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Ch. 13ppt


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Ch. 13ppt

  1. 1. The Medical Record, Documentation, and Filing
  2. 2.  Patient’s personal information  Demographic information  Marital status, children, and living arrangements  Social habits  Occupation information Medical history and family history  Medications  Testing performed
  3. 3.  Maintains and documents the course of patient care  Provider’s evaluation  Prescribed treatment  Responses to treatment Provides for a continuity of care Eliminates incompatible therapies, duplication of efforts, or unnecessary expenses Provides legal protection Maximizes reimbursement Helps conduct research
  4. 4.  HIPAA Privacy Rule HIPAA Security Rule  Ensures confidentiality of patient’s medical record  Protects against use or disclosure of information without the patient’s consent  All employees must comply with HIPAA
  5. 5.  EMR  Electronic medical record  Electronic record of health-related information for an individual that is created, gathered, managed, and consulted by licensed clinicians and staff that is maintained through a single organization
  6. 6.  EHR  Electronic health record  Aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization  Often used interchangeably with “EMR”
  7. 7.  PHR  Personal health record  Collection of medical records compiled and maintained by the individual
  8. 8.  Searchable databases Results can be transmitted to different providers and departments immediately Legible prescriptions sent to pharmacy immediately Reminder systems for routine maintenance and testing
  9. 9.  Encourages coordination of care between providers and departments Plug-ins for voice recognition software to decrease transcribing needs Automatic CPT/ICD code assignment Photo upload capabilities to ensure correct patient is selected
  10. 10.  Administrative  Clinicaldata data  Progress notes Financial and  Diagnostic information insurance  Lab information information  Medications Correspondence Referrals Past medical records
  11. 11.  Subjective  Objective  Provided by the  Provided by the provider patient and health care team  Routine information  Vital signs about the patient  Exam findings  Chief complaint  Diagnostic tests
  12. 12.  Demographics HIPAA Notice of Privacy Practices Insurance information
  13. 13.  All correspondence received by the medical office Referral or follow-up letters from specialists In an EHR, these are scanned and uploaded into the patient record
  14. 14.  Records from previous providers or facilities  Release of information form  Ensures continuity of care
  15. 15.  Arranged chronologically  Most recent note on top Each entry is timed, dated, and signed Medical office or provider will indicate preferred format for progress notes
  16. 16.  Imaging information  X-rays, MRIs, and many others Lab reports  Critical values should be highlighted and presented to the provider for review
  17. 17.  Medications administered in the office  Complete documentation Prescriptions
  18. 18.  Problem-oriented medical record (POMR) SOAP  Subjective, objective, assessment, plan HPIP  History, physical exam, impression, plan CHEDDAR  Chief complain, history, examination, details, drugs/dosages, assessment, return visit
  19. 19. Generally the medical assistant files three types of items: Individual Previously New documents filed patient for patient record existing record folders folders folders
  20. 20. Place the files in the appropriate location for easy retrieval whenneeded StoringPlace files in order to save time when storing SortingAdd an identifying mark to ensure that Codingthe file is put in the correct placeName the file using the officeclassification system IndexingMake suredocument is Inspectingready tobe filed
  21. 21.  Alphabetic Numeric Subject Geographic Chonologic
  22. 22.  With alphabetic filing systems  Each letter is assigned a color  The first two letters of the last name are color- coded with colored tabs  Can easily tell if files are filed correctly File these in the correct order: Allen, E.S. Allen, William C. Allard, Wm. Allens, M.R. Allen, Edna
  23. 23.  With numeric filing systems  Numbers 1 to 9 assigned a distinct color  Helps identify numeric files that are out of place File these in the correct order: 02-17-25 12-25-35 08-17-35 10-07-25
  24. 24.  Inventory Copies of orders Financial Records Tax records
  25. 25.  Tickler files  Reminder files  Check on a regular basis  Organizedby month, week of month or day of week  Computers systems offer tickler files in the form of a calendar  Reminders set to alert prior to event
  26. 26.  Take a close look at the contents of patient records each time you pull or file them Keep files neat  Do not overstuff file folders  Papers should not extend beyond edge of folder Remove file from drawer when adding documents  Prevents damage to documents
  27. 27.  Determine where the file was when last seen or used Look for the file while retracing steps from that location Check filing cabinet where it belongs  Check neighboring files Check underneath files in drawer or on shelf Check items to be filed Check with other staff members Check other file locations  Similar indexes  Under patient’s first name  Misfiled chart color
  28. 28.  Ask if someone inadvertently picked up the file with other materials Haveanother person complete the steps to double-check your search Straighten the office, carefully checking all piles of information
  29. 29.  Active files are files that you use frequently Inactive files are files that you use infrequently Closed files  Files of patients that no longer consult the office  The physician determines when a file is deemed inactive or closed
  30. 30.  Certain records have legal criteria for the length they must be maintained in the office, such as  Immunizations  Employee health records  Medical office financial records Criteria from  IRS – financial records  AMA, American Hospital Association  HIPAA law  Federal and state laws
  31. 31. Paper Microfilm ComputerStorage Storage Basic Storage Options Microfilm, microfiche and filmformat  Files remain in their original cartridges offer Patient records can be scanned and saved on a paperless way of storing records. DVDs, flash computer boxes recordable CDs even stacking  Labeled tapes, with lids to allowor drives, paper becomes brittle, transfer  If theor external hard drives. documents to another storage medium. 10-32
  32. 32.  Some offices have extra storage space on-site Smaller offices require the use of off-site storage  Use a facility that takes precautions against fires and floods  Maintain a list of all files stored at off-site locations Inactive and closed files must remain safe and secure Evaluate storage sites carefully Preferably place files in fireproof and waterproof containers The storage site should be safe from  Fire and floods  Vandalism and theft  Extremes of temperature