Chapter Six Flashcards
What is a medical record? What does it enable the physician to do what?
The medical record is a written story of a patient’s medical history
It enables the physician to do the following:
■ Assess family medical history
■ Compare progress or lost ground in treatment
■ Prescribe appropriate treatment plans
■ Offer appropriate advice
■ Refer to specialists
■ Manage hospitalization, if necessary
■ Manage information that could be used in the legal system
The medical record makes it possible for the healthcare professional to provide what?
- the most appropriate patient services.
- For example, the patient with more than one physician should be sure that all physicians involved in his or her care have the most current information so they can work together for the greatest benefit
What is a hopper
A patient who switches from doctor to doctor
Why do some people hop doctors? (3)
- Patients go from doctor to doctor because they cannot find the satisfaction they are looking for in a healthcare provider
- It may be because they owe money.
- They are seeking prescribed medications (e.g., pain medication)
Advocates of a nationally standardized electronic medical records system contend that electronic records would virtually do what?
do away with a hopper
What is the medical record considered?
a legal document because the information in the record is often used as a primary source of evidence in lawsuits
- Remember this in your everyday documentation practices because what you provide in writing could win or lose a legal case
Every medical record should possess the following characteris- tics, which you can remember with what mnemonic ?
FLOAT:
■ Factual
■ Legible
■ Objective
■ Accurate
■ Timely
What is Factual in FLOAT?
- Since the medical record is a legal document, it is essential that it be factual.
- The information, if brought into a legal case, will be reviewed and possibly presented as evidence.
- The judge or jury will not be able to come to a conclusion on a point if it is not in the record
- The phrase “not recorded . . . did not happen” will be enforced.
- Additionally, if you are about to perform a procedure (such as an injection), do not record until after you have completed the procedure.
What is Legible in FLOAT?
- It is often overlooked that many healthcare professionals do not make extra efforts to write legibly
- If people cannot read your writing, how can they assess patient information?
- If you find that your own handwriting is not the most legible, do what you can to improve it. Believe it or not, this could come up in a lawsuit.
Medical records should be done in what?
- Should be done in blue or black ink only.
- Never make an entry in pencil or colored ink and never use erasable ink.
What are physicians now choosing for legible?
are now often choosing preprinted forms to save time and improve legibility issues
As specified by the Centers for Medicare and Medicaid Services (2009), “Authentication of medical record entries may include what?
written signatures, initials, computer key, or other code
What is going on with EMR and handwritting?
Sorry, i did not know how to ask this question lol
- EMR (the Electronic Medical Records, also known as the electronic Health Record, or EHR) have changed the systems that offices use to document patient information.
- With the EMR, much of the trouble with illegible handwriting has been eliminated. However, many prescrip- tions are still handwritten, so a brief discussion on legibility is necessary.
What is Objective in FLOAT?
- The word objective suggests impartiality and fairness
- Just the facts
- It makes sense that the information contained in the medical record be objective
- Terms such as “disagreeable” are subjective and do not belong in the record. Terms such as “every” or “never” are rarely true
What happens when a record is clogged with personal comments and a doctor reading it?
- It could hinder the assessments made in offering patient care.
- Always document as if you were trying to explain something very important to someone else: Be concise, but do not leave out any relevant details.
What happened with Jacques Flemee?
What is Accurate in FLOAT?
- The medical record is only as accurate as the efforts of those who record in it
- The lack of accuracy, after all, can be the difference between a patient experiencing improved health and one experiencing a life-threatening situation
What is also crucial in Accuracy?
- Spelling and grammer
- Accuracy does not refer just to the information either
- Though it may seem obvious, you should always double-check to assure that you have the correct medical record before beginning to document—a simple, yet costly mistake.
What is controversial issue in charting?
- Abbreviations
- There are so many abbreviations that some could be confused.
- That is why professional organizations, educational institutions, and government agencies often have their own lists of approved abbreviations. The facility where you work should have an approved list on file and could even post some near work stations as reminders.
What are words to the wise in Accuracy?
Whether an unclear statement or a spelling mistake, a poorly written entry in the medical record can hinder accurate patient care
What is Timely in FLOAT?
- Timeliness is of the essence in medical accountability
- When you are with a patient, you should be making notes immediately to ensure the most accurate information. To do anything else is a disservice to the patient, and this reflects on your professionalism
According to the American Health Information Management Associ- ation, if you are not able to enter the information in a timely manner, What did you do?
ou may add a late entry or an addendum, if it is clearly marked as such.
Do not confuse a late entry or addendum
- either of which is permitted, with information added unethically to enhance a medical record in preparation for court use
- Unethical practices of adding information can result in punishment to the person making the entry
What is the Joint Commission?
not-for-profit agency established in 1951, is an accreditation agency in the United States that reviews patient documentation
What is the Joint Commission mission?
“to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value”
Joint commission does not only review records of hospirals but what?
Evaluates other patient service facilities such as dental offices, nursing homes, clinics, surgery facilities, and urgent care facilities
To earn and maintain TJC’s “Gold Seal of Approval, an organization must undergo what?
must undergo an on-site survey by a Joint Commission survey team at least every 3 years
If a TJC representative visits your place of employment, remember what?
- that he or she is just there to help suggest improvements according to Gold Seal of Approval standards. Your best strategy is to cooperate fully.
- The representative will complete a written report of the audit, and your facility will be given time to make corrections.
What can an audit be?
a valuable learning experience so should your employer be audited, take the opportunity to learn from the experience and pay attention to the kinds of information that they are gathering, if you’re able.
Though individual states vary regarding the specific information required, in general a satisfactory record will include the following:
When you make a mistake in a traditional medical record, you should never do what? What should you do?
- You should never use correction fluid or erase the entry in any way.
- Instead, draw a thin line (also called a “strikethrough”) through the mistake and write your initials and the date above the line.
- In doing so, the former statement can be seen in case there is any discrepancy
- Corrections on the electronic medical record will be dependent on the type of system utilized by your employer.
What are the two common methods of medical charting?
SOAP method and narrative method
What is the narrative charting method
- Consists of thorough but concise documentation.
- At first glance, it may seem to be the easiest method, but in the long run, this method can make it quite difficult to decipher patient information and to fit all the informa tion together to make decisions about patient care.
- Progress notes often are a part of this method.
What is the SOAP charting method?
Often produces a more consistent record. SOAP is a mnemonic for the sections included in the record:
- Subjective—The patient’s chief complaints
- Objective—The healthcare professional’s observations and findings through examination and conversation
- Assessment—Conclusions based on the subjective and objective information
- Plan of action—The treatment that is advised based on the conclusions
By using this method, entries are easy to track throughout the record by category and, therefore, may even save time for the physician(s) reviewing it.
What is the preferred delivery method of medical information?
- through registered mail or through a reliable delivery service where a signature is required.
- Faxing is a common way of sending medical information,
When should faxxing be used?
- It, like e-mail, should be used only when the information is needed immediately and/or when other communication avenues are not feasible, and it should be used only with proper documentation of permission.
- Some states have laws that prohibit the faxing of medical information
- sending medical information by e-mail is quite risky, as unauthorized persons may be able to view it
What are following are tips for faxing medical information
What is subpoena duces tecum
Only send the portion of the record that has been requested. If you send more, it could change the results of a court case. Only sending the portion requested is known as subpoena duces tecum, which is Latin for “bring with you under penalty of punishment.”
the following information should be included on the cover sheet:
a. Date and time of transmission, along with number of pages (including
cover page)
b. Sender’s name and name of facility, telephone number, and fax number
c. Recipient information: name, facility, telephone number, fax number, and address
d. A request for notification of receipt of information
e. The patient’s name, included on each page of the information except the cover page
What is Frank Smith?
The purpose of confidentiality is to protect the patient. Reflecting upon this, you can rationalize that to further protect some patients, there are sometimes reasons why?
it is not good for the patient to have access to his or her own medical record
* For example, the patient might do himself or herself harm, or the patient might be in an at-risk group (such as in the case of children, elderly patients who might not be capable of making sound decisions, or mental health patients).
What is electronic medical record (EMR)
medical record documented on and available by computer. It is also referred to as an EHR (electronic health record). For purposes of this writing, we will use the acronym EMR.
What has not been established by EMR?
An electronic national medical registry has not been established, but many have advocated for one, saying it would be advantageous to achieving cohesiveness in patient care. Also, advocates maintain that a national registry would prevent the “hopper” problem.
How many U.S. office-based physicians use electronic medical records?
according to the CDC (Centers for Disease Control and Prevention, 2017), about 87% (86.9 to be precise)
What are some concerns surrounding the EMR ?
vulnerability to hackers and that any altered records could jeopardize the health, and possibly the very life, of the patient
The U.S. federal government mandated every medical facility to provide evidence of what?
“meaningful use” of an EMR system mandated by 2015
When was EMR introduced?
What is the Angelica Diaz Case?
Consider the following ethical principles as they relate to the EMR:
What is fidelity?
Fidelity in the field of ethics simply means loyalty
American Medical Association Statement: E-7.05 Retention of Medical Records
Both medicine and Medicaid, through the centers for Medicare and Medicaid services (CMS), offer what?
Financial incentives to health care providers and facilities to become certified in electronic/online records (EMR)
The goal is to teach the facility to provide and maintain a high standard of electronic data entry and usage. These are called?
MUR, or Meaningful Use Regulations
What are the three stages to MUR certification?
What is the timeline of the three stages of MUR certification?
- Participation must meet Stage 1 requirements of meaning use for 90 days of the first year and a full year of the second year.
- Participants must meet Stage 2 requirements for two full years
- Stage 3 is a fairly new component and requires the participant to demonstrate advanced use of EHR (electronic health record) technology to promote health information exchange and improved outcomes for patients
From April 2003 (the compliance date for the Privacy Rule) to March 2018, almost _ complaints have been filed with the OCR (Office of Civil Rights) . Ninety-six percent of those cases have been resolved .
178,000
