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 Filing Techniques and Common Filing Systems • Components of numeric filing – – – – Serially numbered dividers with guides Miscellaneous (general) numeric file section Alphabetic card file Accession record © 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 Filing Techniques and Common Filing Systems • Subject filing – Convenient for locating frequently used services or for filing reference materials for patient needs • Choosing a filing system – Facility primary objectives with storage of patient files, business records, research files – Selecting alphabetic or numeric system – Confidentiality of charts – HIPAA compliant © 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 Filing Procedures • Cross-referencing – Store files for quick and accurate retrieval – Especially helpful with foreign names, hyphenated names, stepfamilies – Does not need to be elaborate – Steps for cross-referencing © 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 Filing Procedures • Tickler files – Reminder that some action needs to be taken at date in future – Can be accomplished manually or electronically – Should contain the following: • • • • Patient name Tickler date when action should be taken Required action Additional relevant information © 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 Filing Procedures • Release marks – Provider’s initials – Quality-control measure • Checkout system – Out sheets or out guides for use when chart removed – List of information that should be included on out sheet © 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 Filing Procedures • Locating missing files or data – Conduct systematic search – Steps to searching – Check files for proper filing order whenever returning or retrieving file folder – When finished with a record, refile it immediately © 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 Filing Procedures • Filing chart data – Types of reports • • • • Clinical notes Correspondence Laboratory reports Miscellaneous © 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 Filing Procedures • Retention and purging – – – – Record purging Active files Inactive files Closed files © 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 Correspondence • Filing procedures for correspondence – Remove paper clips and staple items together – Inspect to see if item is ready to be filed – On incoming correspondence, be sure letterhead is related to letter © 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 Correspondence • Filing procedures for correspondence – On outgoing correspondence, look at inside address and reference line – On incoming or outgoing correspondence, code indexing units of designated label – Create miscellaneous folder for items that not have enough in number to warrant individual folder © 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 Electronic Medical Records • Mandated; one day will replace all paper/manual medical records • Fewer errors created • Create, store, edit, retrieve patient data • Allow more than one person to access chart at same 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 Electronic Medical Records • Purchased as single computer application or part of larger practice management system • EMR capability list • Providers use computers to open and view charts and write prescriptions • System administrators can identify access and privileges for confidentiality • EMR fully recognized as legal document © 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 Archival Storage • Providers preserve patient medical records for life of practice • Computers help to solve space issues through EMRs • Records copied onto optical disks or CDs Should have backup system â 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 Archival Storage • Transfer of data – EMRs easily emailed in whole or in part – Faxing – Scanners (optical character recognition) © 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 Archival Storage • Confidentiality – Major issue in using computer and online devices for storage and transfer of medical information – Never discuss information outside clinic – Unwise to discuss private information within facility if it is not your concern © 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 ... 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... 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... 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