after something was documented
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-39
Correcting Patient Records

When mistakes happen, correct
them immediately

Draw a line through the original
information





It must remain legible
m/d/yyyy 00:00pm
misspelled JHC
/chj
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-40
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-41
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-42
Release of Records

Records are property of
physician



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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9-43
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
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-44
Release of Records (cont.)

Special cases

Divorce


Death



Legal guardian of
children (may be one or
both parents)
Next of kin
Legally authorized
representative
If unsure, ask
supervisor

Confidentiality

18-year-olds


Considered adults in
most states
Must have written
consent to release their
records
Legal and ethical
principle:
Protect patient’s right to
privacy at all times.
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-45
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.
Nice Job!
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-46
In Summary

Medical assistants must properly prepare and
maintain patient records

There are several methods for documentation, but
regardless of method, records must be complete,
legible, current, accurate, and professional

Properly maintain, correct, update, and release
patient medical records
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
9-47
Organization is the power of the day; without
it, nothing is accomplished.
~ Sophia Palmer
From A Daybook for Nurses: Making a Difference Each Day
© 2009 The McGraw-Hill Companies, Inc. All rights reserved