Summary Chapter 14 Medical Records Management

Summary – Chapter 14 – Medical Records Management:

I. Ownership:

a. – provider owns the physical medical record, while the patient owns the information contained within it (i.e., pt has right to a copy)

b. subpoena – legal document demanding access to the chart

II. Organization of the Medical Record:

a. Source-Oriented – progress notes filed in chronological order and in separate sections (e.g., nursing, lab, x-ray)

b. POMR – problem Oriented Medical Records – may be referred to as the Weed system (after its founder). The record is divided into 4 sections – 1. the database – pt history, demographics, lab reports, PE (physical exam), history, 2. The problem list, 3. The treatment plan, 4. The progress notes – numbered to correspond with problem list.

c. SOAP notes vs SOAPER – see p238

d. CHEDDAR – see pg 238

III. Contents of Medical Records

a. Demographics

b. Personal and Medical History

c. Family History

d. Social History

e. Chief Complaint

f. PE – physical exam

g. Progress Notes

h. etc

IV. Retention and destruction

a. Laws for retention vary state to state; when no rules exists, best practice is to keep them for 10 years. For minors , keep record until the minor reaches age of majority plus 3 years. For all cases, keep the record for at least the period of the statue of limitations, usually 3 years or longer since the last patient contact. Records of Medicare/Medicaid must be kept for 10 years b. Destroy records by shredding. Keep a master list of all records destroyed

c. Long term storage – microfilm

d. Purging – process of moving active files to inactive status

e. When records are temporarily out of the office, a colored OUTfolder should be inserted into the file in place of the regular folder and a notation made of the name, date, and to whom the record was released to.

f. Release of Information form – must be signed prior to giving information to a third party payor; Revocation of release of medical records – used when pt. no longer wishes to allow records to be released.

g. Power of attorney – authorizes person/attorney to see the patient record

V. Filing

a. Alphabetical, Numerical, Alpha-numerical (If numerical system is used, cross indexing or referencing is required.

b. Terminal digit – the number after the decimals, file first

c. Tickler files– helps remember a certain action must be taken on a certain date

d. Shingling – a method of file in which one report is layered on top of the older report (like shingles of a roof)e.g., lab reports

e. OUTguides – heavy guides used to replace a folder that has been removed temporarily

f. Filing procedures: 5 steps:

i. Conditioning – removing clips, stapling related papers, etc

ii. Releasing – some mark is placed on the paper indicating that it is ready for filing; – usually “FILE” stamp in upper left corner or med asst initials

iii. Indexing – deciding where to file the letter or paper

iv. Coding - if more than one logical place to file the paper, the original is coded and a cross-reference sheet prepared

v. Sorting – arranging the papers in filing sequence

g. Rules of Indexing: i. Order by - Last (surname), First name, Middle name or initial

ii. Words such as the, on , a, of, and, an are not counted

iii. When initials are part of the name, move the initials to the end – i.e., E.J. Thomas Company would be filed as Thomas, E.J., Company

iv. Familiar abbreviations (e.g. St. ,Mt., Co., U.S.) are spelled out

v. Hyphenated names are considered as one unit

vi. Prefixes such as De, La, Le, Mc, San, Von, O’ are treated as part of the name (e.g., Van Dyke becomes Vandyke

vii. Titles and degrees (e.g., RN, MD, DDS are not considered in filing, but are written in parentheses at the end of the indexed name. EXCEPTION is religious names, they are filed as written – i.e., Sister Ann, Prince Philip would be filed as

Sister, Ann and Prince, Philip viii. If two individuals have the same name, geographic location is used for filing. For example: Smith, John (Cleveland, Ohio) is filed before Smith, john (Columbus, Ohio)

ix. Terms of seniority such as Jr, Sr, or II are usually used as the last indexing unit

x. If a woman is married and uses her husband’s name, his first name and a Mrs. Is placed in parentheses. So. Mrs. Beth Simmers Narter is indexed as Narker, Beth, Simmers (Mrs. Brian)

xi. Numbers in a name are indexed as though the number are spelled in letters (e.g., 3rd Street Fisheries becomes Third, Street, Fisheries)