Behavioral Emergencies - Vista Unified School District
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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?
Directing activities that relate to keeping
patients’ medical information
Maintaining medical records
Preparing medical reports
Releasing medical information
Compiling statistics
Coding for billing and insurance
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3
Purposes of Recordkeeping
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
Paper
Electronic
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
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
All employees and volunteers should be
required to sign confidentiality agreements
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7
Confidentiality and Computerized
Records
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)
Regulation includes
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
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
Summary sheet
Medical history
Progress notes
SOAP note
Chart note
Chart entries
Medication list
Immunization record
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11
Laboratory report
Pathology report
Radiology report
Other specialized documents
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
Specific guidelines should detail
Who may document information in a patient’s
record
What type of information should be documented
In a paper record
Do not leave large gaps in progress notes section
Handwritten entries done in black ink
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13
Hospital Records
History and Physical (H&P)
Operative report
Discharge summary
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14
Corrections in Records
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
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
Digital equipment is the norm
Tapes are outdated
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17
Signature
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
Source-oriented (SOMR)
Similar information is kept together
Most commonly used
Problem-oriented (POMR)
Information pertaining to a specific problem is
grouped together
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19
Chart Order
Dividers can separate sections of a chart
Each office should establish specific chart
order
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20
Documentation Guidelines
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
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
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
Verifies that all essential information is in
chart
Incomplete records should not be filed
Deficiency form
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24
Filing Supplies
Charts – durable heavy-stock folder
Labels – numeric or alpha
Outguides – hold place of record
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Filing Methods
Filing should be kept up-to-date for easy
retrieval of records
Numerical system
Accession ledger – tracks each chart number as
assigned
Alphabetical system
Alphanumeric system
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26
Consecutive Number Filing
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
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
Combination of letters and numbers
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Alphabetical Filing
Offices should adopt one set of rules
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
Assigning a color to a letter or number
Reduces misfiles
Saves time when locating chart
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31
Locating Missing Files
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
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
Local obituaries should be checked with office’s patient
database
Disposed records should be properly destroyed
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33
Tickler File
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
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
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
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
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
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
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39
HIV and AIDS Records
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
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40
Future of Health Records
Increased use of computers for health
information activities
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