Health Information Management Records and Files

1. Health Information ManagementRecords and Files 11.13 Differentiate between types and content of health records (patient, pharmacy, and laboratory). 11.14 Ensure that documentation in the health record reflects timeliness, completeness, and accuracy. 11.15 Adhere to information systems policies and procedures as required by national, state, local, and organizational levels.

2. Confidentiality • What do you remember about patient records and confidentiality? • They are legal documents • Records should not be released to other parties without the written consent of the patient. • The records belong to the physician or health agency. • Does the patient have a right to obtain copies of his/her medical records?

3. Statistical Data Sheet • Also called patient or medical information form. • Contains name, personal data and insurance information. • Often filled out by hand and then typed into computer. • Some are online.

4. Medical Record • Also called patient chart, medical chart or patient record. • Collection of documents pertaining to a patient. • Purpose of medical record: • Communication • Documentation • Legal protection • Who does a medical record protect?

5. What is in a Medical Record? • Medical History • A process of questioning by a healthcare professional for the purpose of gathering information used to help diagnose and care for a patient. • The history can vary based on circumstances. • Who would take a longer medical history – a paramedic responding to a patient with chest pain, • Or a psychiatrist who is evaluating a suicidal patient?

6. What is in a Medical Record? • Physician’s Orders • Communicates patient treatment plan. • Can be handwritten, • Pre-printed and checked off, • Or printed electronically.

7. What is in a Medical Record? • Diagnostic Tests • Laboratory reports • Radiology reports • EKGs • What other diagnostic tests might be included in a medical record?

8. What is in a Medical Record? • Reports • Can include operative reports, consultations, and other important information. • Consent forms • Meet informed consent requirements • Signed by patient and witness

9. What is in a Medical Record? • Medication Records • Documentation of all medication – drug, dosage, time administered, and by whom • Progress Notes • Healthcare workers document evaluation of patient’s clinical status and achievements during a hospital stay, or over a span of time. • Physicians will update findings after seeing patient. • Therapists will note what was done and results. • Nurses record treatment they perform and patient response.

10. Problem Oriented Charting - SOAP • S - Subjective • Subjective information – sensed by the patient • Chief complaint – reason patient is seeking medical care • O - Objective • Objective information – observed by health care worker • A – Assessment • Health care professional’s assessment of what is wrong, based on signs and symptoms • P – Plan • Procedures, treatments and patient instructions

11. You Try It • A friend comes to you and says “I have a sore throat.” • What is S? • “My throat is sore.” • “It hurts when I swallow.” • What is O? • You look in the throat and see redness. • What is A? • Local throat irritation could be caused by a virus or strep. • What is P? • Get a throat culture. • Gargle with warm salt water

12. Computerized Medical Records • It’s the wave of the future for medical records. • Where have you seen the use of computerized medical records? • Why?

13. Computerized Medical Records • Advantages • Improved legibility of charting • Quicker to record which increases efficiency • Fewer errors • Improved communication among health team members • Records easily transmitted to other hospital departments and health care providers who need them.

14. Computerized Medical Records • Disadvantages • Possible system crash • Cost of converting to a computerized system – hardware, software and training costs • Potential problems with confidentiality • What do you think is the biggest obstacle?

15. Insurance Forms and Statements • Insurance card usually photocopied • Insurance information on patient data sheet • Most agencies now file insurance claims electronically • All purpose electronic claim form is CMS-1500

16. Coding Systems • International Classification of Diseases (ICD) • Used for diagnosis coding

17. Coding Systems • Current Procedural Terminology (CPT) • Used for procedures and services

18. Health Careers • What healthcare professionals work most closely in health information management? • Coder – certificate level • Transcriptionist • Medical records administrator • RHIA – Registered Health Information Administrator • Degree levels from certification to Master’s degree • American Health Information Management Association http://www.ahima.org/