Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. UNIT 4 SEMINAR Hello Students. The...

Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.

UNIT 4 SEMINAR

Hello Students.

The seminar will begin shortly.


Questions

Do you have any questions about the course?

Only the students that have questions should be typing for the next few minutes.

Keep in mind that certain questions might require research; thus don’t be offended if I ask you to email the question to me.


The information in this Seminar was designed for Gerald Burke’s students. Contact your instructor for clarifications if you are not in Gerald Burke’s class. Your instructor might have different course expectations.


QUESTION 1Which of the following are not needed when describing a patient’s chief complaint?

a. Remedies the patient has tried to relieve symptoms

b. Duration of painc. Time when symptoms were first noticedd. How many family members are healthy


ANSWER QUESTION 1

D


QUESTION 2Continuity of care means:

a. an aggregate of activities designed to ensure adequate quality, especially in manufactured products or in the service industries

b. a formal examination of an organization’s or individual’s accounts

c. that which continues smoothly from one provider to another, so that the patient receives the most benefit

d. granted or endowed with a particular authority


ANSWER QUESTION 2

C


QUESTION 3Which of the following is not objective

information?

a. Progress notes

b. Family history

c. Diagnosis

d. Physical examination and findings


ANSWER QUESTION 3

B


QUESTION 4 A filing system in which an intermediary source

of reference, such as a file card, must be consulted to locate specific files is called a(n) _____ system.

a. shelf filing

b. indirect filing

c. direct filing

d. Shingling


ANSWER QUESTION 4

B


QUESTION 5 Medical facilities should keep records on minors

for how long?

a. Indefinitely

b. Until the minor is deceased

c. For 10 years

d. Until the minor reaches the age of majority, plus 3 years


ANSWER QUESTION 5

D


Career Tip #3 – Read publications that will enhance your career.

Why should you read publications that will enhance your career?


Which career related publications do you read?


WSJ Online

Wall Street Journal Online

http://online.wsj.com/home-page

Look around and save it to your favorites or make it your home page.


WSJ Online

The WSJ Online contains a tremendous amount of career guidance and a wide range of information.

Most of the articles are free.


WSJ Online


WSJ Online

The WSJ Online helps you stay a step or two ahead.

Learn about it before it happens.

Learn from the mistakes and successes of other professionals and job hunters.


WSJ Online

Learn how to manage your career.– Job search strategy.

– Increase salary.

– Change careers, switch industries, reinvent yourself, etc.

– Stand out from the competition.

– Overcome career obstacles.

– Deal with difficult peers and managers.

– Find out what employers want and need.

– Learn about industry trends.


WSJ Online

Learn which organizations are going to hire more employees.

Learn which organizations are going to layoff part of their staff.


WSJ Online

WSJ Online’s other features– Education

– Personal Finance

– Small Business

– Real Estate

– World News

– US News


WSJ Online

– Financial Markets

– Technology

– Life & Style

– Opinion

– Health Industry

– Economy

– Law

– Management

– Media and Marketing


WSJ Online

Arts & Entertainment

Autos

Books

Fashion

Sports

Travel

And More!


WSJ Online

The WSJ Online provides world-class caliber career guidance. Find out for yourself.


Career Tips

Remember Career Tip #1? – Consider signing up with one or more employment agencies that specialize in your chosen profession(s).


More Employment Agency Strategy

Why should you consider registering with employment agencies in different industries?



Why should you contact the agencies and let them know when you are not available for work(due to a current work assignment, etc.)?



Why should you consider giving a gift to the employment agency/recruiter that has been sending you on the best work assignments?


Introduction

Medical records management systems are only as good as the ease of retrieval of the data in the files.

Organization and adherence to set routines will help to ensure that medical records are accessible when they are needed.


Why Medical Records Are Important

Assist the physician in providing the best possible care to the patient

Offer legal protection to those who provide care to the patient

Provide statistical information that is helpful to researchers

Vital for financial reimbursement

Can you think of other reasons why medical records are important?


Medical records must be kept confidential and in a secured, locked location.


An efficient medical record system should:

provide for easy retrieval

be organized and orderly

contain information that is completely legible

contain accurate information

show information that is easily understood and grammatically correct

What are some other attributes of an efficient medical record system?


Types of Records

Name some disadvantages of paper-based medical records?


Disadvantages of Paper-Based Medical Records

Only one person can use the record at a time, unless multiple people are crowding around the same record.

Items can be easily lost or misfiled or can slip out of the record if not securely fastened.

The record itself can be misplaced or be in a different area of the facility when needed.


Organization of the Medical Record

What are source-oriented records?


Source-Oriented Medical Records

Traditional method of keeping patient records.

Observations and data are cataloged according to their sources.

Forms and progress notes are filed in reverse chronologic order.

Separate sections are established for laboratory reports, x-ray films, radiology reports, and so on.


Organization of the Medical Record

What are problem-oriented records?


Problem-Oriented Medical Records

Divides records into four bases:

1. Database

2. Problem list

3. Treatment plan

4. Progress notes



Database Includes:– Chief complaint

– Present illness

– Patient profile

– Review of systems

– Physical examination

– Laboratory reports



Problem List– Numbered and titled list of every problem the patient

has that requires treatment

– May include social and demographic troubles as well as medical and/or surgical notes



Treatment Plan Includes:– Management

– Additional workups needed

– Therapy

Each plan is titled and numbered with respect to the problem.



Progress Notes– Structured notes are numbered to correspond with

each problem number.

– Progress notes follow the SOAP approach.

What does the acronym SOAP stand for?


SOAP Approach to Progress Notes

SOAP acronym

S—Subjective impressions

O—Objective clinical evidence

A—Assessment or diagnosis

P—Plans for further studies, treatment, or management


Obtaining the History

There are different ways to obtain a patient’s medical history. What are some of those ways?


Obtaining the History

Histories may be obtained by:

Patient questionnaire

Medical assistant asking the patient questions

Physician asking the patient questions

Combination of questionnaire and questions


What is “authentication” as it pertains to medical records?


Authentication

For a chart to be admissible as evidence in court, the person dictating or writing the entries must be able to attest that they were true and correct at the time they were written.

This is “authentication” and is best done by initialing entries (or the equivalent) made to the medical record.


Progress Notes

Have you ever seen or worked with progress notes?

Continually added to the medical record.

Must list each patient visit and any notations about the visit.

Instructions, prescriptions, and telephone calls for advice should be noted in the progress notes.

Always initial entries in progress notes.


Corrections and Alterations to Medical Records

How do you correct an error in a paper based medical record?


Correcting an Error

Three Steps

1. Draw one line through the error.

2. Insert the correction above or immediately after the error.

3. In the margin, write “correction” or “corr” and initial the entry.


Corrections and Alterations to Medical Records

Never use correction fluid, erasers, or any other type of obliteration methods.

Do not mark through information to obliterate it.

Do not hide errors.


Correcting Electronic Records

An electronic medical record contains an error. How do you correct the error?

Four


Correcting Electronic Records

If an error is made while typing, simply backspace and correct the error.

If the error is discovered later, make an additional entry with corrected information.

Most of the time you will not have the computer authority to delete or change previous entries on electronic medical records.

Why will most health care organizations not permit the deletion or alteration of electronic medical record entries?


Keeping Records Current

Records must be methodically kept current.

The patient’s health is jeopardized when current, accurate records are not available to the physician.

Remember that the physician bases his decisions on the information in the patient medical record.

Do not allow paper-based histories and reports to accumulate for a long time before filing them. In your opinion, how long is too long?


Classifications of Records in the Physician’s Office

Active files– patients currently receiving treatment

Inactive files– patients who have not been seen for about 6 months to

a year.

Closed files– patients who have died, moved away, or otherwise

discontinued treatment


Transfer of Records

Follow office policies regarding transferring medical records from active to inactive or closed categories.

Files may need to be physically rearranged to accommodate transfers.


Retention and Destruction

Most physicians keep medical records for 10 years at a minimum.

Some records may warrant longer retention periods.

Follow local, state, and federal guidelines for retention and destruction of records.

In most cases, keep medical records at least as long as the length of time of the statute of limitations for medical professional liability claims.


Retention and Destruction

Medicare and Medicaid patient records must be kept for at least 6 years.

Follow office policies for record retention and destruction.

How long should you keep records on patients who are deceased?


Keep records on patients who are deceased for at least 2 years.


Releasing Medical Record Information

Requests must be made in writing for release of records.

Patients must sign an authorization for release of medical records.

Patients can revoke previously signed authorizations for release of records.

Release only records that are specified on the request.


SAMPLE


Filing Equipment

Various types of equipment are available for storing medical records in today’s medical offices.


What does your office need to consider before it purchases filing equipment?


Considerations in Choosing Filing Equipment

Office space availability

Structural considerations

Cost of space and equipment

Size, type, and volume of records

Confidentiality requirements

Retrieval speed

Fire protection


Color-Coding

Almost all medical offices use some sort of color-coding in their filing systems.

Numeric color-coding provides a high degree of patient confidentiality. Why is this statement true?


QUESTIONS?

Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. UNIT 4 SEMINAR Hello Students. The...

Documents

Transcript of Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. UNIT 4 SEMINAR Hello Students. The...