Business for Health Business Skills for Private Medical Practices

1. Business for Health Business Skills for Private Medical Practices Module 8: Manage Medical Records

2. A Quick Start Welcome! While you are waiting for the class to begin, please take the Pre-Test and make sure your name is on it before you hand it to the facilitator. Thank you!. Business Skills for Private Medical Practices

3. Agenda Welcome Outpatient Medical Records Medical Records Policies and Procedures Medical Records Audits Medical Records Management Manage Medical Records Summary and Evaluation Close Business Skills for Private Medical Practices

4. Learning Objectives During this session, you will: • propose the patient information and forms that should be included in outpatient medical records; • recommend how an outpatient medical record can be organized; • assess the content of your current medical records; Business Skills for Private Medical Practices

5. Learning Objectives • discuss your current medical records policies and procedures; • assess your current medical records policies and procedures; • design a checklist for auditing the completeness of medical records; Business Skills for Private Medical Practices

6. Learning Objectives • design a peer review checklist for auditing the quality of medical records; • assess your current medical records management; • decide how to handle issues related to medical records management; • discuss the next step; and • state your key take-away from this session. Business Skills for Private Medical Practices

7. Introduction You will have 1 minute to introduce yourself: 1. Your name 2. Your position 3. Your business 4. How long you have been in business Business Skills for Private Medical Practices

8. Outpatient Medical Records Business Skills for Private Medical Practices

9. Outpatient Medical Forms Design a well organized and complete outpatient medical record. Please identify: • The forms you need in the medical record • The information that should be collected on each form • The order in which the forms should be placed in the medical record, with # 1 being the first form you would see Business Skills for Private Medical Practices

10. Medical Records Content Assessment Medical Records Should Contain: Business Skills for Private Medical Practices

11. Example of Primary Care Medical Record Documentation Standards Business Skills for Private Medical Practices

12. Medical Records Policies and Procedures Business Skills for Private Medical Practices

13. Medical Records Policies and Procedures • Who prepares a new patient medical record? • What system is used for filing and retrieving medical records? • Who is allowed to make entries into the record? Business Skills for Private Medical Practices

14. Medical Records Policies and Procedures • What procedure do you use to indicate the need to follow up on patient referrals or external diagnostic test results? • What are your security procedures regarding medical records? • How do you maintain patient confidentiality? Business Skills for Private Medical Practices

15. Medical Records Policies and Procedure Assessment Patient Medical Record Information Management Business Skills for Private Medical Practices

16. References • Simple Ambulatory Medical Record Documentation Standard • Sample Clinical Records Management Policy • Policy and Procedures Writing Guide and Template Business Skills for Private Medical Practices

17. Medical Record Audits Business Skills for Private Medical Practices

18. How to Conduct Medical Record Audits What are the best ways to conduct audits of medical records for completeness of data and documentation of quality of care? Business Skills for Private Medical Practices

19. Auditing for Completeness of Medical Records Create a peer review audit checklist. For example: • Are all of the necessary forms in the record? • Are all clinical notes signed, dated and timed? • Are patient vital signs recorded for each visit? Business Skills for Private Medical Practices

20. Reference • Sample Peer Review Policy and Procedure: Quality Audit • Sample Peer Review Worksheet Business Skills for Private Medical Practices

21. Quality Issues in Medical Records Identify five issues that need a medical record peer review. For example: • Did the provider prescribe the correct drug? • Were the blood tests that were ordered the correct tests? • Was the chest x-ray consistent with the differential diagnosis? Business Skills for Private Medical Practices

22. Auditing for Quality of Medical Records Create a peer review audit checklist based on the issues listed in the previous activity. Business Skills for Private Medical Practices

23. Reference • Sample Peer Review Policy and Procedure: Quality Audit • Sample Peer Review Worksheet Business Skills for Private Medical Practices

24. Medical Record Management Business Skills for Private Medical Practices

25. Medical Record Management Assessment ✔1. The practice maintains complete and accurate medical records ✔2. Medical records are stored in a secure location ✔3. There is a unique medical record for each patient ✔4. Records are organized for easy retrieval Business Skills for Private Medical Practices

26. Manage Medical Records Business Skills for Private Medical Practices

27. Case Study: Filing Folly Working with your table, please identify: 1. the issues 2. the causes 3. how to avoid them in the future; and 4. what the hospital should do to manage the current situation. Business Skills for Private Medical Practices

28. Case Study: Filing Folly Business Skills for Private Medical Practices

29. Summary and Evaluation Business Skills for Private Medical Practices

30. Evaluation Sheet Business Skills for Private Medical Practices

31. The Next Step • Develop a Medical Record Data Quality Checklist • Ensure your Medical Record Policies and Procedures include file management, confidentiality, and record retention Business Skills for Private Medical Practices

32. The Next Step • Design a monthly Patient Medical Record Peer Review process for quality and appropriate use of services • Randomly pull five patient medical records and conduct a review for data completeness and quality of service. Document results and take action when needed. Business Skills for Private Medical Practices

33. Let’s See How Much You’ve Learned Please take the Post-Test. We will compare it to your Pre-Test to see how much you’ve learned in this session. Thank you. Business Skills for Private Medical Practices

34. My Key Take-Away Business Skills for Private Medical Practices