Chapter 21- The Health Record Flashcards
Medical Record:(The Chart)
Important legal docs in the healthcare
CC:
Chief Complaint
EHR:
Electronic Health Record
PMH:
Past Medical History
SOAP: ( A method for charting)
Subjective, Objective, Assessment, Plan
HIPPA:
Health Insurance Portability & Accountability Act
HITECH:
Health Information Technology for Economic and Clinical Health Act
What is the advantage of EHR?
-Reducing the incidences of medical error by improving accuracy of medical record.
- It is efficient
-Management capabilities
- Able to read co workers notes/ handwriting
Parts of a Medical Records:
Demographics, PMH, Social History, CC
Demographics:
Pt’s name, DOB, Contact Info, Home Address, Healthcare Insurance, etc.
PMH: Past Medical History
Previous illnesses, injuries, usual childhood diseases (UCD), hospitalizations, surgeries; current health status
Social History: (SH)
Marital status, substance use, diet, occupation, pets, personal habits, sexual preferences, lifestyle
CC:
CC is the reason for the visit
Usually documented in patient’s own words (with quotation marks)
OLDCARTS
HPI:
History Present Illness
- The detailed part of the issue for coming into the office.
Signs:
Anything that can be measured or observed by others.
Ex: Edema, Rash, Bruise
Symptoms:
Something that is only perceived by the pt. also called subjective data/
( Pain, Headache, Dizziness, and Nausea)
Type of Chart Formats:
SOMR, POMR
SOMR:
Source Oriented Medical Records*
- Common in paper charts, which are divided by sources.
- It’s the most common and traditional
POMR:
Problem Oriented Medical Record
(4 components)
- Database, Problem List, Treatment Plan, Progress Notes
- Not very commonly used
SOAP Notes:
Subjective Data: obtained from PT. (Symptoms)
Objective Data: Clinical evidence or observations from the provider. (Signs)
Assessment: The provider indicates the problem number & diagnoses.
Plan: Includes providers suggested treatments.
- The MA fills our the S & O.
- The Provider does the A & P.
Anaphylaxis:
A severe reaction that can be life- threatening.
What is continuity of care?
Continuity of care is the smooth continuation of care from one provider to another. This allows the patient to receive the most benefit with no interruption or duplication of care.
Reasons to have accurate records:
- Proof needed for a legal defense
- Reimbursement
- Higher Quality of Care
- Track Vital Statistics
Who owns the medical record?
The Physians office
- The place where the chart was created.
HITECH:
- A law that enforces HIPAA.
- HIPAA on steroids x10”
- Gives providers incentives. $$
-Find doctors and providers and fine them for the ones not using electronic.
Introduction to the Health Record:
Serves as a legal document
Documents health information and provides support for treatment plan
Enables continuity of care
Supports reimbursement claims
Provides legal protection to provider(s)
Provides statistical information for research
Types of Health Records:
Paper and electronic (EHR)
Benefits of EHR:
Practice management capabilities
Scheduling
Billing and claims
Report generation for quality control, research
Storage space
Safety from accidental destruction
Financial incentives from government for implementation
Promotes communication and continuity of care
Ownership of the Health Record:
Health record itself (paper or electronic)
Provider or healthcare facility
Information in health record
(Patient)
Vested interest, right to confidentiality
Best practices for security of paper records
What are some best practices for maintaining security of paper records?
Never remove them from the facility; lock storage area when facility is closed)
Contents of the Health Record:
Personal demographics
Name, date of birth, home address, contact information, healthcare insurance, etc.
Past medical history (PH or PMH)
Previous illnesses, injuries, usual childhood diseases (UCD), hospitalizations, surgeries; current health status
Family history (FH)
Health or age and cause of death of grandparents, parents, siblings; hereditary diseases
Social and occupational history (SH, OH)
Marital status, substance use, diet, occupation, etc.
Contents of Health Record:
Chief complaint (CC) and history of present illness (HPI)
CC is the reason for the visit
Usually documented in patient’s own words (with quotation marks)
OLDCARTS
Allergies
Immunization and medication records
Physical exam
Range of systems (ROS) for new patients
Baseline
Provider’s findings
OLDCARTS:
Onset: When did it begin?
Location: Where is it?
Duration: How long has it been going on?
Characterization: How would you describe it?
Alleviating and aggravating factors: What makes it better? What makes it worse?
Radiation: Does it stay in one location or move?
Temporal factor: Isi it better or worse at different times of the day?
Severity: Using a scale of 0 to 10, with 0 being none and 10 being worse the worse, how does it rate?
Contents of the Health Record:
Progress notes
Signs, symptoms, feelings, concerns
Clinical findings from PE and labs, diagnostics
Provider’s impression and diagnosis
Treatment plan
Laboratory and diagnostic imaging results
Consultation reports
Hospital documents
Discharge summary, operative report, ED report.
What is the difference between the sign and a symptom?
A sign is something that can be measured or observed by others; also called objective data. Examples include redness, swelling or edema, blood pressure, and pulse. A symptom is something that is only perceived by the patient; also called subjective data. Examples include pain, headache, dizziness, and nausea.)
What are some examples of labs? Diagnostic imaging?
(Answers will vary and may include, for labs, tests on blood, urine, sputum, tissues, or other substances from the body; for diagnostic imaging, x-rays, CT scans, nuclear medicine scans, MRI, ultrasound.)
What is a medical consult?
A medical consult occurs when a patient is referred to another healthcare provider for examination and treatment.
Miscellaneous documents-
Correspondence, release of information forms, disclosure authorization forms, Notice of Privacy Practices (NPP), consent for treatment and authorization form, other consent forms, images/copies of health insurance card and patient ID, advance directives, past health records
Source-Oriented Medical Records (SOMR):
Observations and data categorized according to source
Examples:
Provider (progress notes)
Laboratory
Radiology
Hospital
Consultations
Reverse chronologic order
What is reverse chronologic order and what is a reason it is used?
Reverse chronologic order is when the most recent item is listed first and the oldest item is last. One reason it’s used is that the provider and staff members do not have to search to the bottom of the record to find a recent laboratory report or a test.)
Problem-Oriented Medical Records (POMR):
Database
-CC, HPI, PE, labs
Problem list
-Each numbered and titled
Plan
-Numbered and titled diagnosis and treatment plan correlating to each problem on the problem list
Progress notes
-Structured notes numbered to correspond to each problem
SOAP Note:
Subjective data (S)
-Obtained from patient; includes CC, HPI, other histories, ROS, current meds, allergies, etc.
Objective data (O)
-Clinical evidence, including vital signs, measurements, PE findings, labs, diagnostics results
Assessment (A)
Diagnosis correlated with problem number
Provisional, differential
Plan (P)
Provider’s suggested treatments
What is a differential diagnosis?
A differential diagnosis is the process of weighing the probability of one disease causing the patient’s illness against the probability that other diseases are causative.)
What is a provisional diagnosis?
A provisional diagnosis is a temporary diagnosis made before all test results have been received
Variations of the Progress Note Format:
-SOAPE
Evaluation
-SOAPIE
Intervention and evaluation
-SOAPER
Education and response
-CHEDDAR
CC
Exam
Details of problem and complaints
Drugs and dosages
Assessment
Return visit or referral
Documenting in the Health Record:
What to document:
Patient visits
No shows
Telephone calls
Correspondence
Electronic communication
What are examples of electronic communication that must be documented?
Email, patient portal communications
Documenting in the Health Record:
Guidelines:
Check patient name first
Document immediately after procedure
Document in order steps were completed
Be accurate, specific, and concise
Use correct words and facility-approved abbreviations
Use quotation marks when recording patient’s own words
Use punctuation
Don’t use first person
Review
Handle errors correctly
What does concise mean?
Concise means using as few words as possible to express the message.
Documenting in the Paper Health Record:
Guidelines:
New entry on next blank line, starting with date
MM/DD/YYYY followed by time
Write legibly in ink (black preferred)
Patient name and medical record number on each page
Sign per facility policy
Correction:
Follow facility policy
Draw a single line through error
Insert correct above, after, or in the margin
Write error
Date and sign or initial with title
True or false: Erasing the error, writing in the correct information, and signing with an “OK” next to your name is an acceptable means of making a correction on a paper health record.
False. Obliteration is never acceptable
Documenting in the Electronic Health Record:
-Radio buttons and drop-down menus
Enable standardization of content
-Free-text boxes
Used to document unique circumstances
-Unique user identification
Allows for audit trail
What is an audit trail?
An audit trail is a record of computer activity used to monitor users’ actions within software, including additions, deletions, and viewing of electronic records
Dictation and Transcription-
Dictation:
To say something aloud for another person to write down
Machine transcription unit, portable transcription unit, phone system
Transcription:
To make a written copy of dictated or handwritten material
Provider reviews and initials transcript before placement in health record
Voice recognition software:
Converts dictation into readable text
Paper Filing Equipment:
Drawer files
Horizontal shelf files
-Also called open file with fixed shelves
Rotary circular files
Electronic lateral files
-Also called vertical carousel files
Mobile shelving system
Card files
What are important considerations in the selection of filing equipment for paper health records?
Available space, potential volume of records, lock system, fireproof)
Paper Filing Supplies:
Divider guides
Out guides
File folders
File folder dividers
Labels
-Patient name, allergies, advanced directive
Paper Filing Systems:
-Basic systems
Alphabetic by name
Numeric
Subject
-Direct or indirect
Advantages and disadvantages
Is a numeric system direct or indirect?
Indirect
Alphabetic Filing:
Indexing rules
Updated by Association of Records Managers and Administrators (ARMA)
Use units
-Surname (first unit)
-Given name (second unit)
Specifics for patients
Specifics for businesses
Numerical Filing:
Consecutive numeric filing
- Also called straight numeric system
Terminal digit filing
Middle digit filing
Subject Filing, Color Coding, and Tickler File:
Subject filing
-Paper records are arranged and filed based on content or subject matter
Alphabetic, numeric, or alphanumeric
Color coding
-Specific color identifies letter or number
Ticker file
-Chronological reminder system for tasks
What does alphanumeric mean?
System using a combination of letters and numbers
Paper Filing Process:
Group by patient
Inspect for provider sign-off
Prepare
Index and code
Sort per facility procedures
Verify placement per facility policy
Refile
-Remove out guide
Electronic Health Records Terminology:
Electronic health record (EHR)-
Electronic record of health-related patient info
Conforms to nationally recognized interoperability standards
Can be created/managed/consulted by authorized clinicians and staff from more than one healthcare organization.
Electronic medical record (EMR)-
Electronic record of health-related patient info
Can be created/managed/gathered/consulted by authorized clinicians and staff within a single organization.
Which is the preferred record, the EHR or the EMR?
The EHR, because it facilitates continuity of care
Personal health record (PHR):
Electronic record of health-related patient info
Conforms to nationally recognized interoperability standards
Can be drawn from multiple sources
Managed, shared, and controlled by individual.
Patient portal:
Electronic access to EHR for patients that enables
Communication with provider
Online form completion
Prescription refill requests
Appointment scheduling
Meets some Promoting Interoperability Programs requirements.
What are the Promoting Interoperability Programs?
Formerly known as the Medicare and Medicaid EHR Incentive Program, the Promoting Interoperability Programs encourage providers to adopt, implement, upgrade, and demonstrate meaningful use of certified electronic health record technology.
How is an electronic personal health record created?
Answers may vary and may include as a service of healthcare insurance companies, employers, or healthcare facilities.
Health Information Technology for Economic and Clinical Health (HITECH) Act:
Encouraged widespread of adoption of EHR to
-Improve efficiency and coordination of care
-Improve privacy and security
Through:
Financial incentives linked to meaningful use
E.g., e-prescribing, sharing health information to improve quality of care, submitting reports, using computerized physician/provider order entry (CPOE)
Increased penalties for HIPAA violations
What is interoperability?
The ability to work with other systems.
What is compliance?
Meeting the standards and regulations of the practice’s established policies and procedures. Can also mean cooperation
Features of EHR:
EHR:
Immunization data sharing with state registry
Mobile access for providers
Clinical decision support systems
E-prescribing
Appointment scheduling
Lab order integration
Features of Practice Management Software (PMS):
PMS:
Appointment scheduling
New patient registration
Insurance verification
Billing, coding, financial management
Claim denial management
Electronic claim submission
Financial and management reporting
EHR and PMS:
May have overlapping capabilities
Interface
The Medical Assistant’s Role with EHRs:
-Enter patient visit data
Vital signs, measurements, allergies, medications, chief complaint, histories
Update medications and vaccinations
Review patient information for relevant needs
Document procedures performed
Document patient coaching
-Arrange referrals
-Schedule follow-up visits and/or tests
-Scan and upload paper documents
-Check patient portal for communications and requests
HIPAA Privacy Rule:
National standards that define and limit how PHI can be used or disclosed
Also outlines patients’ rights regarding their PHI
Examine their own health information
Obtain a copy of their health records
Request corrections be made if information is incorrect
Permissions
Reasons that health information can be released
Disclosure authorization
Records release process
HIPAA Security Rule:
National standards that define protections for electronic PHI (ePHI)
Administrative safeguards
Physical safeguards
Technical safeguard
Applies to records created, used, received, and maintained by covered entities
Backup Systems for the EHR:
Backing up
Process in which network files are copied using an external hard drive, server, online system, or cloud backup services
HIPAA requires daily offsite EHR software backup
Use of paper records in case of malfunction
Plan to integrate data from paper into EHR
Storage, Retention, and Destruction of Health Records:
Record status:
Active
Inactive
Closed
Purging:
Separating inactive from active records
Retention schedule:
Schedule outlining how long inactive and/or closed records are kept
Destruction:
Must be in accordance with federal and state laws
Permanent log of destroyed records
What is the usual length of time closed health records are retained?
7 to 10 years after patient’s last interaction with facility
How long are inactive or closed Medicaid and Medicare patient health records retained?
10 years
Storage, Retention, and Destruction of Health Records:
Storage of paper records:
Limited access, secure, temperature and humidity ranges, lockable area away from water and heat
Retention of paper records:
Sticker system
Offsite storage
Destruction of paper records:
Burning or shredding
Storage, Retention, and Destruction of Health Records:
Storage of electronic health records
Via backup
Retention of electronic records
Automated movement of inactive and closed records to different server
May be placed on CDs, hard drives, inactive cloud space
Patient-Centered Care and the Electronic Health Record:
Make eye contact when asking questions
Look at the screen only when entering information
Don’t shield the screen from the patient
Sit next to or at an angle to the patient
EAQ:
Which section of the SOAP note will the statement “ I feel like someone is pounding nails into my head” belong in?
Subjective
In which order will the pt name be placed on paper chart name label?
Last name, first initial, middle name
Which information is part of a problem- oriented medical record (POR)?
SOAP note
POR-
is a form of documentation that organizes patient data in a logical sequence.
Voice recognition software can be used for which functions?!
- Dictate progress notes
- Dictate letters
- Generate emails
Which pt file is considered active?
A paper record of a pt seen last year for a complete physical exam.
How long are pt files active?
- has been seen within the past 1 to 5 years and need to be readily available for daily use.
Which classification is given to pt who have not received treatment from the healthcare provider for 6 months or longer?
Inactive
Closed files:
are records of pt who have died, moved away, or otherwise terminated their relationship with the provider.
What does a provider do when he wants to terminate a relationship with a pt?
A dismissal letter will be sent to the pt and the pt is then considered dismissed by the clinic.
Which method of filing is most commonly used?
Alphabetic
In which part of the pt record will the MA chart the pt’s current health problem?
CC {Chief Complaint}
