Managing Patient Records - What Are The Best Practices?

1. Managing Patient Records - What Are The Best Practices? Chris York & Lynne Shoemaker, OCHIN

2. Electronic Medical Records are a Legal Document • Federal Rules of Evidence Accept Medical Records as “First Hand Evidence” in a Court of Law As Long As: • The record was documented as part of the normal course of business • Record was created at or near the time of the delivery of healthcare • The person that is documenting in the record had actual knowledge of the events that are being recorded and has the legal ability to document in the chart

3. Correction of Errors in the Medical Record Must be Made Correctly in Order for the Record to Continue to be Considered a Legal Document • Errors in the record should not be obliterated. They need to be documented as an error, and the correct information needs to be entered. The information still has to be viewable. One way of making an error correction is to create an addendum note that contains the corrected information. • Making error correction changes in the medical record without the proper documentation is illegal and unethical • An audit trail must show who made error correction changes in the medical record, the date and time of the error correction • If errors are not corrected properly, the legality of the medical record in a court of law can be called into question

4. Relationship between Medical Record and Billing • Only the individual who is legally allowed by state law to document in the medical record should document or make changes in the chart • The provider is legally responsible for documentation contained in the patient’s medical and billing record, including ICD and CPT coding • The provider is legally responsible for the bills that are submitted to payors, e.g. Medicaid and Medicare • Billers should not change codes without confirmation of the changes being made by the provider

5. Whose patient is it anyway? • Single patient record • Available to anyone with a legitimate, medical need to access the information • Within OCHIN and throughout community (via CareEverywhere)

6. What about non-patients? • Non-patient’s information should not be documented in the patient’s medical record • Release of information legal requirements for the non-patient can not be met by having the patient sign a release of information form • We get questions about PCP requirements • According to our report writing team - who manage the information for UDS and meaningful use, there is no requirement or measure for PCP assignments.

7. When a patient record is corrupted • Provider makes an error in charting • Charts on the wrong patient • Lab results on the wrong patient • Process for “fixing” the patient record

8. Chart Correction Process • Un-merge • On occasion a patient is merged incorrectly with another patient • When that happens we can unmerge. • Often there are charges that also need to be moved, and we can do that • Contact move • When there is incorrect charting on a patient, one of the options is to move the encounter (contact) to a different patient in the system. OCHIN has such a patient: Zzzincorrect,Lab • Clinical data move • We can also move specific orders/results to the Zzzincorrect, Lab patient

9. Chart Correction Process (cont) • There have been occasions when a patient record is being used by two difference service areas for two different patients. • Service Areas create a second “correct” patient in Registration • OCHIN moves all contactsand charges to new patient record • OCHIN removes the incorrect SA MRN type

10. Questions or Feedback? • Lynne Shoemaker, RHIA,CHP,CHC OCHIN Integrity Officer shoemakerl@ochin.org • Chris York, Technical Lead/Supervisor OCHIN Help Desk and Maintenance Team yorkc@ochin.org