Tải bản đầy đủ

Administrative medical assisting 5th by lindh chapter14

Chapter 14

Medical Records Management

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Medical Records Management
and the TPMS

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Purpose of Medical Records
• Provide base for managing patient care
• Provide interoffice and intraoffice
communication as necessary
• Determine any patterns that surface to
signal provider of patient needs


© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Purpose of Medical Records
• Serve as basis for legal information to
protect providers, staff, patients
• Provide clinical data for research

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Ownership of Medical Records
• Property of those who create record
• Information belongs to patient and is
protected with privacy and
confidentiality
• Patients are allowed access to their
medical records and can ask certain
information be added or excluded from
their file
© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Ownership of Medical Records
• Providers who include their patients in
their medical record keeping foster trust
and respect with their patients

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Authorization to Release Information
• Before information released from
medical record, patient notified and
written approval received


• Identify reason for release and what
information specifically requested
• Only that information released
• Does not include release of information
to patient’s chosen insurance carrier
© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Manual or Electronic
Medical Records
• Americans to have EHRs by 2014
• Planned projects: transmitting x-rays
and laboratory results electronically
• 2011: Electronic prescribing (eprescribing) of medications for Medicare

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Manual or Electronic
Medical Records
• Manual
– Advantages
• Currently established and understood
• Easier to protect confidentiality
• No worry of computer malfunction

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Manual or Electronic
Medical Records
• Manual
– Disadvantages





Can be used by only one person at a time
Easily misplaced or misfiled
Equipment and storage space required
More susceptible to error

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Manual or Electronic
Medical Records
• Electronic
– Advantages










Multiple users possible
Not easily misplaced or misfiled
Errors less likely
Patterns and data more easily accessed
Quickly available in emergencies
Office storage space not required
Legible, organized patient documentation
Improved medication management
Improved quality of care
© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Manual or Electronic
Medical Records
• Electronic
– Disadvantages





Need protection to prevent loss of data
Expensive to establish and maintain
May require on-site assistance
Can require up to 12 weeks for staff to prove productive

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Manual or Electronic
Medical Records
• 2009: American Reinvestment and
Recovery Act (ARRA)
– Incentives for physicians and hospitals to make
transition to EMR

• Solo practitioners least likely to use
EMRs
• EMRs grow faster in larger, multi-provider
clinics
• Medical record system must fit facility
© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Importance of
Accurate Medical Records
• Accuracy essential to patient care
• Critical to facility’s smooth functioning
• Important when referring patient to
outside specialists
• Essential in controlling costs
• May be needed in medical litigation

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Importance of
Accurate Medical Records
• Creating paper and electronic charts
– Chart prepared on or before day of patient’s first
visit
– Paper medical records require assembly of
appropriate file folders and forms
– Electronic medical charts prepared in much the
same manner except that all information stored
electronically

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Importance of
Accurate Medical Records
• Correcting medical records
– Paper medical record







Draw single line using red ink pen through error
Make correction
Write Corr. or Correction above area corrected
Indicate your initials and current date
Never obliterate
Forensic experts able to determine when and how
corrections were made

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Importance of
Accurate Medical Records
• Correcting medical records
– Errors in EMRs
• Draw line through error (using “tracking” device in word
processing software)
• Correction made immediately after information lined out
• “Corr.” or “Correction” indicated with your initials and
date correction made
• EMR software locks out chart additions after specified
time

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


The Importance of
Accurate Medical Records
• Correcting medical records
– If information or chart sent elsewhere, make copy
of corrected information and send it as quickly as
possible

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Types of Medical Records
• Problem-oriented medical records
(POMRs)
– Vital identification data, immunizations, allergies,
medications, problems
– Identified by a number that corresponds to
charting relevant to that problem number
– Each problem followed with the SOAP(ER)
approach for all progress notes

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Types of Medical Records
• Problem-oriented medical records
(POMRs)





S: Subjective impressions
O: Objective clinical evidence
A: Assessment or diagnosis
P: Plans for further studies, treatment,
management
– E: Education for patient
– R: Response of patient to education and care
given
© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Types of Medical Records
• Problem-oriented medical records
(POMRs)
– Internists, family practitioners, pediatricians use
POMR system
– Used in manual medical records as well as EMRs
– Various formats for POMR manual charts

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Types of Medical Records
• Source-oriented medical records
(SOMRs)
– Groups information according to its source
– Makes different types of information quickly
accessible
– Many providers use SOAP(ER) method to record
their chart notes
– SOMR does not have problem list
– Many EMR software packages use POMR or
SOMR format
© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Types of Medical Records
• Strict chronological arrangement
– Data filed strictly with most recently charted
materials to top of folder
– Difficult for provider or MA to quickly assess
patient’s clinical picture
– May fit specialty office where patients seen on
short-term basis

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Equipment and Supplies
• Vertical files
• Open-shelf
lateral files
• Movable file
units

• File folders
• Identification labels

Open-shelf lateral file
cabinet >>

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Equipment and Supplies
• Guides and positions
• Out guides

An out guide indicating name
of person who has
possession of the file >>

© 2014 Cengage Learning. All Rights Reserved. May not be scanned, copied
or duplicated, or posted to a publicly accessible website, in whole or in part.


Tài liệu bạn tìm kiếm đã sẵn sàng tải về

Tải bản đầy đủ ngay

×