Transcript Behavioral Emergencies - Vista Unified School District

Medical Office Administration
2nd edition
Brenda A. Potter, CPC
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Chapter 9
Health Information
Management
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
What is Health Information
Management?
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Directing activities that relate to keeping
patients’ medical information
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Maintaining medical records
Preparing medical reports
Releasing medical information
Compiling statistics
Coding for billing and insurance
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
3
Purposes of Recordkeeping
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Documentation of care given to patient
Legal purposes
Documentation for insurance claims
Data used in planning for healthcare services
Education and research
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4
Types of Records
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Paper
Electronic
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EHR – electronic health record (preferred by
AHIMA)
CPR – computerized patient record
EMR – electronic medical record
EPR – electronic patient record
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5
Confidentiality
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All information seen, heard, and done must
be kept confidential
Releasing information without permission is
breach of confidentiality
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6
Confidentiality Agreements
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All employees and volunteers should be
required to sign confidentiality agreements
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7
Confidentiality and Computerized
Records
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Portion or entire record can be stored on a
computer
Computer systems must be protected
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8
Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
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Regulation includes
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Requirements for protecting information
Patient’s right to know how information is used
Patient’s right to a copy of his/her record
Restrictions on using information
Civil and criminal penalties for violations
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9
Notice of Privacy Practices
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Written notice detailing how the healthcare
provider responsibilities pertaining to the
patient’s health information
Sign and dated by patient and retained by
provider
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10
Components of the Medical Record in a
Medical Office
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Summary sheet
Medical history
Progress notes
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SOAP note
Chart note
Chart entries
Medication list
Immunization record
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11
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Laboratory report
Pathology report
Radiology report
Other specialized documents
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Pediatric growth chart
Pregnancy flow sheet
EKGs, EEGs, EMGs
Photographs, CDs, DVDs
Correspondence
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12
Entering Information in a Patient’s Record
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Specific guidelines should detail
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Who may document information in a patient’s
record
What type of information should be documented
In a paper record
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Do not leave large gaps in progress notes section
Handwritten entries done in black ink
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13
Hospital Records
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History and Physical (H&P)
Operative report
Discharge summary
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14
Corrections in Records
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Person making the mistake should correct the
entry
Do not obliterate information
Electronic records may require an entirely
new entry to correct a mistake
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15
Medical Transcription
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Production of a typewritten report from
physician’s dictation
Dictation saves time for a physician
Transcription is more legible compared to
handwriting
Transcriptionists are medical language
experts
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16
Transcription Equipment
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Digital equipment is the norm
Tapes are outdated
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17
Signature
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Reports and other documents placed in a
patient’s chart must be signed or initialed by
patient’s physician
Signature or initials verify that physician has
reviewed documents
Electronic signatures used for electronic
reports
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18
Organizing Medical Record
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Source-oriented (SOMR)
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Similar information is kept together
Most commonly used
Problem-oriented (POMR)
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Information pertaining to a specific problem is
grouped together
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19
Chart Order
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Dividers can separate sections of a chart
Each office should establish specific chart
order
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20
Documentation Guidelines
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A Joint Commission requirement
Medicare 1995 documentation guidelines
Use of abbreviations
Dangerous abbreviations
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21
What Does Not Belong in the Record
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A report without a physician's signature or
initials – EVEN normal lab results
Information regarding a patient’s financial
status
Callous remarks about a patient
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22
Records Flow
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Chart is pulled for appointment
When patient is placed in exam room, chart is
placed outside door
Nurse records vital signs in chart
Physician brings chart into exam room
Chart returned to records room after visit
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23
Quantitative Analysis
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Verifies that all essential information is in
chart
Incomplete records should not be filed
Deficiency form
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24
Filing Supplies
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Charts – durable heavy-stock folder
Labels – numeric or alpha
Outguides – hold place of record
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25
Filing Methods
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Filing should be kept up-to-date for easy
retrieval of records
Numerical system
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Accession ledger – tracks each chart number as
assigned
Alphabetical system
Alphanumeric system
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26
Consecutive Number Filing
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Charts filed from lowest to highest number
Easy to learn
Numbers may be transposed
Master patient index for numeric systems
requires knowledge of alpha filing rules
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27
Terminal Digit Filing
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Chart number broken into groups of numbers
Chart #145365 becomes 14 53 65
65 – primary unit
 53 – secondary unit
 14 – tertiary unit
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28
Alphanumeric System
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Combination of letters and numbers
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Alphabetical Filing
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Offices should adopt one set of rules
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Every name indexed: last name, first name, MI
Complete legal name should be obtained – no nicknames
Abbreviations indexed as spelled out
Identical names filed with oldest DBO first
Nothing comes before something
Prefixes are included with name
Punctuation is disregarded
Professional and religious titles disregarded
Entry of names in computer system should be consistent
Cross-references important
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30
Color Coding
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Assigning a color to a letter or number
Reduces misfiles
Saves time when locating chart
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31
Locating Missing Files
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Check before and after the chart’s location
and inside other nearby charts
Check all areas of office
Determine last department or individual who
used the chart
Scan shelves for color out of place
Check areas behind shelves or drawers
If alpha filing, check other possible spellings
for patient’s last name
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32
Records Retention and Disposal
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Verify state requirements for retention
Medicare requirements – minimum of 5 years after
last visit
Minor records may have special requirements
Active record – current patient
Inactive record – patient has not received treatment
in a specific period of time
Closed record – patient has died or moved away
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Local obituaries should be checked with office’s patient
database
Disposed records should be properly destroyed
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33
Tickler File
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File that reminds assistant of specific tasks
Electronic tickler files available in many
computer calendar packages
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34
File Storage and Protection
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Lateral shelving is common and often works
best
Shelving with pull-out drawers or file cabinets
also used
Be aware of fire codes
Duty of medical office to protect records from
destruction
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35
Disaster Plan
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Medical office is responsible for protecting
records from destruction
Fire codes must be considered when setting
up a records room
Fire suppression system
Computer backups
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36
Multiple Locations
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One chart may be shipped between locations
Each location may have separate chart
Electronic record ideal for multiple sites
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37
Release of Information
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Written documentation necessary to release
information
In most instances, patient must authorize release
information
Copy of release kept with patient’s record
Photocopies of records, not originals, are sent
Fax machines not encouraged for releasing
information
Redisclosure – office cannot copy and release
records received from another office
Release not required in some instances (small
number of exceptions)
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38
Ownership of Medical Record
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Physician owns the paper
Patient owns the content
HIPAA standards – patient has a right to a
copy of his or her record
Psychiatric records may not be released to
patient
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
39
HIV and AIDS Records
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Patients may be required to sign consent
form for HIV testing
Take great care to protect record privacy
Patients may have to authorize listing the
diagnosis on an insurance claim
Copyright © 2010, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved.
40
Future of Health Records
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Increased use of computers for health
information activities
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41