Medical Records Management

Chapter 14

ICBS 120

Importance of Accurate Medical Records

• Essential to patient care• Smooth operations• Coordinating care• Legal issues

– Standard in court, if there is no record of any piece of information related to a patient and that patient’s care and treatment, it did not happen.

Correcting Medical Records

• With a paper medical record, draw a single line through the error using red ink and write “corr” or correction above the error and indicate your initials and current date.

• With EMRs (electronic medical records), a line is drawn through the error using a tracking device in the program.

Types of Medical Records

• Problem-Oriented Medical Record (POMR)

– Problems identified by a number that corresponds to the charting relevant to that problem.

– For example: bronchitis #1; broken wrist #2

Types of Medical Records Cont’d

• Each problem is followed with SOAP for all progress notes:– S = Subjective impressions– O = Objective Clinical Evidence– A = Assessment or diagnosis– P = Plans for further studies, treatment or

management.

Equipment and Supplies

• Vertical Files – pullout drawers where files are stored.

• Open-shelf Lateral Files - quick retrieval of files.

• Movable File Units – easy access to large record systems.

Equipment and Supplies

• File Folders – designed for different types of labels.

• Identification Labels – display information for file.

• Guides and Positions – used to separate file folders.– Captions – used to identify major sections of

folders.

Basic Rules for filing

• Out Guides – devices to help in tracking charts.

Basic Rules for filing

• Indexing Units– A unit identifies each part of a name.

• Rule #1: Last name, first name, middle.• Rule #4: When titles are used, they are

considered separate indexing units.

Basic Rules for filing

• Rule #5: Names that are hyphenated are considered as one unit.

• Rule #7: Seniority, professional and academic degrees are the last indexing unit.

• Rule #9: Numeric units are broken down such that numeric seniority terms are filed before alphabetical terms.

Chronological Filing

• March 7, 1950• September 21, 1999• 6-6-82• December 14, 1995• August 29, 1971• 9-22-88

Chronological Filing-correct order

• March 7, 1950• August 29, 1971• 6-6-82• 9-22-88• December 14, 1995• September 21, 1999

Numerical Filing

• 1.000457• .000445• 49.1007• 110.32345• 11.277889• 892.67• 11032.345• 895

Numerical Filing -correct order

• .000445• 1.000457• 11.277889• 49.1007• 110.32345• 892.67• 895• 11032.345

Steps for filing Medical Documentation

• Inspect – identify pt, subject, or other• Index – determine how to locate chart• Code – mark data as to how it should be

filed• Sort – if multiple documents, sort according

to captions on charts• File – place in proper charts and return

Filing Techniques/Common Filing Systems

• Color coding makes retrieval of files more efficient with the use of visible color differences that facilitate easier maintenance of the files.– Tab-Alpha (each alphabetical letter is assigned

a different color)– Alpha-Z (another color-coding system)– Customized Color-Coding Systems (specific to

office needs)

Filing Techniques/Common Filing Systems

• Alphabetic Filing (simplest method)• Numeric Filing (assigned a number;

consecutive or nonconsecutive)

• To select a filing system, each office must decide what the primary objectives are with respect to storage of patient files, business records, and research files within the office.

HIPAA

• To make the medical facility HIPAA compliant when using traditional paper-based or manual charts, you need to ensure that there is no identifiable information on the outside of the chart.

Filing Procedures

• Cross-Referencing – if there is any doubt where the file would be located, use inserts or labels.

Tickler Files

• A well-organized, efficient office will maintain what is known as a tickler file, a method that serves as a reminder that some action needs to be taken at a date in the future.

• Many computer systems today have provision for establishing ticklers on files.

Medical Record

• Written or graphic information documenting facts and events during the rendering of patient care.

• The standard in court is that if there is no written record it did not happen.

• ALL MEDICAL TREATMENT MUST BE DOCUMENTED

Filing Chart Data

• Miscellaneous – would encompass matters not related to direct treatment.

Retention and Purging:• Record Purging – requires sorting through

records and removing those not in use.

Contents of the Medical Record

• Patient information form• Patient health questionnaire• Physical examination form• Progress notes• Medication record sheet• Laboratory and radiology reports• Hospital reports• Consultation reports• Correspondence

Problem-Oriented Medical Record (POMR)

• The problem-oriented medical record (POMR) type of record-keeping uses a sheet, generally on the inside cover or other prominent location, which lists vital information data, immunizations, allergies, medications, and problems.

• SOAP– subjective, objective, assessment, plan

Retention and Purging

• States have different time requirements for retention of various types of records

• Active Files – records readily accessible• Inactive Files – not currently be accessed

(2-3 years)• Closed Files – no longer needed/deceased

Correspondence

• Incoming Correspondence• Outgoing Correspondence

– Remove staples and paper clips– Inspect to see if item is ready to be filed– Take necessary copies and care of letters– Take action if required now or take future

action