Order ready-to-submit essays. No Plagiarism Guarantee!
Note: All our papers are written from scratch by human writers to ensure authenticity and originality.
The assignment needs to be done by Tuesday , March 12, 2013 by 8:00 pm New york times.. Please find attached files for review and used for assignment. Fill in template paper.
Get an Official Turnitin Report for Just $8.99!
Check your paper with the same Turnitin report your professor uses. AI detection + similarity score without storing your work. Pay once, no subscription
Check My Assignment!The Part 1 essay must be a minimum of 300 words TOTAL for all three answers. A reference citation must be included.
PART I: The Medical Record Management System your office implements is only as good as the ease of retrieval of the data in the files. Organization and adherence to set routines will help to ensure that medical records are accessible when they are needed.
Questions:
- Why do medical records exist? (See Chapter 14, page 251 of your text.)
- Discuss the advantages and disadvantages of establishing and maintaining electronic health records (EHRs). (See Chapter 14, page 252 of your text.)
- Discuss and explain the five basic filing steps. Include why each is important (conditioning, releasing, indexing, etc.). (See Chapter 14, pages 271 and 272 of your text).
Filing:
- Download the Filing Medical Records Template from Doc Sharing.
- Place the names in the template in the correct alphabetical filing order.
- Use the following format: LAST NAME, FIRST NAME (e.g., CLAIRE, JENNIFER).
Thanks,
bakiliyam
Susan Beezler has just begun her career in the medical assisting profession. She is attending medical assisting school in the morning hours and works part-time for a family practitioner in the afternoons as a clerical record assistant. Susan is eager to learn about medicine and looks forward to taking on more responsibility at the offi ce.
The practice is growing swiftly and recently added a new physician, Dr. Alex Thomas. Dr. Thomas has enjoyed working with Susan and feels that her energy will be just what his patients need. He has taken a special interest in Susan and often lets her assist him with patients when her other duties allow.
Susan knows that although she is a beginner in the offi ce, she will gain trust from her supervisors and patients as long as she projects a teachable attitude. She cheerfully performs fi ling and often does transcription for Dr. Thomas. The other staff members are pleased with her willingness to perform the most mundane tasks. Her warm personality and caring way with patients ensure that she has a great chance at a long career in this medical offi ce.
Susan enjoys sharing her experiences with the other students in her class. She is the only person who is currently working in the medical fi eld, so the other students ask many questions about what Susan has experienced in the real world of medicine. She is very careful not to breach patient confi dentiality as she discusses situations in general, never mentioning any patient names.
Susan feels a great sense of pride that she is already a member of the healthcare team and able to make a positive contribution to the lives of her patients.
While studying this chapter, think about the following questions:
249
14 SCENARIO
UNIT THREE: HEALTH INFORMATION IN THE MEDICAL OFFICE
Medical Records Management
• How can the medical assistant help to alleviate patient concerns about electronic medical records?
• How can the medical assistant earn the patient’s trust so that he or she is comfortable revealing the very private information contained in health histories?
• Why is the simple task of fi ling such a critical action in the physician’s offi ce?
1. Defi ne, spell, and pronounce the terms listed in the vocabulary. 2. State several important reasons for keeping accurate medical
records. 3. Discuss the ownership of records. 4. Explain the difference between a traditional medical record and a
problem-oriented medical record. 5. Illustrate the difference between subjective and objective
information. 6. Discuss changing an entry in the patient record and the
importance of following correct procedures. 7. List and discuss the basic equipment used in a fi ling system. 8. Describe the steps in fi ling a document. 9. List and discuss application of the basic fi ling systems.
10. Explain how color-coding of fi les can be useful in a medical facility.
11. Establish a patient’s medical record. 12. Prepare an informed consent for treatment form. 13. Add supplementary items to an established patient record. 14. Prepare a record release form. 15. Transcribe a machine-dictated letter using a computer or word
processor. 16. File medical records and documents using an alphabetic system. 17. File medical records and documents using a numeric system. 18. Color-code medical records. 19. Document appropriately and accurately.
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE250
alphabetic filing Any system that arranges names or topics according to the sequence of the letters in the alphabet.
alphanumeric Of or relating to systems made up of combina- tions of letters and numbers.
audit A formal examination of an organization’s or individual’s accounts or financial situation; a methodic examination and review.
augment To make greater, more numerous, larger, or more intense.
caption A heading, title, or subtitle under which records are filed.
chronologic order Of, relating to, or arranged in or according to the order of time.
continuity of care Continuation of care smoothly from one provider to another, so that the patient receives the most benefit and no interruption in care.
dictation (dik-tay -shun) The act or manner of uttering words to be transcribed.
direct filing system A filing system in which materials can be located without consulting an intermediary source of reference.
gleaned Gathered bit by bit (e.g., information or material); picked over in search of relevant material.
indirect filing system A filing system in which an intermediary source of reference, such as a card file, must be consulted to locate specific files.
microfilm A film bearing a photographic record on a reduced scale of printed or other graphic matter.
numeric filing The filing of records, correspondence, or cards by number.
objective information Information that is gathered by watching or observation of a patient.
obliteration (uh-bli-tuh-ra -shun) Act of making undecipherable or imperceptible by obscuring or wearing away.
OUTfolder A folder used to provide space for the temporary filing of materials.
OUTguide A heavy guide that is used to replace a folder that has been temporarily moved from the filing space.
power of attorney A legal instrument authorizing one to act as the attorney or agent of the grantor.
pressboard A strong, highly glazed composition board resembling vulcanized fiber; heavy card stock.
procrastination (pruh-kras-tuh-na -shun) The intentional post- ponement of doing some thing that should be done.
provisional diagnosis A temporary diagnosis made before all test results have been received.
quality control An aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries.
requisites (re -kwuh-zuhts) Entities considered essential or necessary.
retention schedule A method or plan for retaining or keeping medical records, and their movement from active, to inactive, to closed filing.
shelf filing A system that uses open shelves rather than cabinets for storing records.
shingling A method of filing whereby one report is laid on top of the older report, resembling the shingles of a roof.
subjective information Information that is gained by ques- tioning the patient or taken from a form.
tickler file A chronologic file used as a reminder that something must be taken care of on a certain date.
transcription To make a written copy of, either in longhand or by machine.
vested Granted or endowed with a particular authority, right, or property; to have a special interest in.
National Accreditation Competencies and Content
CAAHEP COMPETENCIES ABHES COMPETENCIES
Administrative Communication 3.a.(1)(c). Organize a patient’s medical record 2.j. Use correct grammar, spelling, and formatting techniques in written works 3.a.(1)(d). File medical records 2.n. Application of electronic technology 2.o. Fundamental writing skills General 3.c.(2)(c). Establish and maintain the medical record Administrative Duties 3.c.(2)(d). Document appropriately 3.b. Prepare and maintain medical records 3.h. File medical records
Legal Concepts 5.a. Determine needs for documentation and reporting 5.b. Document accurately 5.c. Use appropriate guidelines when releasing records or information 5.d. Follow established policy in initiating or terminating medical treatment
251CHAPTER 14 Medical Records Management
Amedical records management system is only as good as the ease of retrieval of the data in the files. Because the pace of the medical office is usually quite rapid, patient medical records must be found quickly and also be functional, so that the information inside is easily obtainable.
Few phrases are more frustrating to the patient than “we cannot locate your records.” Patients have every right to question the competence of the medical care they are receiving if the office has problems simply finding a chart. Organization and adherence to set routines will help to ensure that medical records are accessible when they are needed.
WHY MEDICAL RECORDS ARE IMPORTANT
Medical records exist for four basic reasons. First, the medical record assists the physician in providing the best possible medical care for the patient. The physician examines the patient and enters the findings on the patient’s medical record. These findings are the clues to diagnosis. The physician may order many types of tests to confirm or augment the clinical findings. As the reports of these tests come in, the findings fall into place like the pieces of a jigsaw puzzle. Then, with the confirmation data to support the diagnosis, the physician can prescribe treatment and form an opinion about the patient’s chances for recovery, assured that every resource has been used to arrive at a correct judgment. The medical record provides a complete history of all of the care given to the patient.
The medical record also provides critical information for others. By reading through the record and discovering the methods used to treat the patient, healthcare professionals can provide a continuity of care. Each person knows what the patient has experienced and can provide continued care, even from one facility to another. For example, when a patient is transferred from a hospital to a skilled nursing facility, the information from the patient’s hospital record will help the nursing facility staff to better care for the patient. When patients move from place to place or caregivers change, copies of the pertinent information should move with the patient to provide this continuity of care.
The second reason for keeping medical records is to offer legal protection for those who provided care to the patient. A documented medical record is excellent proof that certain procedures were performed or medical advice was given. An accurate record is the foundation for legal defense in cases of medical professional liability. This is one reason that it is critical to write legibly in the record and document exactly what happens to the patient. Remember: If it isn’t charted, it didn’t happen.
Third, medical records provide statistical information that is helpful to researchers. The patient’s record provides information about medications taken and the reactions to them. Medical records may be used to evaluate the effectiveness of certain kinds of treatment or to determine the incidence of a given disease. Often, physicians take part in drug studies that track adverse reactions and side effects. The effects of various treatments and procedures can also be tracked and statistics gleaned from the information gathered from patient records.
Correlation of such statistical information may result in a new outlook on some phases of medicine and can lead to revised techniques and treatments. The statistical data from medical records are also valuable in the preparation of scientific papers, books, and lectures.
Fourth, medical records are vital for financial reimbursement. The information in the medical record supports claims for reimbursement and is required by most third-party payors.
OWNERSHIP OF THE MEDICAL RECORD
Who actually owns the medical record? Patients often assume that because the information contained in the medical record is about them, the ownership of the record rightfully belongs to the patient. However, the owner of the physical medical record is the physician or medical facility, often called the “maker,” that initiated and developed the record. The patient has the right of access to the information within but does not own the physical chart or other documents pertaining to the record. The patient has a vested interest and therefore has the right to demand confidentiality of all of the information placed in the chart.
The actual medical record should never leave the medical facility from which it originated. Even the physician should refrain from taking the record from the office to the hospital or nursing facility. If information from the record is needed, copies can be placed in a file, and progress notes written on-site and returned to the original record later. Patient records should be kept in a locked room or locked filing cabinets when the office is closed.
On Susan’s third day at work, a man comes into the office and demands to see his mother’s medical chart. Susan pulls the chart and sees an entry stating that the mother does not wish the son to have any information about her. What should Susan do in this situation? Are there any viable reasons why the son should have access to the mother’s medical information?
CREATING AN EFFICIENT MEDICAL RECORD MANAGEMENT SYSTEM
The medical record management system used in the medical office should provide an easy method for retrieving information. The files should be organized in an orderly fashion, and all of the information within the record must be completely legible to the average reader. The information must also be accurate, and corrections should be made and documented properly. The wording in the record should be easily understood and grammatically correct. An efficient method of adding documents to the chart must be in place so that the physician or other provider always has the most up-to-date information.
Above all, the medical record management system must be one that works for the individual facility. Attempting to adopt a method used by another facility may not always be best. The system should be adapted to the needs of the facility and the provider.
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE252
Types of Records
The two major types of patient records include the paper-based medical record and the computer-based medical record. As computer technology advances, the paper-based medical record seems more and more inefficient. It is difficult to use a paper- based record for multiple purposes. In most cases, only one person can use the paper-based record at any given time, and the record is not available to others who need it when it is in use by a single person. Misfiled information is common, and the entire record can be misfiled as well. Data cannot be accessed easily for research and quality control, and in facilities with multiple departments the information is difficult to share. The paper-based record is a good evidence of patient care, but it not nearly as useful in other capacities.
The computer-based medical record (also called the electronic health record) is much more efficient than the paper-based record. The book Electronic Health Records: Changing the Vision offers the following definition:
An electronic health record is any information relating to the past, present, or future physical/mental health, or condition of an indi- vidual which resides in electronic systems used to capture, transmit, receive, store, retrieve, link, and manipulate multimedia data for the primary purpose of providing healthcare and health related services. Some healthcare professionals distinguish between a
computer-based medical record and an electronic health record. To simplify a difficult definition, consider the computer-based medical record as one in which the bulk of information is entered via computer but there are still paper aspects to the record. For instance, an x-ray film may not be included in a patient’s computer-based record. The x-ray film may still be filed in a room among all other patient x-ray films. However, using an electronic health record, all healthcare information is stored in one format. This means that x-ray studies, bone scans, magnetic resonance imaging (MRI) studies, and so on would be scanned into the electronic health record and become a permanent part of the record.
Granted, not all physicians today have the means or desire to convert to a total electronic health record. The cost of such a conversion would be tremendous. However, physicians who are just opening and establishing their practices may look more toward the future and plan for an electronic medical practice. Even today, many physicians use laptop computers, or smaller electronic units, to record patient information during office visits.
Be aware that for a medical assistant, learning never stops. As facilities grow, medical assistants will be asked to make changes and learn new ways of completing tasks. Be willing to move into the future and embrace new ideas. Those who balk and complain about change will find themselves left behind as technology advances.
The computer-based medical record is a great improvement over the paper-based record, but it is not without its disadvantages. Patient confidentiality is critical and sometimes difficult to maintain with computer-based records. Many providers worry about computer malfunctions that would inhibit access to the record in an emergency.
Still, the advantages of the computer-based record seem to far outweigh the disadvantages. Information can be accessed in a variety of physical locations, and more than one person can see the record at any given time. The patient database usually allows various types of statistical information to be recalled, which is a valuable tool. Patient information is available quickly in an emergency, even when the patient is not in his or her hometown. All of these advantages mean that the computer- based record will continue to be a key tool in the future.
Some of the patients who visit Dr. Thomas have expressed concern that computer-based medical records may not be private enough. They are worried that unauthorized individuals could somehow access their information on the computer and somehow cause the patients harm. How might Susan alleviate the patients’ fears? What disadvantages regarding confidentiality are associated with the computer-based patient record? Should a patient be allowed to decide whether his or her records will be kept on computer or on paper?
ORGANIZATION OF THE MEDICAL RECORD
Source-Oriented Records The traditional patient record is source oriented; that is, observations and data are cataloged according to their source— physician, laboratory, radiology department, nurse, technician— with no recording of a logical relationship among them. Forms and progress notes are filed in reverse chronologic order (most recent on top) and filed in separate sections of the record by the type of form or service rendered—all laboratory reports together, all x-ray reports together, and so on.
Problem-Oriented Medical Records The problem-oriented medical record (POMR) is a radical departure from the traditional system of keeping patient records. It is sometimes referred to as the Weed system, because it was originated by Dr. Lawrence L. Weed, a professor of medicine at the University of Vermont’s College of Medicine. The POMR is a record of clinical practice that divides medical action into four bases:
• The database includes chief complaint, present illness, patient profile, review of systems, physical examination, and laboratory reports.
• The problem list is a numbered and titled list of every problem the patient has that requires management or workup. This may include social and demographic troubles as well as strictly medical or surgical ones.
• The treatment plan includes management, additional workups needed, and therapy. Each plan is titled and numbered with respect to the problem.
• The progress notes include structured notes that are numbered to correspond with each problem number.
Several companies have developed file folders for the organization of patient data consistent with the POMR (Figure 14-1). The problem list is entered on the divider cover for
253CHAPTER 14 Medical Records Management
laboratory reports. Special sections are provided for current major and chronic problems and for inactive major or chronic problems. The divider cover for progress notes is a chart for listing medications and other therapeutic modalities. Progress notes follow the SOAP approach. SOAP is an acronym for the following:
• Subjective impressions • Objective clinical evidence • Assessment or diagnosis • Plans for further studies, treatment, or management Some medical offices also used an “E” in the record, to
represent “Evaluation.” This section is used to record an assessment of the patient’s understanding of and possible compliance with the treatment plan. As this is not used in every practice, the medical assistant may never see or use it to complete a patient record.
The POMR has the advantage of imposing order and organization on the information added to a patient’s medical record. The records are more easily reviewed, and the likelihood of overlooking a problem is greatly reduced. The SOAP method essentially forces a rational approach to patient problems and assists in formulating a logical and orderly plan of patient care (Figure 14-2).
Dr. Thomas wants Susan to thoroughly understand the SOAP method of charting. How would Susan explain each aspect of this method to a classmate? Distinct differences exist between the SOAP method and the POMR. Help Susan distinguish between the two. Which method seems easier and more efficient to you?
Popularity of the POMR has continued to grow since its introduction in the 1960s, and it is especially advantageous in clinics, group practices, and hospitals, where more than one person must be able to find essential information in the chart.
CONTENTS OF THE COMPLETE CASE HISTORY
The medical case history is the most important record in a physician’s practice. For completeness, each patient’s record should contain subjective information provided by the patient and objective information provided by the physician. If all entries are completed, the case history will stand the test of time. No branch of medicine is exempt from the necessity of keeping patient history records.
Subjective Information
Personal Demographics The patient’s case history begins with routine personal data, which the patient usually supplies on the first visit (Procedure 14-1). Most patients are required to complete a patient information form (Figure 14-3). The basic facts needed are the following:
• Patient’s full name, spelled correctly • Names of parents if patient is a child • Patient’s sex • Date of birth • Marital status • Name of spouse, if married • Number of children, if any • Home address, telephone number, and email
DATE # PROBLEM OR CONDITION PLAN RESOLVED
PROBLEM LIST
11/8/37
FIGURE 14-1 A chart designed for a problem-oriented medical record (POMR). Some charts are specifically adapted to the POMR. (Courtesy Bibbero Systems, Inc., Petaluma, Calif. 94954, (800) 242-2376, www.bibbero.com.)
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE254
OUTLINE FORMAT PROGRESS NOTES
Patient Name
DATE Subjective Objective Assess Plans Page
Prob. No. or Letter
S O A P
Start each Progress Note (Subjective, Objective, through the intervening columns to the right
ANDRUS/CLINI-REC® PRIMARY CARE CHARTING SYSTEM FORM NO. 26-7115, ©1976 BIBBERO SYSTEMS, INC., PETALUMA, CA.
Assessment and Plans) at the appropriate margin of the page.
shaded column to create an outline form. Write
Fletcher, LeRoy
1
2 01/26/06 Patient complains of two days of severe high epigastric pain and burning,
radiating through to the back. Pain accentuated after eating.
On examination there is extreme guarding and tenderness, high epigastric
region. No rebound. Bowel sounds normal. BP 110/70
R/O gastric ulcer, pylorospasm.
To have upper gastrointestinal series. Start on
Cimetidine, 300 mg. q.i.d. Eliminate coffee, alcohol, and
aspirin. Return in two days.
FIGURE 14-2 SOAP progress notes. The SOAP method keeps information organized and in a logical sequence. An actual progress note would include the physician’s signature or initials after this entry. (Courtesy Bibbero Systems, Inc., Petaluma, Calif. 94954, (800) 242-2376, www.bibbero.com.)
255CHAPTER 14 Medical Records Management
• Occupation • Name of employer • Business address and telephone number • Employment information for spouse • Healthcare insurance information • Source of referral • Social Security number
Personal and Medical History The personal and medical history, which is often obtained by having the patient complete a questionnaire, provides information about any past illnesses or surgical operations that the patient may have had and includes data about injuries or physical defects, whether congenital or acquired (Figure 14-4). It also includes information about the patient’s daily health habits. The presence of allergies, advance directives, and other information can be easily indicated on the front of the medical record by the use of stickers (Figure 14-5). These are useful when important facts about the patient need to be on the forefront of the health professional’s mind while treating the patient.
Patient’s Family History The family history is composed of the physical condition of the various members of the patient’s family, any illnesses or diseases that individual members may have experienced in the past, and a record of the causes of death. This information is
important, because a hereditary pattern may be present in the case of certain diseases.
Patient’s Social History The patient’s social history includes information about the lifestyle the patient lives. If the patient drinks, how many drinks per day or per week are consumed? If the patient uses cigarettes, how many packs a day are smoked? Drug use and even marital information can be considered part of the social history.
While taking a medical history from a patient, Susan asks about the social history. She questions the patient as to whether he drinks alcohol. The patient immediately becomes defensive and accuses Susan of getting too personal about his affairs. How might Susan explain her reasons for asking these questions? What options are available if the patient refuses to discuss the social history with Susan? Could this opposition to questions about the social history raise suspicion in Susan’s mind? What might she suspect?
Patient’s Chief Complaint The patient’s chief complaint is a concise account of the patient’s symptoms, explained in the patient’s own words. It should include the following:
PROCEDURE 14-1
Establish the Medical Record CAAHEP COMPETENCY: 3.a(1)(c), 3.c.(2)(c) ABHES COMPETENCY: 3.b
GOAL: To initiate a medical file for a new patient that will contain all the personal data necessary for a complete record and any other information required by the facility.
EQUIPMENT and SUPPLIES
• Computer or typewriter • Clerical supplies (pen, clipboard) • Information on the agency’s filing system • Registration form • File folder • Label for folder • Identification (ID) card if using numeric system • Cross-reference card • Financial card • Routing slip • Private conference area
PROCEDURAL STEPS
1. Determine that the patient is new to the office. 2. Obtain and record the required personal data.
PURPOSE: Complete information is necessary for credit and insurance claim processing.
3. Type the information onto the patient history form.
4. Review the entire form. PURPOSE: To confirm that the information is complete and
correct. 5. Select a label and folder for the record.
EXPLANATION: If color-coding is used, a decision must be made regarding the appropriate color for the patient name.
6. Type the caption on the label and apply it to the folder. EXPLANATION: Use the patient’s name for alphabetic filing or
appropriate number for numeric filing. 7. For a numeric filing system, prepare a cross-reference card and
a patient ID number. PURPOSE: Numeric filing is an indirect system and requires
a cross-reference to a patient’s name for locating the chart. The patient will use the number of the ID card when arranging appointments or making inquiries.
8. Prepare the financial card, or place that patient’s name in the computerized ledger.
9. Place the patient’s history form and all other forms required by the agency into the prepared folder.
10. Clip an encounter form on the outside of the patient’s folder.
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE256
Thank you for selecting our health care team! To help us meet all your health care needs, please
fill out this form completely in ink. If you have any questions or need assistance, please ask us – we will be happy to help.
Patient #
Soc. Sec. #
Date
Home phone
State Zip
State
Work phone
State Zip
Work phone
Phone
Full time
Name
Address
Check appropriate box:
If student, name of school/college
Patient’s or parent’s employer
Business address
Spouse or parent’s name
Whom may we thank for referring you?
Person to contact in case of emergency
(CONFIDENTIAL)
Name of person responsible for this account
Address
Driver’s license #
Employer
Is this person currently a patient in our office?
Name of insured
Birth date
Name of employer
Address of employer
Insurance company
Ins. co. address
How much is your deductible?
Name of insured
Birth date
Name of employer
Address of employer
Insurance company
Ins. co. address
How much is your deductible?
I authorize release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor.
DO YOU HAVE ANY ADDITIONAL INSURANCE?
Relationship to patient
Date employed
Work phone
State Zip
Policy/ID #
State Zip
Birth date
City
City
City
Employer
Relationship to patient
Home phone
SSN#
Minor Single Married Divorced
Yes No
Yes No IF YES, COMPLETE THE FOLLOWING:
Widowed Separated Part time
Financial institution
Work phone
Birth date
Max. annual benefit
Union or local #
City
Group #
City
How much have you used?
Social Security #
Relationship to patient
Date employed
Work phone
State Zip
Policy/ID #
State Zip
Max. annual benefit
Union or local #
City
Group #
City
How much have you used?
Signature of patient or parent if minor X
Date
Social Security #
FIGURE 14-3 The patient information form provides all of the information that the medical assistant needs to construct a patient chart.
257CHAPTER 14 Medical Records Management
• Nature and duration of pain, if any • Time when the patient first noticed symptoms • Patient’s opinion as to the possible causes for the
difficulties • Remedies that the patient may have applied before seeing
the physician • Other medical treatment received for the same condition
in the past
Objective Information Objective findings, sometimes referred to as signs, become evident from the physician’s examination of the patient.
Physical Examination and Findings and Laboratory and Radiology Reports This section of the case history varies greatly with the specialty of the physician and the complaint of the patient. After the
FIGURE 14-4 Database self-administered general health history questionnaire. Lengthy questionnaires should be completed by the patient before he or she is seen by the physician. Either mail the information to the patient in advance or ask the patient to come in early to complete the paperwork. (Courtesy Bibbero Systems, Inc., Petaluma, Calif. 94954, (800) 242-2376, www.bibbero.com.)
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE258
physician has examined the patient, the physical findings are recorded in the history. Results of other tests or requests for these tests are then recorded or, if they appear on separate sheets, are attached to the history.
Diagnosis The physician, on the basis of all evidence provided in the patient’s past history, the physician’s examination, and any supplementary tests, places the diagnosis of the patient’s condition on the medical record. If some doubt remains, this may be termed a provisional diagnosis.
Treatment Prescribed and Progress Notes The physician’s suggested treatment is listed after the diagnosis. Generally, instructions to the patient to return for follow-up treatment in a specific period of time are noted here as well. If surgery or other treatment is needed, the patient must sign a consent form (Procedure 14-2).
On each subsequent visit the date must be entered on the chart and information about the patient’s condition and the results of treatment added to the history, on the basis of the physician’s observations. Notations of all medications prescribed or instructions given, as well as the patient’s own progress report, should be placed in the record. Any home visits are noted. If the patient is hospitalized, the name of the hospital, the reason for the admission, and the dates of admission and discharge are recorded. Much of this information may be obtained from the hospital discharge summary.
Condition at the Time of Termination of Treatment When the treatment is terminated, the physician will record that information. For example:
August 18, 2006. Wound completely healed. Patient discharged.
Obtaining the History The medical assistant usually secures the routine personal data. The personal and medical history and the patient’s family history may be secured by asking the patient to complete a questionnaire, with the physician augmenting the information provided during the patient interview (see Procedure 27-1).
The Medical Assistant’s Role When the medical assistant is responsible for recording the patient’s history, care must be exercised to ensure that the patient’s answers are not heard by others in the reception room. If privacy is not possible, it is better to give the patient a form to fill out, then to transfer this information to permanent records later. When privacy is available, the medical assistant may ask the patient questions and at the same time write or type the answers directly on the record. This method offers an opportunity to become better acquainted with the patient while completing the necessary records. In facilities where lengthy questionnaires are to be completed by the new patient, the questionnaire may be mailed to the patient with a request that it be completed and returned to the physician before the appointment. If the record
ALLERGIC:
B
C
A
FIGURE 14-5 Chart stickers. Information on stickers on the outside of the chart allows the physician and medical staff to quickly see important information about the patient. (Courtesy Bibbero Systems, Inc., Petaluma, Calif. 94954, (800) 242-2376, www.bibbero.com.)
259CHAPTER 14 Medical Records Management
is to be computerized, requesting the information ahead of time gives the office staff the opportunity to transfer information to the computer before the new patient’s visit.
The patient’s chief complaint may have been indicated to the medical assistant, but the physician will question the patient in more detail. Many practitioners write their own entries on the chart in longhand. Some may key the findings directly into the computer. Others may dictate the material, either directly to the medical assistant or by using a recording device. If the material is dictated and typed, the physician should check each entry then initial the entry to verify accuracy. For a chart to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written. The best indication of that is the physician’s signature or initials on the typed entry.
MAKING ADDITIONS TO THE PATIENT RECORD
As long as the patient is under the physician’s care, the medical history is building. Each laboratory report, radiology report, and progress note is added to the record, with the latest information
always on top (Procedure 14-3). Although each item is important, the most recent is usually of greatest significance to the patient’s care. Again, the physician should read and initial each of these reports before it is placed in the record.
Laboratory Reports Different colors of paper are often used for reporting different procedures. For example, urinalysis report forms may be yellow, blood count forms pink, and so on. When laboratory slips are smaller than the history form, they should be placed on a standard 81/2- × 11-inch sheet of colored paper. Type or print the patient’s name in the upper right corner; then, with transparent tape, fasten the first report even with the bottom of the page. The second laboratory report will be taped or glued in place on top of and approximately 1/2 inch above the first slip, allowing the date to show on the first report. By this method, called shingling, the latest report always appears on top (Figure 14-6). When checking previous reports, it is necessary only to run a finger down the slips until the desired date is found; then fl ip up the slips above. Laboratory report carrier forms with adhesive strips may be purchased.
PROCEDURE 14-2
Establish and Maintain the Medical Record: Prepare an Informed Consent for Treatment Form CAAHEP COMPETENCY: 3.c.(2)(d) ABHES COMPETENCY: 3.b., 5.a
GOAL: To adequately and completely inform the patient regarding the treatment or procedure that he or she is to receive, and to provide legal protection for the facility and the provider.
EQUIPMENT and SUPPLIES
• Pen • Consent form
PROCEDURAL STEPS
1. After the physician provides the details of the procedure to be done, prepare the consent form. Be sure that the form addresses the following: • The nature of the procedure or treatment • The risks and/or benefits of the procedure or treatment • Any reasonable alternatives to the procedure or treatment • The risks and/or benefits of each alternative • The risks and/or benefits of not performing the procedure or
treatment PURPOSE: To make certain that the patient is fully informed
about the procedure or treatment and the risks and/or benefits of having or not having it performed.
2. Personalize the form with the patient’s name and any other demographic information that the form lists.
PURPOSE: To correctly identify the patient and the procedure. 3. Deliver the form to the physician for use as the patient is
counseled about the procedure.
PURPOSE: To avoid charges of practicing medicine without a license. The physician should explain procedures, risks, benefits, and alternatives and answer all of the patient’s questions.
4. Witness the signature of the patient on the form, if necessary. The physician will usually sign the form as well.
5. Provide a copy of the consent form to the patient. PURPOSE: To make certain that the patient is fully informed
regarding the procedure and has a copy of the information for his or her personal records.
6. Place the consent form in the patient’s chart. The facility where the procedure is to be performed may require a copy.
PURPOSE: To maintain a permanent copy of the signed consent form.
7. Ask the patient if he or she has any questions about the procedure. Refer questions that the medical assistant cannot or should not answer to the physician. Be sure that all of the questions expressed by the patient are answered.
PURPOSE: To make certain that the patient is fully informed. 8. Provide information regarding the date and time for the
procedure to the patient.
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE260
Radiology Reports Radiology reports are usually typed on standard letter-size stationery. They are placed in the patient’s history folder, with the most recent report on top. All radiology reports may be stapled together or kept behind a special divider in the chart.
Progress Notes Reports on the patient’s progress are continually being added to the medical record. Each visit of the patient should be entered on the chart, with the date preceding any notations about the visit. The medical assistant can type or stamp the date on the chart when readying the charts for the patient’s visits. Every instruction, prescription, or telephone call for advice should be entered with the correct date. It is always advisable to initial each entry, especially when several persons are handling and making entries on a patient’s record. This aids in tracing entries about which there may be some question.
MAKING CORRECTIONS AND ALTERATIONS TO MEDICAL RECORDS
Sometimes it is necessary to make corrections to medical records. Erasing, using correction fl uid, or any other type of obliteration is never acceptable. To correct a handwritten entry, follow these three steps:
1. Draw a line through the error. 2. Insert the correction above or immediately after the
error.
3. In the margin, write correction or Corr., the initial of the person correcting the entry, and the date.
Errors made while typing are corrected in the usual way. However, an error discovered in a typed entry at a later date is corrected in the same manner as described for a handwritten entry. Never attempt to alter medical records without using this specific correction procedure, because this alteration of records may indicate a fraudulent attempt to cover up a mistake made by a staff member or the physician. Do not hide errors. If the error could in any way affect the health and well-being of the patient, it must immediately be brought to the attention of the physician.
Additions to electronic health records must be made by making an additional entry. Never delete a previous entry or change it, unless it was entered seconds ago. A good rule of thumb is to avoid changing any electronic entry after the initials of the maker have been added. This, of course, should happen immediately after the note is placed into the record. Once this has happened, a new entry must be made to correct information in a previous entry.
Susan has been using an incorrect abbreviation for several weeks and is having a difficult time remembering the right abbreviation. After taking a call from Mrs. Johnston, she remembers that she used the incorrect abbreviation in her chart last week. When Susan pulls the
PROCEDURE 14-3
Establish and Maintain the Medical Record: Add Supplementary Items to Established Patient Records
CAAHEP COMPETENCY: 3.c.(2)(c) ABHES COMPETENCY: 3.b
GOAL: To add supplementary documents and progress notes to patient histories, observing standard steps in filing, while creating an orderly file that will facilitate ready reference to any item of information.
EQUIPMENT and SUPPLIES
• Assorted correspondence, diagnostic reports, and progress notes • Patient files • Computer or typewriter • Mending tape • FILE stamp or pen • Sorter • Stapler
PROCEDURAL STEPS
1. Group all papers according to patients’ names. PURPOSE: To expedite the fi ling process.
2. Remove any staples or paper clips. PURPOSE: Staples in the file folders are hazardous; paper clips
are bulky and may become inadvertently attached to other materials.
3. Mend any damaged or torn records. 4. Attach any small items to standard-size paper.
PURPOSE: Small items are easily lost or misplaced in files. 5. Group any related papers together. 6. Place your initials or FILE stamp in the upper left corner.
PURPOSE: To indicate that the document is released for filing. 7. Code the document by underlining or writing the patient’s name
in the upper right corner. PURPOSE: To indicate where the document is to be filed.
8. Continue steps 2 through 7 until all documents have been conditioned, released, indexed, and coded.
9. Place all documents in the sorter in filing sequence. EXPLANATION: Sorter can be taken to file cabinet or shelf for
placing documents in patient folders.
Continued
261CHAPTER 14 Medical Records Management
chart, she notices that entries have been made after the ones that Susan made on Mrs. Johnston’s last visit. How does Susan correct her error?
KEEPING RECORDS CURRENT
One of the greatest dangers to good record keeping is procrastination. The record must be methodically kept current (Procedure 14-4). The medical assistant is responsible for seeing that this is done.
Case histories and reports may accumulate on the physician’s or the medical assistant’s desk during the day. After the last patient has gone, check each history to make certain that all necessary information has been recorded and that each entry is sufficiently clear for future understanding. Give the physician all abnormal reports to read and initial so that action can be taken and they may be filed in the patient’s case history folder. Some physicians will want to see every laboratory report, whether it is normal or abnormal. Follow the requirements as set forth in the office policy and procedure manual.
While the physician is reviewing these reports, pull the histories of any patients seen outside the office that day, as well as those of patients who have been given special instructions by telephone or for whom prescriptions were ordered. These entries are made in the same manner as for an office visit, but the type of call is explained in parentheses after the date.
A prescription pad, printed on no-smear, carbonless paper, is available for a timesaving, write-it-once system. By placing the prescription blank over the patient’s record, the prescription is automatically copied on the record as it is written. Prescription carriers with adhesive strips are also available for the physician who uses duplicate prescription blanks (Figure 14-7).
The patient record should not leave the office. A physician’s pocket call record can be used for outside calls, and the information can be transferred to the chart in the office (Figure 14-8). Notations should be made of any missed appointments or of refusals to cooperate with instructions as they occur.
After all records have been reviewed for the day, they should be placed in a file tray and locked away for the night if there is insufficient time to file them. Do not leave histories out in view at night, especially if the facility has a cleaning service. On
REMOVE ADHESIVE TAPE COVERING. ADD 1ST REPORT TO BOTTOM
LINE AND SUCCESSIVE REPORTS TO LINES ABOVE.
25-7210-3 ©1996 BIBBERO SYSTEMS, INC., PETALUMA, CA. TO REORDER CALL 800-BIBBERO (800 242-2376) OR FAX (800) 242-9330
HEMATOLOGY
REMOVE ADHESIVE TAPE COVERING. ADD 1ST REPORT TO BOTTOM
LINE AND SUCCESSIVE REPORTS TO LINES ABOVE.
25-7210-3 ©1996 BIBBERO SYSTEMS, INC., PETALUMA, CA. TO REORDER CALL 800-BIBBERO (800 242-2376) OR FAX (800) 242-9330
LABORATORY REPORTS
LABORATORY REPORTS
FIGURE 14-6 Shingled laboratory report forms. These forms make filing laboratory reports easy and provide a good adhesive so that the reports will not fall out of the chart if they are not standard size. (Courtesy Bibbero Systems, Inc., Petaluma, Calif. 94954, (800) 242-2376, www.bibbero.com.)
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE262
PROCEDURE 14-4
Maintain the Medical Record CAAHEP COMPETENCY: 3.c(2)(c) ABHES COMPETENCY: 3.b
GOAL: To make certain that the medical record is maintained and usable by all parties involved in patient care.
EQUIPMENT and SUPPLIES
• Patient medical record • Various forms used inside the medical record • Results and reports, if applicable • Clerical supplies
PROCEDURAL STEPS
1. Verify that the correct medical record has been pulled. PURPOSE: To make certain that all items placed into the medical
record pertain to the right patient. 2. Inspect the medical record to determine which forms need to be
added. PURPOSE: To make certain that the forms that the physician
needs are available at all times. 3. Add all necessary forms to the record to enable the physician to
document the offi ce visit properly. PURPOSE: To make certain that the forms that the physician
needs are available at all times. 4. Attach the forms to the record permanently or according to offi ce
policy.
PURPOSE: To keep information from falling out of the chart and getting lost or misplaced.
5. Make certain that all laboratory results and reports are available to the physician in the medical record.
PURPOSE: All results and reports must be available to the physician so that he or she can make an accurate diagnosis and treat the patient accordingly.
6. Permanently attach laboratory results and/or reports in the record, with the most recent on top.
PURPOSE: To easily access the most recent patient data. 7. Place the record in the designated place to await arrival of the
patient. 8. If other documents are to be added to the record, condition each
document. 9. Release each document to be added to the record.
PURPOSE: Releasing the record means to place a mark on the document to indicate that the information is ready to be fi led.
10. Index all documents to be added to the medical record. 11. Code all documents to be added to the medical record.
PURPOSE: To determine where the document is to be fi led.
arrival the next morning the medical assistant can index the histories for filing. Attach extra reports and information sheets. Always attach material to the chart permanently—do not simply drop forms into the folders. When this has been done, the records are ready for filing.
The physician may prefer to dictate progress notes rather than write them in longhand. At appropriate times during the day, everything is dictated: patient histories, physical examination findings, medications prescribed, follow-up findings, and summaries of telephone conversations. At the end of the day, the recorded information is given to the medical assistant for transcribing onto the records.
A great deal of time may be saved in transcribing these notes by using a continuous roll or pages of self-adhesive strips. When the transcription has been completed, the physician may wish to check the notes, underline important points, and initial each entry before returning the notes to the medical assistant for insertion into the charts to verify that they are correct in the event of audit or litigation. The use of self-adhesive strips saves removing the sheet from a chart that may be bound with metal fasteners, inserting the sheet into the typewriter, and putting the sheet back into the folder (Figure 14-9). It also simplifies the physician’s part in checking and initialing the notes, because only the transcribed material is handled, not the bulky charts.
TRANSFER, DESTRUCTION, AND RETENTION OF MEDICAL RECORDS
Regular Transfer of Files In most medical offices, records are filed according to three classifications:
• Active files are those of patients currently receiving treatment.
• Inactive files generally are those of patients whom the doctor has not seen for 6 months or longer. When such individuals return for care, their folders are replaced in the active file.
• Closed files are records of patients who have died, moved away, or otherwise terminated their relationship with the physician.
Some system must be established for regular transfer of files from active to inactive status or possibly destruction. The yearly expansion of charts and the file space available can infl uence the transfer period. Charts for patients who are currently hospitalized may be kept in a special section for quick reference, then placed in the regular active file when the patient is discharged from the hospital. In a surgical practice there frequently is a specific date on which the patient is discharged from the physician’s care, and
263CHAPTER 14 Medical Records Management
REMOVE ADHESIVE TAPE COVERING. ADD 1ST REPORT TO BOTTOM
LINE AND SUCCESSIVE REPORTS TO LINES ABOVE.
25-7210-3 ©1996 BIBBERO SYSTEMS, INC., PETALUMA, CA. TO REORDER CALL 800-BIBBERO (800 242-2376) OR FAX (800) 242-9330
PRESCRIPTION CARRIER
FIGURE 14-7 Filing copies of prescriptions. The self-adhesive on this form allows a copy of the prescription to be filed inside the patient’s chart, and saves time over handwriting the information a second time. (Courtesy Bibbero Systems, Inc., Petaluma, Calif. 94954, (800) 242-2376, www. bibbero.com.)
PHYSICIANS POCKET CALL RECORD
NAME SYMBOL
Post these TOTALS to office book daily.
MONEY
RECEIVED
HOME
CHARGES
HOSPITAL
CHARGES
ADDRESS OR REMARKS
DATE
FIGURE 14-8 Physician pocket call record. The pocket call record may be used to record information about patients seen away from the clinic, such as skilled nursing facility patients or hospital patients.
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE264
the notation made on the chart “Return prn” (for the Latin pro re nata, “as the occasion arises” or “when needed”). This record may safely be placed in the inactive file. In a general practice office, the outside of the folder may be stamped with the date of the visit each time the patient is seen. It will then be a simple matter to determine when the chart should be transferred to the inactive status. This is called the perpetual transfer method.
Retention and Destruction Physicians have an obligation to retain patient records that may reasonably be of value to a patient, according to the American Medical Association (AMA) Council on Ethical and Judicial Affairs. There is no standard, nationwide rule to follow in establishing a records retention schedule at this time.
Medical considerations are the primary basis for deciding how long to retain medical records. For example, operative notes and chemotherapy records should always be part of the patient’s chart. The laws regarding the retention of medical records vary from state to state, and many governmental programs, such as Medicare and Medicaid, have their own guidelines for records retention. These guidelines range anywhere from 3 years to permanent retention. When no restriction exists for the retention of medical records, it is best to keep the records for a 10-year period. However, when retaining the records of a minor, the facility should keep the records until the minor reaches the age of majority, plus an additional 3 years.
J. Barton 4-17-99
Disp:
Examination: 5 mm diameter raised, round, sharply marginated, gray-pink, finely papillomatous and keratotic lesion, left dorsal hand. Impression: Verruca vulgaris 1) Discussed treatment by electrosurgery vs. cryotherapy, with father, including
scarring with electrosurgery. 2) Lesion removed by D & C under local anesth with Xyl. + Epi. 3) Monsels, DSD, T.I.D. 4) See prn
B. Kolo 4-17-99
Disp:
Has been treating superficial multicentric BCCA, distal left mandible, with Efudex 5% cream b.i.d. for 3 wks. See inflammation with central erosion and peripheral crusting in involved area. Response appears appropriate. 1) Cont Efudex 5% cream b.i.d. 2) See in 3 wks
F. Schroeder 4-17-99 Pt. points out very small, quiescent-appearing actinic keratosis—inferior right lateral
arm x 1 and proximal left extensor forearm x 1. Discussed nature of lesions with pt. L N2 about 10 sec. each. Re/ck p.r.n. persistence.
N. Mywea 4-17-99
A
Imp:
Exam:
Pt. inquires about lesion, medial right left. Possibly present since birth. No change in size or color over time. No trmt to date. Inferior right medial left: 17 x 15 mm diameter round, sharply marginated, macular, uniformly medium-brown lesion; a few terminal hairs penetrate surface of lesion. 1) Discussed benign appearance of lesion with pt. 2) No treatment at this time 3) Re/ck prn change
B FIGURE 14-9 Self-adhesive progress notes. Progress notes can be quickly filed into the chart when self-adhesive forms are used.
If a particular record no longer needs to be kept for medical reasons, the physician should check state law to see whether there is a requirement that records be kept for a minimum length of time (most states do not have such a provision). The time is measured from the last professional contact with the patient.
In all cases, medical records should be kept for at least as long as the length of time of the statute of limitations for medical malpractice claims, which may be 3 or more years, depending on state law. In the case of a minor the statute of limitations may not apply until the patient reaches the age of majority.
The records of any patient covered by Medicare or Medicaid must be kept at least 6 years. The Health Insurance Portability and Accountability Act (HIPAA) recommends that records for patients who have died should be kept for at least 2 years.
Before old records are discarded, patients should be given an opportunity to claim a copy of the records or have them sent to another physician, if it is feasible to give the patient that opportunity. To preserve confidentiality when discarding old records, the documents should be destroyed by shredding or through a professional document destruction service.
Protection of Records Releasing original case histories to anyone outside the healthcare facility should be avoided. Instead, prepare a summary or photocopy the materials needed for reference and retain the
265CHAPTER 14 Medical Records Management
screen, resulting in an electronic medical record. Records can be scanned and stored in electronic format on writeable CD- ROM or DVD-ROM. The bulky paper files can then be put in storage or eliminated. There is no longer a need to fill hundreds of square feet of storage space or search through stacks of storage file boxes for an inactive or closed file.
RELEASING MEDICAL RECORD INFORMATION
The medical facility must be extremely careful when releasing any type of medical information. The patient must sign a release for information to be given to any third party (Procedure 14-5).
Often a family member will call to inquire about a patient, but without the patient’s specific request or release, no information may be given. Some offices have a “code” system whereby the patient gives the facility a code word that must be used by a family member to receive medical information about the patient.
Requests for medical information should be made in writing (Figure 14-10). It is unwise to accept a faxed request for medical information or a faxed release of information from a patient. Even requests from the patient’s attorney or third-party payors must be cleared by the patient to receive information. Some attorneys may present a legal document called a power of attorney, which authorizes them to see the records. Still, this document is signed by the patient, so it is a release in itself.
original in the physician’s office. With the facsimile machine becoming standard equipment in business facilities, as well as in many of our homes, the transfer of information is simplified and the records remain in safekeeping. Often only certain aspects of the record are requested by colleagues or others, and these can easily be supplied by faxing the required pages, observing precautions for confidentiality.
Occasions may arise when records are temporarily out of the office, although this should be an extremely rare occurrence. Some physicians release case histories to their colleagues, or an original record may be subpoenaed by the court. In such instances, a colored OUTfolder should be inserted in the file in place of the regular folder and a notation made of the name, date, and to whom the record was released. Interim papers may be placed in the OUTfolder until the original is returned.
Long-Term Storage Large healthcare facilities may find it advisable to microfilm records for storage. Another option is the transfer of paper records by laser beam onto optical disks. Microfilm and optical disk technology are both expensive and probably are not practical for any but a very large group practice or health maintenance organization.
Facilities that have computerized the patient records will be able to keep those records indefinitely on disk. Scanners can convert a paper record into an image on the computer
PROCEDURE 14-5
Establish and Maintain the Medical Record: Prepare a Record Release Form CAAHEP COMPETENCY: 3.c.(2)(c) ABHES COMPETENCY: 5.c
GOAL: To provide a legal document that indicates the patient’s consent to the release of his or her medical records to another provider or healthcare facility.
EQUIPMENT and SUPPLIES
• Medical record release form • Pen • Envelope
PROCEDURAL STEPS
1. Explain to the patient that a medical record release form will be necessary to obtain records from another provider. If the patient is having records sent to another provider, a release for that will also be required.
PURPOSE: To ensure the patient’s understanding of the record release procedure and purposes.
2. Review the record release form with the patient and ask if the form is understood or if the patient has any questions about the form.
PURPOSE: To provide the opportunity for questions and to ensure the patient’s understanding of the form.
3. Have the patient sign the form in the space indicated. If other demographic information is required, such as a social security number or other names used, complete that information as well.
PURPOSE: The patient must sign the form for records to be released by any medical facility.
4. Make a copy of the form for the file, then mail it to the appropriate facility. Note the date that the form was sent. Provide a copy to the patient if requested.
PURPOSE: To provide a record that the information or documents were actually requested on a certain date
5. Follow up to ensure that the requested records actually arrived. PURPOSE: To make certain that the records needed by the
physician to accurately and competently treat the patient are available in a timely manner.
6. Check the patient’s medical record to determine if a signed, current privacy policy document is on file. If not, have the patient sign one, and place it in the record.
PURPOSE: To ensure that all patients are notified of the office privacy policy.
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE266
Susan has never seen a power of attorney and is curious about this type of document. How might she investigate and learn more about them? Whom should Susan approach first for this information? The physician has an attorney that Susan has met once. Should she call him and ask about the document without notifying the physician? Why or why not?
The time may come when a patient decides that he or she no longer agrees to the release of medical information. In this case the patient should sign a revocation form, and it must be made a part of the medical record (Figure 14-11).
Sometimes the patient will want to view his or her own record. They certainly have a right to see this information, but some patients may not understand the terminology used in the record. A staff member should always remain with the patient who is viewing his or her medical record. Remember, the original medical record should never leave the medical facility.
When a release is presented to the office, copy only the records requested in the release. Do not provide additional information that is not requested. It is acceptable to charge reasonable copying fees to the person requesting the information.
DICTATION AND TRANSCRIPTION
Administrative medical assistants may find that transcribing dictation is one of the job requirements they perform periodi- cally. Transcription can be performed from handwritten notes, such as those in shorthand, or from machine dictation. In a healthcare facility, the medical transcriptionist is a part of the team. Smooth operation of the facility may depend on the timely and accurate performance of assigned responsibilities, such as record documentation and the preparation of special reports.
The transcriptionist will find that accuracy and speed are primary requisites, as well as a strong grasp of medical knowledge, especially anatomy and physiology (Figure 14-12). Income depends on the transcriptionist’s productivity, which may be measured by the number of pages, characters, or lines typed. The person who intends to do transcribing exclusively should take a special course in transcription techniques. Certification is available through the American Association for Medical Transcriptionists.
Machine Transcription Three stages of activity are involved in the process of dictation and transcription:
TO _________________________________________________________________________________
____________________________________________________________________________________
I HEREBY AUTHORIZE AND REQUEST YOU TO RELEASE TO:
ALL RECORDS IN YOUR POSSESION CONCERNING ___________________________________
____________________________________________________________________ILLNESS AND/OR
TREATMENT DURING THE PERIOD FROM __________________TO __________________.
NAME ____________________________________________TEL. _____________________________
ADDRESS___________________________________________________________________________
SIGNATURE ____________________________________________DATE _______________________
WITNESS_______________________________________________DATE _______________________
Doctor or Hospital
Address
RECORDS RELEASE AUTHORIZATION
(If relative, state relationship)
25-8104 © 1973 BIBBERO SYSTEMS, INC., PETALUMA,, CA.
FIGURE 14-10 Authorization to release medical records. All requests for medical records should be in writing, and the request should be kept in the patient chart. (Courtesy Bibbero Systems, Inc., Petaluma, Calif. 94954, (800) 242-2376, www.bibbero.com.)
267CHAPTER 14 Medical Records Management
REVOCATION OF AUTHORIZATION TO RELEASE MEDICAL RECORDS
Name
Name
Street Address
City/State/Zip
Name
Patient’s Printed Name Date
Witness Date
Patient’s Signature (or Guardian, if for a minor) Revocation Date (if other than 60 days from date above)
Social Security # (for identification purposes only)
Street Address
City/State/Zip
City/State/Zip
Street Address , who resides at
, hereby revokes authorization to the physician, hospital, clinic,
lab, radiology center or other healthcare provider listed below:
to disclose information from the medical records of:
My revocation extends to the data or documents I have initialed below:
This revocation is given freely with the understanding that:
Records of visits (all visits)
#25-8402 • 12/02 • BIBBERO SYSTEMS, INC • PETALUMA, CA TO REORDER FORMS: (800) BIBBERO (800 242-2376) OR FAX: (800) 242-9330 MFG IN U.S.A.
1. Disclosures made in good faith may have already occured based upon my previously issued authorization and that this renovation cannot apply retroactively to such disclosures. I also understand that the disclosure of health information may be required by law in some instances, such as for the reporting of communicable diseases. 2. The facility, it’s employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the information I authorized previously.
Record of visit for a specific date or dates, including or limited to Copies of records or reports provided to the above named (i.e. hospital, lab, etc.) Statements of charges or payments Mental health, alcohol and/or drug abuse treatment HIV information Hepatitis information Other (specific)
FIGURE 14-11 Revocation of release of medical records. (Courtesy Bibbero Systems, Inc., Petaluma, Calif 94954, (800) 242- 2376, www.bibbero.com.)
FIGURE 14-12 Medical transcriptionists must have excellent typing skills and good hearing. They must be accurate and use good grammar while completing transcription duties.
• Dictating into a dictation unit • Listening to what has been dictated • Keyboarding the dictated text to a printed document
using correct format and required punctuation
Dictation Unit A dictation unit is used by the physician to record material to be typed. Dictation units vary in design and capabilities. A desktop dictation unit is common in an office setting. This may be a combination unit used for both dictation and transcription. Alternatively, a machine used only for dictation may remain at the physician’s desk; a separate transcription unit, including headphones and a foot pedal, remains at the transcriptionist’s station. A lightweight, portable, handheld dictation unit may be used for times when the physician wishes to dictate while traveling or attending meetings away from the office. Digital dictation machines are now available; these are lightweight and portable and hold more information than standard dictation recorders. Physicians in a larger setting may install transcribing
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE268
equipment that they can access by telephone wherever they may be. Many hospitals have this arrangement. All produce a recording that the transcriptionist listens to while keyboarding the text.
Susan would like to practice transcription skills at home, but she does not have a transcription unit. How could she do this without the proper equipment? Medical terminology is important to the medical assistant who does transcription. What are some ways Susan can improve her medical terminology skills?
Transcriber Unit The unit operated by the transcriptionist may use magnetic tape, a cassette, or a disk. A desktop unit using minicassettes, microcassettes, or standard cassettes is typical in the physician’s office.
There are many types and manufacturers of transcribing equipment, but most units contain certain standard features. Before using any equipment, the medical assistant should study the manufacturer’s instruction manual. Most transcription units have at least the following features:
• Stop and start control, with backup and fast-forward ability
• Speed control • Volume control • Tone control • Indicator for locating special instructions and determining
the document length A beginning transcriptionist tends to listen to a few words,
stop the machine, type those words, then restart the transcriber unit. Through practice, the transcriptionist learns to coordinate keyboarding activity with listening skills and listen ahead, thereby retaining in memory more and more of the dictated material so that it becomes unnecessary to stop and start the machine for this purpose.
Keyboarding Unit The most important piece of equipment for the transcriptionist is the typewriter or computer on which the printed text will be produced (Procedure 14-6). Many improvements have occurred within the past few years. Computers have attachable foot pedals and headphones that allow the medical assistant to perform transcription directly onto the unit. A variety of computer programs are available to assist with transcription duties.
FILING EQUIPMENT
The vertical four-drawer steel filing cabinet, used with manila folders with the patient’s name on the tab, was the traditional system of choice for years. The most popular system today is color-coding on open shelves. Rotary, lateral, compactable, and automated files are also available. Some records are kept in card or tray files. Regardless of the type or style of equipment, the best quality is always an economy. Some of the considerations in selecting filing equipment are as follows:
• Office space availability • Structural considerations • Cost of space and equipment • Size, type, and volume of records • Confidentiality requirements • Retrieval speed • Fire protection
Drawer Files Drawer files should be full suspension; they should roll easily, close securely, and be equipped with a locking device. The best cabinets have a center trough at the bottom of each drawer with a rod for holding divider guides. Floor space of twice the depth of the drawer must be allowed so that the drawer can be pulled out to its full extent. A drawback of the vertical four-drawer files is that only one person can use a file cabinet at any given time. Filing is also slower because the drawer must be opened and closed each time a file is pulled or filed. Drawer files are
PROCEDURE 14-6
Transcribe a Machine-Dictated Letter Using a Computer or Word Processor CAAHEP COMPETENCY: 3.c.(1)(a) ABHES COMPETENCIES: 2.j, 2.n, 2.o
GOAL: To transcribe a machine-dictated letter into a mailable document without error or corrections, using a computer or word processor.
EQUIPMENT and SUPPLIES
• Transcribing machine • Word processor or computer with appropriate software • Stationery • Reference manual
PROCEDURAL STEPS
1. Assemble supplies. 2. Set up format for selected letter style. 3. Keyboard the text while listening to the dictated letter. 4. Edit the letter on the monitor.
PURPOSE: The letter should be in mailable form before printing. 5. Execute a spell check. 6. Direct the letter to the printer.
269CHAPTER 14 Medical Records Management
relatively easy to move, but for safety reasons they should be bolted to the wall or to one another.
File cabinets are heavy and can tip over, causing serious damage or injury unless reasonable care is observed. Open only one file drawer at a time, and close it when the filing has been completed. A drawer left even slightly open can cause injury to a passerby.
Shelf Files Shelf files should have doors to protect the contents. A popular type of shelf file has doors that slide back into the cabinet; the door from a lower shelf may be pulled out and used for work space. Approximately 50% more material per square foot of fl oor space may be filed in shelf files when compared with the four-drawer file. Open shelf units hold files sideways and can go higher on the wall because there is no drawer to pull out (Figure 14-13). File retrieval is faster because several individuals can work simultaneously.
Open shelf units without doors are the most economic but offer little protection or confidentiality to the records. They are susceptible to water and fire damage. Shelf files are available in many attractive colors and can add a decorative note to the business office. Special storage or shelf space should be provided for x-ray films, if many films are stored.
Rotary Circular Files Rotary circular files can hold a large volume of records. They save space and clerical motion. The files revolve easily; some come with push-button controls. Several persons can work at one rotary file and use records at the same time. One disadvantage is that they afford less privacy and protection than files that can be closed and locked.
Lateral Files Lateral files are good for personal files and are especially attractive for the physician’s private office. They use more wall space than the vertical file but do not extend out into the room
so far. The folders are filed sideways in the lateral file, left to right, instead of front to back as in a vertical file. Some have a pull-out drawer, as the vertical file does; others have doors that slide into the cabinet, exposing the filing space.
Compactable Files The office with little space and a great volume of records might use compactable files, which are a variation of open shelf files. The files are mounted on tracks in the fl oor, and the units slide along the tracks so that access is gained to the needed records. The rolling may be either automated or manual. One drawback is that not all records are available at the same time.
Automated Files Automated files are very expensive initially and require more maintenance than do the other types of filing equipment. They will probably be found only in very large installations such as clinics or hospitals. These files bring the record to the operator instead of the operator going to the record. When the operator presses a button indicating the appropriate shelf, the shelf automatically moves into position in front of the operator for record retrieval. The automated or power file is fast and can store large numbers of records in a small amount of space. Only one person can use the unit at one time.
Card Files Almost every office has some occasion to use a card file. This may be for patient ledgers, a patient index, a library index, an index of surgical tray setups, telephone numbers, or numerous other records. A good-quality steel box or tray is a sound investment.
Special Items Metal framework is available that can convert a regular drawer file into suspension-folder equipment. The assistant with a great deal of filing may wish to purchase a portable filing shelf that fits on the side of an opened drawer and can be moved from place to place as needed. Another special filing item is a sorting file, which can be a great time saver. A portable file cart for the temporary filing of unbilled insurance claims may be quite useful. It may also be used for the preliminary sorting of charts to be refiled. This is sometimes called a suspense file.
SUPPLIES
Divider Guides Each file drawer or shelf should be equipped with plenty of dividers or guides. Some authorities recommend one guide for approximately each 11/2 inches of material, or every eight to ten folders. Guides should be of good-quality pressboard or strong plastic. Economy guides will soon become bent and frayed and have to be replaced. Divider guides have a protruding tab, which either may be an integral part of the card or may be made of metal or plastic. The guides reduce the area of search and serve as supports for the folders. They are available in single, third, or fifth cut (one, three, or five different positions). The guide
FIGURE 14-13 Open shelf filing is an efficient method, especially for color- coded filing systems. The shelf doors can often be used as workspace.
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE270
may have a projection at the bottom edge with a ring or hole through which a rod may go. This type of guide card is used in drawers that have a trough for the projection and a rod to hold the guides in place.
OUTguides An OUTguide is a heavy guide that is used to replace a folder that has been temporarily removed (Figure 14-14). It should be of a distinctive color for quick detection. This makes refiling simpler and alerts the file clerk that a file is missing. Several colors may be used, each color designating the temporary location of the file. The OUTguide may have lines for recording information, or it may have a plastic pocket for inserting an information card.
Chart Covers of Folders Most records to be filed are placed in covers or tabbed folders. The most commonly used is a general-purpose third-cut manila folder that may be expanded to 3/4 inch. These are available with a double-thickness reinforced tab that will greatly lengthen the life of the folder. Folders kept in drawers have tabs at the top; those kept on shelves have tabs at the side. Many variations of folder styles are available for special purposes.
The vertical pocket, which is of heavier weight than the general-purpose folder, has a front that folds down for easy access to contents and is available with up to a 31/2-inch expansion. These are used for bulky histories or correspondence.
Hanging or suspension folders are made of heavy stock and hang on metal rods from side to side in a drawer. They can be used only with files equipped with suspension equipment.
Binder folders have fasteners with which to bind papers within the folder. These offer some security for the papers, but filing the materials is time consuming.
The number of papers that will fit in one folder depends on the thickness of the papers. Near the bottom edge of most folders are one or more score marks, which should be used as the contents of the folders expand. If folders are refolded at these score marks, the danger of their bending and sliding under other folders is reduced, and a neater file results. Papers should never protrude from the folder edges, and they should always be inserted with their tops to the left. When papers start to ride up in any folder, the folder is overloaded.
Labels The label is a necessary filing and finding device. Use labels to identify each shelf, drawer, divider guide, and folder. A label on
FIGURE 14-14 OUTguides provide tracking for files that are not in their proper location. The guide gives information as to where the file can be located. (Courtesy Bibbero Systems, Inc., Petaluma, Calif. 94954, (800) 242-2376, www.bibbero.com.)
271CHAPTER 14 Medical Records Management
the drawer or shelf identifies the nature of its contents. It should also indicate the range (alphabetic, numeric, or chronologic) of the material filed in that space.
The label on the divider guide identifies the range of folder headings following that divider guide up to the next divider; for example, BaBo. The label on the folder identifies the contents of that folder only. This may be the name of the patient, subject matter of correspondence, a business topic, or anything at all that needs to be filed. Label a folder when a new patient is seen or existing folders are full or when materials need to be transferred within the filing system.
Paper labels may be purchased on rolls of gummed tape; another type has adhesive backs that are peeled from a protective sheet. Labels are available in almost any size, shape, or color to meet the individual needs of any facility. Visit a stationer and study the catalogs to find the best product to meet the needs of the facility.
A narrow label applied to the front of the folder tab is the easiest to use and is satisfactory for folders kept in a drawer file. Labels for shelf filing should be identifiable from both front and back. Always type the label before separating it from the roll or protective sheet. Type the caption on the label in indexing order.
FILING PROCEDURES
Filing of all materials involves five basic steps: conditioning, releasing, indexing and coding, sorting, and storing and filing.
Conditioning Conditioning of papers involves removing all pins, brads, and paper clips; stapling related papers together; attaching clippings or items smaller than page-size to a regular sheet of paper with rubber cement or tape; and mending damaged records.
Releasing The term releasing simply means that some mark is placed on the paper indicating that it is now ready for filing. This will usually be either the medical assistant’s initials or a FILE stamp placed in the upper left corner.
Indexing and Coding Indexing means deciding where to file the letter or paper, and coding means placing some indication of this decision on the paper (Table 14-1). This may be done by underlining the name or subject, if it appears on the paper, or writing the indexing subject or name in some conspicuous place. If there is more than one logical place to file the paper, the original is coded for the main location and a cross-reference sheet prepared, indicating this location and coded for the second location. Every paper placed in a patient’s chart should have the date and name of the patient on it, usually in the upper right corner.
Sorting Sorting is arranging the papers in filing sequence. Sort papers before going to the file cabinet or shelf. Do any necessary
TABLE 14-1 Application of Indexing Rules INDEXING RULE NAME UNIT 1 UNIT 2 UNIT 3 1 Robert F. Grinch Grinch Robert F. R. Frank Grumman Grumman R. Frank
2 J. Orville Smith Smith J. Orville Jason O. Smith Smith Jason O.
3 M. L. Saint-Vickery Saint-Vickery M. L. Marie-Louise Taylor Taylor Marielouise
4 Charles S. Anderson Anderson Charles S. Anderson’s Surgical Supply Andersons Surgical Supply
5 Ah Hop Akee Akee Ah Hop
6 Alice Delaney Delaney Alice Chester K. DeLong Delong Chester K.
7 Michael St. John Stjohn Michael
8 Helen M. Maag Maag Helen M. Frederick Mabry Mabry Frederick James E. MacDonald Macdonald James E.
9 Mrs. John L. Doe (Mary Jones) Doe Mary Jones (Mrs John L.)
10 Prof. John J. Breck Breck John J. (Prof.) Madame Sylvia Madame Sylvia Sister Mary Catherine Sister Mary Catherine Theodore Wilson, M.D. Wilson Theodore (M.D.)
11 Lawrence W. Sloan, Jr. Sloan Lawrence W. (Jr.) Lawrence W. Sloan, Sr. Sloan Lawrence W. (Sr.)
12 The Moore Clinic Moore Clinic (The)
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE272
stapling of papers at the desk or filing table. Invest in a desktop sorter with a series of dividers, between which papers are placed in filing sequence. One general-purpose sorter has six means of classification: alphabetic sections, numbers 1 to 31, days of the week, months of the year, numbers in groups of five, and space on the tabs for special captions to be taped when desired. In the preliminary sorting, place the papers in the appropriate division in the sorter. Then it is comparatively simple to arrange these groups into the proper sequence for filing.
Storing and Filing In storing or filing papers in the folder, items should be placed face up, top edge to the left, with the most recent date at the front of the folder. Lift the folder 1 or 2 inches out of the drawer before inserting new material, so that the sheets can drop down completely into the folder. It is best to permanently attach items to the file folder. When refiling completed folders, arrange them in indexing order before going to the file cabinets.
Locating Misplaced Files Unless files are promptly replaced after use, they may become lost. Papers may be misfiled, requiring a thorough search to find them, which wastes valuable time. After a methodic and complete search through the proper folder, there are several places one may look for a misplaced paper: (1) in the folder in front of and behind the correct folder; (2) between the folders; (3) at the bottom of the file under all the folders; (4) in a folder of a patient with a similar name; or (5) in the sorter.
Indexing Rules Indexing rules are fairly well standardized, based on current business practices. The Association of Records Managers and Administrators takes an active part in updating the rules. Some establishments adopt variations of these basic rules to accommodate their needs. In any case the practices need to be consistent within the system.
1. Last names of persons are considered first in filing; given name (first name), second; and middle name or initial, third. Compare the names beginning with the first letter of the name. When a letter is different in the two names, that letter determines the order of filing. For example:
abe abi abm abx acl acm ada ade adi
2. Initials precede a name beginning with the same letter. This illustrates the librarian’s rule, “Nothing comes before something.” For example:
Smith, J. Smith, Jason
3. Hyphenated personal names. The hyphenated elements of a name, whether first name, middle name, or sur- name, are considered to be one unit. For example:
Carlotta Freeman-Duque is filed as Freemanduque, Carlotta Cindy-Jean Green is filed as Green, Cindyjean
4. The apostrophe is disregarded in filing. For example:
Andersons’ Surgical Supply Andersons Surgical Supply
5. When indexing a foreign name when you cannot dis- tinguish the first and last name, index each part of the name in the order in which it is written:
Cau Liu Talluri Devi
If you can make the distinction, you should use the last name as the first indexing unit:
Liu, Jason
6. Names with prefixes are filed in the usual alphabetic order, with the prefix being considered as part of the name. For example:
von Schmidt is filed as Vonschmidt DeLong is filed as Delong LaFrance is filed as Lafrance
7. Abbreviated parts of a name are indexed as written if that is the form generally used by that person. For example:
Ste. Marie is filed as Stemarie St. John is filed as Stjohn Wm. is filed as Wm Edw. is filed as Edw Jas. is filed as Jas
8. Mac and Mc are filed in their regular place in the alphabet:
Maag Mabry MacDonald Machado MacHale Maville McAulay McWilliams Meacham
273CHAPTER 14 Medical Records Management
If the files contain a great many names beginning with Mac or Mc, some offices file them as a separate letter of the alphabet for convenience.
9. The name of a married woman is indexed by her legal name (her husband’s surname, her given name, and her middle name or maiden surname). For example:
Doe, Mary Jones (Mrs. John L.) not Doe, Mrs. John L. (unless first name is unknown)
10. Titles, when followed by a complete name, may be used as the last filing unit if needed to distinguish from another identical name. For example:
Mr. James D. Conley Conley James D Mr. Dr. James D. Conley Conley James D Dr.
Titles without complete names are considered the first indexing unit:
Madame Sylvia Sister Theresa
11. Terms of seniority, or professional or academic degree, are used only to distinguish from an identical name. For example:
Theodore Wilson, PhD Theodore Wilson, Sr. Theodore Wilson, Jr. Theodore Wilson, MD These examples would be filed in the following order: Theodore Wilson, Jr. Theodore Wilson, MD Theodore Wilson, PhD Theodore Wilson, Sr.
12. Articles such as The and A are disregarded in indexing:
Moore Clinic (The)
FILING METHODS
The three basic methods of filing used in healthcare facilities are these:
• Alphabetic by name • Numeric • Subject Patient charts are filed either alphabetically by name or
by one of several numeric methods. Subject filing is used for business records, correspondence, and topical materials.
Alphabetic Filing Alphabetic filing by name is the oldest, simplest, and most commonly used system. It is the system of choice for filing
patient records in the majority of physicians’ offices. If the medical assistant can find a word in the dictionary or a name in the telephone directory, then he or she already knows some of the rules.
The alphabetic system of filing is traditional and simple to set up, requiring only a file cabinet or shelf, folders, and some divider guides (Procedure 14-7). It is a direct filing system, in that the person filing need know only the name in order to find the desired file. Alphabetic filing does have some drawbacks:
• The correct spelling of the name must be known. • As the number of files increases, more space is needed
for each section of the alphabet. This results in periodic shifting of folders from drawer to drawer or shelf to shelf to allow for expansion.
• As the files expand, more time is required for filing or retrieving each folder because of the greater number of folders involved in the search. The time can be greatly reduced by color-coding.
Numeric Filing Some form of numeric filing combined with color and shelf filing is used by practically every large clinic or hospital. Management consultants differ in their recommendations; some recommend numeric filing only if there are more than 5000 charts, more than 10,000 charts, or in some cases more than 15,000 charts. Others recommend nothing but numeric filing. Numeric filing is an indirect filing system, requiring the use of an alphabetic cross-reference to find a given file. Some people object to this added step and overlook the advantages, which are as follows:
• It allows unlimited expansion without periodic shifting of folders, and shelves are usually filled evenly.
• It provides additional confidentiality to the chart. • It saves time in retrieving and refiling records quickly. One
knows immediately that the number 978 falls between 977 and 979. By contrast, an alphabetic system, even with color-coding, requires a longer search for the exact spot.
There are several types of numeric filing systems. In the straight or consecutive numeric system, patients are given consecutive numbers as they visit the practice. This is the simplest of the numeric systems and works well for files of up to 10,000 records. It is time consuming, and the chance for error is greater when filing documents with five or more digits. Filing activity is greatest at the end of the numeric series.
In the terminal digit system, patients are also assigned consecutive numbers, but the digits in the number are usually separated into groups of twos or threes and are read in groups from right to left instead of from left to right. The records are filed backward in groups. For example, all files ending in 00 are grouped together first, then those ending in 01, etc. Next the files are grouped by their middle digits so that the 00 22s come before the 01 22s. Finally the files are arranged by their first digits, so that 01 00 22 precedes 02 00 22.
Middle-digit filing begins with the middle digits, followed by the first digit and finally by the terminal digits.
Some practices use the last four digits of each patient’s Social Security number to file patient records. However, there is no
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE274
legal requirement that every U.S. resident have a Social Security number; if a patient does not, a “pseudo number” would have to be issued.
Numeric filing requires more training, but once the system is mastered, fewer errors occur than with alphabetic filing (Procedure 14-8).
Susan is unsure whether alphabetic or numeric filing is best in the medical office. What are some advantages and disadvantages of each method?
Subject Filing Subject filing can be either alphabetic or alphanumeric (A 1-3, B 1-1, B 1-2, and so on) and is used for general correspondence. The main difficulty with subject filing is indexing, or classifying— deciding where to file a document. Many papers require cross- referencing. All correspondence dealing with a particular subject is filed together. The papers within the folders are filed chronologically, the most recent on top. The subject headings are placed on the tabs of the folders and filed alphabetically.
Color-Coding When a color-coding system is used, both filing and finding are easier, and misfiled folders are kept to a minimum (Procedure 14-9). The use of color visually restricts the area of search for
a specific record. A misfiled chart is easily spotted even from a distance of several feet. In color-coding, a specific color is selected to identify each letter of the alphabet. The application of the principle may be through using colored folders, adhesive colored identification labels, or various combinations of these. Any selection of colors may be used, and the division of the alphabet is determined by one’s own needs. However, studies have shown that there is wide variation in the frequency with which different letters occur.
Alphabetic Color-Coding There are several ways of color-coding files. One alphabetic system uses five different colored folders, with each color representing a segment of the alphabet. The second letter of the patient’s last name determines the color.
As medicine continues to consolidate into larger facilities, with more patients under one management, the filing of patient charts becomes more complicated and color-coding becomes more useful. Several color-coding systems use two sets of 13 colors—one set for letters A-M, and a second set of the same colors on a different background for the letters N-Z.
Many ready-made systems are available (e.g., Bibbero, Colwell, Kardex, Remington Rand, Smead, TAB, VisiRecord). Self-adhesive colored letter blocks with either two or three letters in the specific colors are supplied in rolls. The color blocks with the appropriate letter are placed on the index tab of the folder, along with the patient’s full name. The letters are in pairs so that they can be seen from either side of the chart.
PROCEDURE 14-7
File Medical Records and Documents Using the Alphabetic System CAAHEP COMPETENCY: 3.a.(1)(d) ABHES COMPETENCY: 3.h
GOAL: To file records efficiently using an alphabetic system and ensure that the records can be easily and quickly retrieved.
EQUIPMENT and SUPPLIES
• Medical records • Physical filing equipment • Cart to carry records, if needed • Alphabetic file guide • Staple remover • Stapler
PROCEDURAL STEPS
1. Using alphabetic guidelines, place the records to be filed in alphabetic order. If a stack of documents is to be filed, place them in alphabetic order inside an alphabetic file guide or sorter. Use rules for filing documents alphabetically.
PURPOSE: To organize the filing process and file the record or document quickly without retracing steps and skipping from letter to letter.
2. Go to the filing storage equipment (shelves, cabinets, or drawers), and locate the correct spot in the alphabet for the first file.
3. Place the file in the cabinet or drawer in correct alphabetic order. 4. If adding a document to a file, place it on top so that the most
recent information is seen first. This puts the information in the file in reverse chronologic order.
PURPOSE: To provide access to the most pertinent and recent information.
5. Securely fasten documents to the chart. Do not just drop the documents inside the chart.
PURPOSE: To keep vital information from falling out of the chart and being lost.
6. Refile the chart in its proper place.
275CHAPTER 14 Medical Records Management
PROCEDURE 14-8
File Medical Records and Documents Using the Numeric System CAAHEP COMPETENCY: 3.a.(1)(d) ABHES COMPETENCY: 3.h
GOAL: To file records efficiently using a numeric system and ensure that the records can be easily and quickly retrieved.
EQUIPMENT and SUPPLIES
• Medical records • Physical filing equipment • Cart to carry records, if needed • Numeric file guide • Staple remover • Stapler • Paper clips
PROCEDURAL STEPS
1. Using numeric guidelines, place the records to be filed in numeric order. If a stack of documents is to be filed, write the chart number on the document. Use rules for filing documents alphabetically.
PURPOSE: To organize the filing process and file the records or
documents quickly without retracing steps and skipping from letter to letter.
2. Go to the filing storage equipment (shelves, cabinets, or drawers) and locate the numeric spot for the first file.
3. Place the file in the cabinet or drawer in correct numeric order. 4. If adding a document to a file, place it on top so that the most
recent information is seen first. This puts the information in the file in reverse chronologic order.
PURPOSE: To provide access to the most pertinent and recent information.
5. Securely fasten documents to the chart. Do not just drop the documents inside the chart.
PURPOSE: To keep vital information from falling out of the chart and being lost.
6. Refile the chart in its proper place.
PROCEDURE 14-9
Establish and Maintain the Medical Record: Color-Code Medical Records CAAHEP COMPETENCY: 3.a.(1)(d) ABHES COMPETENCY: 3.h
GOAL: To color-code patient records using the agency’s established coding system to effectively facilitate filing and finding.
EQUIPMENT and SUPPLIES
• List of patient medical records to code • File folders • Information on agency’s coding system • Full range of color tabs
PROCEDURAL STEPS
1. Assemble patient records. 2. Arrange records in indexing order.
PURPOSE: When records have been color-coded, they will be in filing order.
3. Pick up the first record, and note the second letter of the patient’s surname.
EXPLANATION: For the purpose of this activity, the color-coding system described in the text will be used.
4. Choose a tab of the appropriate color. 5. Type the patient’s name on the label in indexing order, and apply
tab to the folder tab. PURPOSE: To identify the sequence of folders in the filing system.
6. Repeat steps 4 and 5 until all records have been coded. 7. Check the entire group for any isolated color.
PURPOSE: If the order and color of the folders are correct, all charts of the same color within each letter of the alphabet will be grouped together.
Strong, easily differentiated colors are used, creating a band of color in the files that makes it easy to spot out-of-place folders (Figure 14-15).
Numeric Color-Coding Color-coding is also used in numeric filing. Numbers 0 through 9 are each assigned a different color. In a terminal digit filing system, the colors for the last two numbers would be affixed
to the tab. If the number 1 is red and 5 is yellow, all files with numbers ending in 15 form a red and yellow band. Usually a predetermined section of the number is color-coded.
Other Color-Coding Applications There are many other ways to make color work for the efficient medical office. Small pressure-sensitive tabs in a variety of colors may be used to identify certain types of insured patients and
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE276
other specific information. For example, a red tab over the edge of the folder may identify a patient on Medicaid; a blue tab may identify a CHAMPUS patient; a green tab may identify a workers’ compensation patient; matching tabs may be attached to the insured’s ledger card; research cases may be identified by a special color tab; and brightly colored labels on the outside of a patient chart can indicate certain health conditions, such as drug allergies. In a partnership practice, a different color folder or label may identify each physician’s patients. Color can also be used to differentiate dates—one color for each month or year.
Business records may also use color-coding. Main divider guide headings may be in one color, subheadings in a second color, and subdivisions in a third color. A fourth color might be used for personal items.
The use of color in filing is limited only by the imagination. One word of caution: Every person in the facility who uses the files must know the key to the coding, and the key should also be written in the facility’s procedures manual.
ORGANIZATION OF FILES
It is very difficult for a physician to study a disorganized history. Some systematic method must be followed in placing items in the patient folder. The content of the patient record has already been discussed. From the filing standpoint, it should be emphasized that when a patient record is not in actual use, it should be in only one place—in the filing cabinet or on the shelf. Many precious hours can be lost in searching for misplaced or lost records that were carelessly left unfiled.
The patient’s full name, in indexing order, should be typed on a label, and the label attached to the folder tab. A strip of transparent tape can be placed on the label to prevent smudging if this is a problem. The patient’s full name should also be typed on each sheet within the folder.
Health-Related Correspondence Correspondence pertaining to patients’ medical records should be filed with the case history. Other medical correspondence should probably be filed in a subject file.
General Correspondence The physician’s office operates as a business as well as a professional service. There will be correspondence of a general nature pertaining to the operation of the office. In all likelihood, a special drawer or shelf will be set aside for the general corres- pondence. The correspondence is indexed according to subject matter or names of correspondents. The guides in a subject file may appear in one, two, or three positions, depending on the number of headings, subheadings, and subdivisions.
Practice Management Files The most active financial record is, of course, the patient ledger. In facilities that still use a manual system, this will be a card or vertical tray file, and the accounts will be arranged alphabetically by name. There will be at least two divisions:
• Active accounts • Paid accounts
Miscellaneous Folder Papers that do not warrant an individual folder are placed in a miscellaneous folder. Within the folder, all papers relating to one subject, or with one correspondent, are kept together in chronologic order, with the most recent on top, then filed alphabetically with other miscellaneous material. Related materials may be stapled together. Never use paper clips for this purpose. When as many as five papers accumulate with one correspondent or subject, a separate folder should be prepared.
FIGURE 14-15 Color-coding patient charts makes it easy to see a file that is misplaced. (Courtesy Bibbero Systems, Inc., Petaluma, Calif. 94954, (800) 242-2376, www.bibbero.com.)
277CHAPTER 14 Medical Records Management
Other business files include records of income and expenses, financial statements, income and payroll tax records, canceled checks, and insurance policies. These papers may be filed chronologically.
Tickler or Follow-Up Files The most frequently used follow-up method is that of a tickler file, so called because it tickles the memory that something needs to be done or followed up on a particular date. The tickler file is always a chronologic arrangement. In its simplest form, it consists of notations on the daily calendar. If information, such as an x-ray report or laboratory report, is expected concerning a patient who has an appointment to come in, the medical assistant might make a note on the calendar or tickler file a day ahead to check on whether the report has arrived.
The tickler file is often a card file with 12 guides for the names of the months and 31 guides printed with numbers 1 through 31 for the days of the month. The guide for the current month, followed by the 31-day guides, is placed at the front of the file. Notations of actions to be taken are placed behind the guides for specific days of the current month. Notations for future months are placed behind the guide for that month. To be effective, the tickler file must be checked the first thing each day.
Susan is responsible for checking the tickler file on a daily basis. What types of documents and duties might she find inside these files?
The tickler file can be used in many ways. It is a useful reminder for recurring events such as payments, meetings, and so forth. On the last day of each month, all the notations from behind the next month’s guide are distributed among the daily numbered guides, and the guide for the month just completed is placed at the back of the file.
Transitory or Temporary File Many papers are kept longer than necessary because no provision is made for segregating those that have a limited usefulness. This situation is avoided by having a transitory or temporary file. For example, if a medical assistant writes a letter requesting a reprint, the file copy is placed in the transitory folder. When the reprint is received, the file copy is destroyed. The transitory file is used for materials that have no permanent value. The paper may be marked with a T and destroyed when the action is completed.
CLOSING COMMENTS
Just as in every aspect of the medical profession, advances in medical records management are occurring rapidly, allowing physicians and other caregivers to perform their duties in a more efficient and accurate way. A medical assistant must constantly be willing to learn and to adapt to changes that result from legislation and technologic strides. Because patients are fast becoming more computer literate, computers will become more generally accepted as a viable means of recording medical information. This is a positive change, because many patients and providers were not in favor of computer-based medical records when the concept was first presented to the general public.
The medical assistant should always explain to the patient any paperwork that he or she may be required to complete. Patients do not like to be told to simply “sign here.” Take the time to explain any form that needs completion or a signature, so that the patient will understand the reason for collecting the information and the necessity for the information to be available to the medical facility.
Many forms are similar, and patients may complain about answering the same questions on multiple forms. It can be frustrating for patients when they must list their address and phone numbers on each of several forms. Review and revise the forms used in the office often so that they are user-friendly for the office and patient alike.
Patients may need reassurance that each staff member in the physician’s office is committed to complete patient confidentiality. Always be open to answering questions regarding the patient medical record.
The authority to release information from the medical record lies solely with the patient unless required by law by subpoena. Ownership of the record is often a subject of controversy. The record belongs to the physician; the information belongs to the patient.
When a medical record is used as evidence in a court case, the person who entered information in the chart must be able to read it, no matter how much time has elapsed since the entry was created. When a chart is corrected, the proper method must be followed, and the record should never be obliterated.
Be sure to understand the laws concerning records retention. Records should be kept through the period of the statute of limitations, and possibly longer in certain situations. Take care with the medical chart, as it is the lifeline of patient care in the medical facility. When a chart is corrected, the proper method must be followed, and the record should never be obliterated (Procedure 14-10).
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE278
PROCEDURE 14-10
Document Appropriately and Accurately CAAHEP COMPETENCY: 3.c(2)(d) ABHES COMPETENCY: 5.b.
GOAL: To document appropriately and accurately on all patient medical records and other offi ce paperwork that concerns the patient.
EQUIPMENT and SUPPLIES
• Any medical document • Clerical supplies • Computer or word processor • Offi ce policy and procedure manual
PROCEDURAL STEPS
1. Determine the information that needs to be added to the patient’s medical record, appointment book, telephone message, or other offi ce paperwork that concerns the patient.
PURPOSE: To place pertinent, accurate information into the document.
2. Make certain that the information is factual, timely, and accurate. PURPOSE: To ensure that the information is usable.
3. Write or type the information into the document. 4. Re-read the information to make certain that it is legible.
PURPOSE: To be sure that the information can be read even after several years by anyone who needs to access the information.
5. Date and sign the entry, if necessary. PURPOSE: To authenticate the entry.
6. Make certain that the entry meets any local, state, or federal guidelines that may apply to the information contained in the document.
PURPOSE: To remain in compliance with local, state, and federal rules and regulations.
7. Make certain that the entry is written in compliance with offi ce policies and procedures.
PURPOSE: To comply with offi ce policy. 8. If the entry needs to be corrected, draw one line through the
entry, and make the new entry below or in the required place within the document.
PURPOSE: To correct the document according to offi ce policy and procedure guidelines.
9. Place the date and initial the corrected entry. PURPOSE: To authenticate the correction.
10. Make certain that the correction has not obliterated any part of the medical record or documentation that affects the patient.
PURPOSE: TNo obliteration is acceptable in any part of the medical record.
Susan looks forward to attending her medical assisting classes each day and works diligently to perform to the best of her ability in the classroom.
She strives to do well on each procedure check-off and each examination that she completes. Her instructors provide excellent feedback and appreciate her contributions to the classroom experience.
Susan has the attitude that everything she is allowed to do in the medical office is a learning tool. She regularly asks for additional responsibilities and is always ready to assist a co-worker. Dr. Thomas has recognized that she has the desire to learn, and he gives her many opportunities to glean more knowledge through the everyday activities in the office.
Although she is new to the medical profession, Susan learns quickly and thinks logically. She knows the rules and regulations regarding patient confidentiality and is always careful about the information she provides to those who request it. She is never hesitant about asking her office manager for guidance if she is unsure about any aspect of her duties. Susan is understanding and respectful when patients are concerned about their privacy. Her confidence and warm personality play a role in the trust that she earns from the patients at the clinic.
Susan is willing to admit when she has made an error and has sought advice from Dr. Thomas and her office manager
SUMMARY OF SCENARIO
when an error needed correction. Although filing is not one of her favorite duties, she can be counted on to do her best while completing this important task. She realizes that filing is a critical task, because the documents contained in the patient’s medical record direct the care provided to the patient. An abnormal laboratory report that is missing may make a crucial difference in the patient’s care. She takes pride in her work and is efficient and accurate where medical records are concerned. When she is faced with a task that is new to her, she considers it a learning experience and seeks help when she is not completely certain about the way to handle a given situation.
Susan’s co-workers are supportive and always willing to assist her as she learns to be the best medical assistant that she can possibly be. Her future as a professional medical assistant will certainly be laden with opportunity and advancement. Just as important, the patients extend their trust to Susan. She has alleviated patient concerns about electronic medical records by taking the time to explain privacy policies and exactly what information will be accessible to third parties. This trust also gives patients the confidence to reveal personal information and know that it will be held in the strictest confidence, not just by Susan, but by each employee at the physician’s office.
279CHAPTER 14 Medical Records Management
1. Define, spell, and pronounce the terms listed in the vocabulary. • Spelling and pronouncing medical terms correctly adds
credibility to the medical assistant. Knowing the definition of these terms promotes confidence in communication with patients and co-workers.
2. State several important reasons for keeping accurate medical records. • Medical records must be accurate primarily so that the right
care can be given to the patient. The record also helps to provide continuity of care between providers so that there is no lapse in treatment of the patient. The record serves as indication and proof in court that certain treatments and procedures were performed on the patient, so it can be excellent legal support if it is well maintained and accurate. Medical records also aid researchers with statistical information.
3. Discuss the ownership of records. • The physician owns the physical medical record, whereas the
patient owns the information contained within it. 4. Explain the difference between a traditional medical record and a
problem-oriented medical record. • The POMR categorizes each problem that a patient has and
elaborates on the findings and treatment plan for all concerns. Detailed progress notes are kept for every individual problem. This method separates each of the patient’s concerns and addresses them separately, whereas a traditional record may address all problems and concerns at one time. The POMR helps to assure that all individual problems are addressed.
5. Illustrate the difference between subjective and objective information. • Very simply, subjective information is provided by the patient,
whereas objective information is provided by the physician or provider. Subjective information includes items such as the patient address, social security number, insurance information, and the patient’s explanation of the condition he or she is experiencing. Objective information is obtained through the questions the physician asks and the observations made during the examination.
6. Discuss changing an entry in the patient record and the importance of following correct procedures. • Correct procedures must be followed when making corrections
to a patient chart. A single line should be drawn through the incorrect information, then initialed and dated. Some offices require a notation of “Corr.” or “correction” on the chart as well. A medical assistant should never try to alter the medical record or cover up an error in charting.
7. List and discuss the basic equipment used in a filing system. • Several types of equipment and supplies are necessary when
managing patient records. A variety of shelving units and filing containers is available. Open shelving allows the maximized use of color-coded charts, which make finding misfiles quick and easy. Many file folder styles are available, and several
types of forms can be used within the patient charts. The preference of the physician and staff members who use these tools is important, as well as concerns such as cost and availability. A medical assistant should be conservative when ordering supplies and purchasing equipment, ordering only the number needed to save on office supply costs.
8. Describe the steps in filing a document. • Five basic steps are involved in filing documents. The papers
are conditioned, which is the preparatory stage for filing. Releasing the documents means that they are ready to be filed because they have been reviewed or read, and some type of mark is placed on the document to indicate this. Indexing involves the decision as to where the document should be filed, and coding is placing some type of mark on the paper relative to that decision. Sorting is placing the files in filing sequence. The last step is the actual filing and storing of the document.
9. List and discuss application of the basic filing systems. • Alphabetic filing is a simple and traditional filing system
whereby documents are filed in alphabetic order. Numeric filing systems use a number code to give order to the files. An alphanumeric system is a combination of the two.
10. Explain how color-coding of files can be useful in a medical facility. • Color-coding is an excellent way to keep patient charts in order
and swiftly locate those charts that have been misfiled. The medical assistant can tell at a glance when a chart is out of place. Color-coding also makes retrieval and refiling of files quick and easy.
11. Establish a patient’s medical record. • The patient’s chart must be organized so that the components
are easy to fi nd. The process for establishing the medical record is outlined in Procedure 14-1.
12. Prepare an informed consent for treatment form. • Patients must sign an informed consent for treatment form
so that the physician can perform specifi c treatments and/or procedures. The process for preparing an informed consent for treatment form is outlined in Procedure 14-2.
13. Add supplementary items to an established patient record. • Items must be periodically added to patient records when
test results arrive or new information becomes available. The process for adding supplementary items to an established medical record is outlined in Procedure 14-3.
14. Prepare a record release form. • Records cannot be released without the express permission of
the patient. The process for preparing a record release form is outlined in Procedure 14-5.
15. Transcribe a machine-dictated letter using a computer or word processor. • At times, the medical assistant will be required to transcribe
information from a recorder or other device into a medical record. The process for transcribing a machine-dictated letter using a computer or word processor is outlined in Procedure 14-6.
Continued
UNIT THREE HEALTH INFORMATION IN THE MEDICAL OFFICE280
Study Guide Connection: Go to Chapter 14 Study Guide. Read the Case Study and Workplace Applications and complete the assignments. Do online research for answers to the questions in the Internet Activities associated with documentation and medical records management.
CD Connection: Go to the Medical Assisting Competency Challenge CD and do the training activities under General Office Duties: The Medical Record.
Evolve Connection: For more information related to documentation and medical records management, go to http://evolve.elsevier.com/kinn/admin and visit related weblinks for Chapter 14. Click on the Medical Assisting Exam Review and do the practice questions to sharpen your test-taking skills. To learn more about office software, do the exercises for the Altapoint demo that is on the CD.
C O N N E C T I O N S
Continued
16. File medical records and documents using an alphabetic system. • Some offi ces use an alphabetic fi ling system. The process for
fi ling records and documents using an alphabetic fi ling system is outlined in Procedure 14-7.
17. File medical records and documents using a numeric system. • Some offi ces use a numeric fi ling system. The process for
fi ling records and documents using a numeric fi ling system is outlined in Procedure 14-8.
18. Color-code medical records. • Color coding records is a great help in fi ling accurately. The
process for color coding records is outlined in Procedure 14-9. 19. Document appropriately and accurately.
• All medical documentation must be correct and complete. The process for documenting appropriately and accurately is outlined in Procedure 14-10.
