SEMINAR 4

1. SEMINAR 4 MO-260 Medical Office Applications

2. TOPICS • Medical records as a legal document • Purposes of medical records • Contents of the Medical Record • Ownership of medical records • Documents / Forms • Changing medical record content • Overcrowded charts • Maintaining medical records • Purging records • Review SOAP

3. Legal Document • The medical record is a legal document and provides evidence of the continuity of care of a patient. • It offers legal protection for those who provided care to the patient. • Legal Guidelines: • Proof of event or procedure • No documentation • No proof • Care is considered not done • Legal document • Must document complete information about patient care • Document if patient is noncompliant

4. Purposes of Medical Records • In addition to being a Legal Document, what are other purposes of Medical Records? • Assist physician in providing the best possible medical care for the patient. • Vital for financial reimbursement. • Provide statistical information that is helpful to researchers.

5. Contents of the Medical Record • Contents are dictated by individual office policy. • Contents usually include selections from the following: • Patient Information Sheet • Problem List • History and Physical Examination Form • Progress Notes • Flow Sheets • Results of Diagnostic Tests • Consultation Reports • Hospitalization Reports • Laboratory Reports • Correspondence • Insurance Claims

6. Contents of the Medical Record 2 • For some medical records: • Stickers for allergies and special instructions are needed. • Special forms for history and physical exams are needed. • Forms for special situations are needed, such as OB flow sheets. • All forms should agree with the routine of the office.

7. Ownership of Medical Records • Who owns the medical record? • The owner of the physical medical record is the physician or medical facility, often called the “maker,” who initiated and developed the record. • The patient has the right of access to the information within but does not own the physical chart or other documents pertaining to the record. • The patient has a vested interest and therefore has the right to demand confidentiality of all of the information placed in the chart.

8. Documents / Forms • What form does the patient complete before the medical office sends a report to another office? • What type of form should be completed if a patient no longer wishes to allow his or her medical records to be released to a person or organization?

9. Changes or Corrections A. What is the correct way to enter the following information into the medical record? The correct date of the appointment should be October 12, 20XX. Psmith wrote: 10-21-20XX Patient did not arrive for scheduled appointment. RMA. B. The patient stated that the chest pain began 2 weeks ago. Explain the steps to correct the following entry: 1-31-20XX Patient complained of chest pain for last 2 months. No pain noted in arms. No nausea. Desires ECG and blood work to check for heart problems. R. Smithee, CMA. C. The correct date for the last refill was 3-20-20XX. Explain the steps to correct the following entry: 4-22-20XX Patient requested that Rx for Vicodin be refilled. Last refull was 4-20-20XX. Dr. Lawton refused refill and requested patient schedule follow-up appointment. S. Ragland, RMA.

10. Overcrowded Charts Preparing new records for established patients: • Always follow office policy when preparing new records for established patients. • Remove the needed materials from the old record as per office policy. • Place the needed information into a new record. Notes: Some offices prefer to move all information from the last 12-months or 1-year into the new record...and place the old record with everything older than 1-year into storage. Or, an office may file both medical records with the new record in the front. (Other offices will have the policy to go back 2 years, or 3 years.) The amount of time may also depend on the size of the practice, the type of specialty and the typical frequency of visits. Both charts (folders) should be labeled as record #1 of 2 and record #2 of 2. When the new chart is created it is important to put the correct service dates on the old record (folder) that will be stored (from when to when)...and on the new chart's folder indicate the service date the information begins. So, if it is a new record with information for the last 12-months placed in it...the correct date would be today's date and the prior year...March 22, 2009.

11. Maintaining Medical Records • To properly maintain medical records: • Be sure the medical report has been signed or initialed by the physician prior to filing. • Repair any damage to records prior to filing, to prevent further damage. • Or, replace the folder if it cannot be repaired.

12. Purging Records • Medical records are purged: • After time specified in Policy Manual. • To prevent time loss in finding current medical records. • To minimize the number of file system components needed. • Color-coded date tabs assist with purging records. • Purged records should be stored for the time indicated in the Policy Manual.

13. Review of “S” and “O” in SOAP • Read the following examples and indicate if the information is usually Subjective (S), or Objective (O). • A. Patient address • B. Yellowed eyes • C. Patient email address • D. Insurance information • E. Elevated blood pressure • F. Bloated stomach • G. Complaint of headache • H. Weight of 143 lbs • I. Bruises on upper arms • J. Patient phone number