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After studying this chapter you will be able to: Explain the importance of patient medical records; identify the documents that comprise a patient medical record; compare SOMR, POMR, SOAP, and CHEDDAR medical record formats; identify the six Cs of charting, giving an example of each;…
CHAPTER 11 Medical Records and Documentation 11-2 Learning Outcomes (cont.) 11.1 Explain the importance of patient medical records 11.2 Identify the documents that comprise a patient medical record 11.3 Compare SOMR, POMR, SOAP, and CHEDDAR medical record formats 11.4 Identify the six Cs of charting, giving an example of each 11-3 Learning Outcomes (cont.) 11.5 Describe the need for neatness, timeliness, accuracy, and professional tone in patient records 11.6 Illustrate the correct procedure for correcting and updating a medical record 11.7 Describe the steps in responding to a written request for release of medical records 11-4 Introduction • Medical assistants role regarding patient health records – Documentation – Maintenance • Medical records – critical to patient care – Evaluation – Management – Treatment 11-5 The Importance of Medical Records • Past medical history and present condition • Communication tool for healthcare team • Legal documentation • Patient and staff education • Quality control and research • Documentation for billing and coding 11-6 Importance of Patient Records (cont.) • General information – Contact information – Occupation – Medical history – Current complaint – Healthcare needs – Treatment plan or services provided – Radiology and laboratory reports – Response to care 11-7 Legal Guidelines for Patient Records • Support a malpractice claim • Support defense for a malpractice claim • Back up financial records • Documentation – Medical care, evaluation and instructions – Noncompliant patient 11-8 Standards for Records • Evidence of appropriate care – Complete – Accurate • Everyone who documents in the patient record has a responsibility to the patient and physician 11-9 Additional Uses of Patient Records Patient Education • Test results • Health issues • Treatment instructions Quality of Treatment Research • Peer review Source of data • TJC review • Health-care analysis and policy decisions 11-10 Apply Your Knowledge What is the purpose of documentation in a patient’s medical record? ANSWER: Documentation in the medical record provides evidence of appropriate care If a procedure is not documented, it is considered not done 11-37 Correcting and Updating Medical Records • Medical records are created in “due course” – Information is entered at the time of occurrence – Untimely submissions may be regarded as “convenient” 11-38 Using Care with Corrections • Correct mistakes immediately – Draw a line through the original information – Insert correct information – Document why correction was made – Date, time, and initial correction – Have a witness, if possible m/d/yyyy 00:00pm misspelled JHC /chj 11-39 Updating Patient Records • Additions should not appear deceptive • Document why late entry is made • Date and initial added items • May have a third party witness addition Addition made to record because patient called back with additional information Mm/dd/yyyy – JHC / chj 11-40 Apply Your Knowledge What is the appropriate way to correct an error in a patient’s medical record? ANSWER: To correct an error in a patient’s medical record: • Draw a line through the original information • It must remain legible • Insert correct information above or below original line or in margin • Document why correction was made • Date, time, and initial correction 11-41 Responding to Release of Records Request • Records are property of the practice • Contain confidential PHI which belongs to the patient • Must have patient’s written consent to release Release of Information to HMO Insurance Company I authorize Dr J Jones to release my healthcare information to the above-named insurance company Christopher Hansen Patient Signature mm/dd/yyyy Date 11-42 Procedures for Releasing Records • New authorization to transfer records – Verbal consent is not valid – File in medical record • Copy original materials – only information requested • Call to confirm receipt of materials Procedures for Releasing Records (cont.) • Special cases • Confidentiality – Not always clear who can authorize release – If unsure, ask your supervisor – 18 years old – Emancipated minor – Mature minor Legal and ethical principle: Protect the patient’s right to privacy at all times 11-43 11-44 Auditing Medical Records • Examination and review – Completeness – Accuracy • Types – Internal – External 11-45 Apply Your Knowledge The medical assistant receives phone call authorizing transfer of medical record information for a client to another physician’s office What would you in this situation? ANSWER: Never release information based on telephone authorization You cannot be sure who the caller is Tell them you need a written and signed release of information 11-46 In Summary 11.1 Medical records are legal documents that give a complete, concise, chronological history of a patient’s past medical history, current medical issues, treatment plan, and treatment outcome Additionally, they act as a communication tool between care providers The patient medical record provides physicians and other healthcare providers with all the important information, observations, and opinions that have been recorded about a patient 11-47 In Summary 11.2 The records that comprise the patient medical record include, but are not limited to the following: • • • • patient registration form medical history form physical exam form laboratory and other test results • records from physicians or hospitals, • physician diagnosis and treatment plan • operative reports • hospital discharge summaries • follow-up notes • records of telephone calls • signed informed consents • correspondence with or about the patient 11-48 In Summary (cont.) 11.3 SOMR files documents in the medical record in strict chronological order POMR files the same documents according to numbered problems found on the patient problem list SOAP notes organize medical record documentation according to subjective, objective, assessment and plan The CHEDDAR format breaks down this information even further into chief complaint, history, exam, details, drugs, assessment, and return visit plan 11-49 In Summary (cont.) 11.4 The six Cs of charting are client’s words, clarity, completeness, conciseness, chronological order, and confidentiality 11.5 Neatness, legibility, accuracy, and professional tone are musts in maintaining medical records Remember that patient medical records are legal documents Personal thoughts and observations should never be a permanent part of the patient medical record 11-50 In Summary (cont.) 11.6 The proper way to make corrections in a medical record is to draw a single line through the error so that the original entry is still legible Any additions to a medical record should also be made as soon as the need for the addition is noted, and the reason for the addition or change should also be clearly documented 11.7 In order to release any confidential medical information, express written permission from the patient must be received Only release records that are expressly requested and authorized by the patient 11-51 End of Chapter 11 Organization is the power of the day; without it, nothing is accomplished ~ Sophia Palmer From A Daybook for Nurses: Making a Difference Each Day .. .11- 2 Learning Outcomes (cont.) 11. 1 Explain the importance of patient medical records 11. 2 Identify the documents that comprise a patient medical record 11. 3 Compare SOMR, POMR, SOAP, and. .. records 11. 6 Illustrate the correct procedure for correcting and updating a medical record 11. 7 Describe the steps in responding to a written request for release of medical records 11- 4 Introduction... information Emergency contact 11- 12 Contents of Patient Medical Records (cont.) • Patient medical history – Past medical history – Family medical history – Social and occupational history – History