CABIN CREEK AND RIVERSIDE HEALTH CENTERS

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CABIN CREEK AND RIVERSIDE HEALTH CENTERS

  1. 1. CABIN CREEK AND RIVERSIDE HEALTH CENTERS P.O. Box 70, Dawes, WV 25054 (304)595-5006 Subject: Medical Records Format Policy No. MR.2 Department: Medical Records Date of Original: 6-25-03 Date of Last Revision: Approval Date Page 1 of 4 General Statement of Policy: To assembly the medical record in a consistent and uniform manner and to assure that it is in chronological order according to the filing order of the medical record. Scope: This procedure applies to all clerical staff responsible for chart assembly. Procedure: Pre-assembly Procedure Completed by front desk upon arrival of patient for visit: Verification and Updates: • Correct address, phone numbers (home & work), emergency contact name and phone number and payor information. • If above information is unchanged, it is acceptable to initial on upper left hand corner of the Data Sheet. Replace old copies of insurance cards with new copies and initial and date. • Any record that is larger than 1 ½ inches, shall be split into volumes. If the chart contains information greater than 3 years old, the chart shall be purged. • If patient has more than one hospital admission/discharge, X-Ray, procedure, lab value; put the two or more in chronological order. • If there are microfilm envelopes, tape them to the inside front of the folder. Items NOT to be included in the medical record: • Multiple copies of X-Rays, hospital admission/discharge reports, etc. • Fax confirmations • Any blank forms
  2. 2. CABIN CREEK AND RIVERSIDE HEALTH CENTERS P.O. Box 70, Dawes, WV 25054 (304)595-5006 Subject: Medical Records Format Policy No. MR.2 Department: Medical Records Date of Original: 6-25-03 Date of Last Revision: Approval Date Page 2 of 4 Assembling Medical Record • Assemble forms in chronological order according to “filing order of the medical record.” • Assemble forms according to the order given in this policy • Charts are identified with typewritten white labels with: 1) Patient Name 2) Date of Birth • Chart is further identified with: 1) Color coded label for most recent / current year patient was seen 2) Color coded labels for first two (2) letters of patients last name Medical Record / Patient Chart Dividers Right side of chart 1. Progress Notes 2. BCCSP (Only Breast and Cervical Cancer Screening Program Patients) o Signed Informed Consent o Visit Note 3. Family Planning (Only Family Planning Patients) o Signed Yearly Consent Form o Visit Note o Counseling Form o BC Consent 4. EPSDT o All child health history forms o Growth charts 5. Prenatal (Only Pregnant Patients) 6. Hospital DC o All hospital discharges including ER visits 7. Cardiac o Echocardiography results o 12-Lead EKGs o Stress Test Results
  3. 3. o Cardiac catherization results CABIN CREEK AND RIVERSIDE HEALTH CENTERS P.O. Box 70, Dawes, WV 25054 (304)595-5006 Subject: Medical Records Format Policy No. MR.2 Department: Medical Records Date of Original: 6-25-03 Date of Last Revision: Approval Date Page 3 of 4 o Carotid Doppler o Venous & / or Arterial Duplex results o All other heart related 8. Procedures o PFTs, Spirometry o Biopsy o Op reports (colonoscopy, cholecystectomy, CABG, etc) o All procedures o Home Health Orders 9. Correspondence o Letters from consulting physicians 10. Medical History (Old Records) 11. Miscellaneous Left side of chart 1. Green “Problem List” o New Patient Questionnaire o Health Maintenance form 2. Medication o Pink Medication Sheet o Yellow Prescription copies o Pink Pharmacy Refill Requests o Immunization records o Injectable BC form o CNP Patient Acknowledgement 3. Lab o Labs o PAP results o Pathology reports i. Protime sheet
  4. 4. CABIN CREEK AND RIVERSIDE HEALTH CENTERS P.O. Box 70, Dawes, WV 25054 (304)595-5006 Subject: Medical Records Format Policy No. MR.2 Department: Medical Records Date of Original: 6-25-03 Date of Last Revision: Approval Date Page 4 of 4 4. X-Rays o All X-Rays o Mammogram o CT Scans, MRIs o Ultrasound o Nuclear Medicine test results o IVPs o DEXA scans o Thyroid scans 5. Referrals o All documentation for referral of patients to outside providers 6. Communication o Orange Telephone Message / Intake Sheets o Any Provider to patient communication including: i. Letters of Missed appointments / no shows ii. Letters of Patient Termination 7. HIPAA o Al Consents – Treatment, Release of Information & Authorization 8. Patient Info / Billing o Patient demographics o CAP information o Insurance information including copies of insurance cards If there is any part of the patient record that is not in the correct order, bring it to the attention of the MRT Team Leader or Record Processing Team Leader.

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