The Medical Record in Optometric Practice Flashcards
What are medical records?
Legal documents and encounter Hx
All optometric physicians have a professional obligation to maintain a _____ and ______ record for each patient
Complete and accurate
What is the risk of failure to keep a complete and accurate medical record?
Malpractice allegations and professional conduct hearings, typically result in judgement against the doctor
T/F most states have specific rules imposing professional discipline for failure to maintain appropriate records
True
What governs the obligations by doctors to keep appropriate records?
Federal and state law
What constitutes a valid record?
Handwritten, typed, or electronic chronology of care rendered with documentation of rationale for dx, tx or management plan, response to tx/management
How can a medical record benefit the patient and the practitioner?
Care management, reimbursement, peer review, utilization management, litigation
Medical records are….
Legal documents, used to communicate tx plans between providers, used to evaluate your clinical performance (quality assurance), an outward impression of your clinical rigor
Medical records are Not…
A place to editorialize
Dr. Wolfe’s Tic Tok pneumonic
Timeline, insightful, concise, thorough, objective, knowledgeable
What are the parts of the SOAP format?
Subjective, objective, assessment, plan
Why use the SOAP format?
Rigor, structure, and a way for practices to communicate with each other, and ability to retrieve all patient records for a given medical problem
What is the subjective?
In brief narrative form, chief complaint, report of compliance with current treatment and/or patient’s observed response to Rx since last encounter (HPI)
What should be included in the chief complaint?
Onset, laterality/location, chronology, quality, severity, modifying factors, additional symptoms, treatment
How many qualifiers must you not for the chief complaint?
4
What is the objective?
Documents objective, repeatable, and traceable facts about the patient’s status
What does the objective include?
Complete chronology of past ocular hx/findings, vital signs (VA, IOP, etc), clinical measurements, examinations, and gross observations, results from imaging or laboratory studies done during the course of examination
What is the assessment?
Medical dx for the visit on the given date of a not written, summary of subjective info gathered from patient and objective findings consolidated into a short assessment
What is the plan?
The plan should include anything that will be done to treat the patient as a consequence of the assessment, including meds or tx prescribed, referrals, orders for labs or special studies, instructions for continuation of care aka RTC
What are the prohibited abbreviations?
Q.D. Needs to be written as daily and MS could be multiple sclerosis, morphine sulfate to magnesium sulfate
How do you use status post in the chart?
The condition post (after) [what] intervention
How should you write “POH: surgery s/p laser repair of retinal tear OD x early 1990s”?
Retinal tear s/p laser Tx OD x 1990
How should you write “+surgery s/p CE OD”?
PCIOL s/p phacoemulsification OD
How must you document refusal of DFE?
Clearly document that… you informed the patient of the medical need to dilate and risk of non-detection, document that the patient fully understood your education, document that once fully informed, the patient continued with their refusal
T/F you need to have proper use of medical terminology
True
T/F one of the charting mishaps could be the referral?
True
How to document to keep out of trouble…
Document when pt is not competent or underage, have adequate pt education and documentation of CC with 4 HPI qualifiers, document risk of blindness, and risks for monocular patients
What makes you “look stupid”?
Using OD/OS/OU constantly… only use it for the globe, use RUL, LUL, etc for adnexa
What is the most important function of the medical record?
The story it tells regarding the patient
What is the second most important function of the medical record?
Reimbursement of the provider
What is the third most important function of the medical record?
Essential evidence it provides the patient and doctor
Most litigation in health care involves actions brought against ___ by the _____
Against the doctor by the patient
When are litigations typically brought against the doctor?
3-5 years after the patient received treatment
How does the TN state board of optometry define essential evidence/maintenance of optometric records?
…as a component of the standard of care and of minimal competence, an optometrist must cause to be created and maintained an optometric record for every patient for whom he or she, and any of his or her supervisees, performs services or provides professional consultation
What are four types of data in patient records?
Personal, financial, social, medical
What is personal patient data?
Usually gathered on or before the first visit, including demographics, items for specific identification (may indicate special confidentiality issues)
What is financial data?
Usually gathered on or before the first visit, includes basic payer information: employer, health insurance company, insurance numbers, copies of ID cards, driver’s license number
What is social data>
Usually gathered on the first visit as a part of the welcome to our office and or medical history forms, includes lifestyle information, ethnic background, family relationships, community activities, tobacco use, alcohol use, avocation
What is medical data?
Gathered at the first visit and as a part of ALL SUBSEQUENT VISITS, includes relevant records from other providers, referral letters and consultation results, diagnostic info, tx info, the entire medical record
What are minor errors?
Transcription errors, minor spelling
What are major errors?
Omission of relevant data (test results, A/P) or inclusion of data not related to the patient (wrong test results)
T/F errors or mistakes in a patient record should NEVER be erased, obliterated or deleted
True, arouses suspicion as to the original contents, correction should be made in a way that facilitates seeing the change that was mad AND indicates the identity of the individual making the change
Explain corrections and alterations on a paper record
Use a single line to mark through the incorrect entry, enter the correction, initial the correction, enter the date and time the correction was made
Explain corrections and alterations on an electronic record
Exact method depends on software, an audit trail is usually created q
What do you do when a correction entry requires more space than is available in the chart?
A reference should be made to an addendum in the record
What is an addendum?
Document or information attached or added to clarify, modify, or support the information in the original document
What is release of information?
Federal and state release of information acts dictate release of copies of records to the patient on demand, failure to comply may result in disciplinary action although judicial decisions have recognized the right of providers to withhold records in special circumstances
What is an optometry release of information example?
FTC’s eyeglasses rule
When can you release patient information to a third party?
Must have patient’s express written consent via documentation of a signed release
When you release information to a third party, what guidelines should be followed?
When divulging consented information, provide only as much information as is needed to comply with the request and keep a copy of the information sent in the original record
What entities work to keep information safe?
HIPAA, the joint commission (JCAHO approved)
How do you keep paper records safe?
Must be stored in a lockable room with limited access
How do you keep electronic records safe?
Electronic records should be stored on a password protected server backed-up remotely or encrypted web-based server, lock your screen, windows L
T/F it is sometimes okay to print/photograph paper copies of electronic documents
false
What is a statute of limitations?
A period of time, established by statute and measured in years, within which a party can bring a lawsuit against another party
What is a key factor in determining record retention policies?
Statute of limitations
What are HIPAA’s four paths to protected health information?
Medical records authorization, subpoena or discover request with notice requirements, subpoena or discovery request with qualified protective order, judicial or administrative order
How long must optometric records be kept in Tennessee?
“Not less than 10 years” from the last professional contact with the patient
What are notable exceptions in record keeping length?
Records should be retained indefinitely for incompetent patients, for minors they must be retained for a period of not less than 1 year after the minor reaches the age of maturity or 10 years from the last contact (whichever is longer)
T/F no optometric record involving services under dispute shall be destroyed until the dispute is resolved
True
Who has ownership of patient records?
Technically, records are owned by the patient once they have reimbursed the doctor for any services or materials provided
If the doctor doesn’t own the patient records, why keep them up?
Doctor has privilege/responsibility/obligation to create and keep the records accurate
What does the Tennessee state board of optometry say about hospital records?
Hospital records are and shall remain the property of the hospitals, subject to a court order to produce the records
T/F when releasing the patient record, never gibe the patient the original record
True
T/F in most states, doctors cannot be denied a copy of the record if they have seen the patient within the past 3 years
True
Does a physician need a patient’s written authorization to send a copy of the patient’s medical record to a specialist?
No, not if they will be continuing care
