Chapter 14
Medical Records Management
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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
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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
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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
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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
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Manual or Electronic
Medical Records
• Manual
– Disadvantages
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•
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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.
Manual or Electronic
Medical Records
• Electronic
– Advantages
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Multiple users possible
Not easily misplaced or misfiled
Errors less likely
Patterns and data more easily accessed
Quickly available in emergencies
Office storage space not required
Legible, organized patient documentation
Improved medication management
Improved quality of care
© 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
• Electronic
– Disadvantages
•
•
•
•
Need protection to prevent loss of data
Expensive to establish and maintain
May require on-site assistance
Can require up to 12 weeks for staff to prove productive
© 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
• 2009: American Reinvestment and
Recovery Act (ARRA)
– Incentives for physicians and hospitals to make
transition to EMR
• Solo practitioners least likely to use
EMRs
• EMRs grow faster in larger, multiprovider clinics
• Medical record system must fit facility
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or duplicated, or posted to a publicly accessible website, in whole or in part.
The Importance of
Accurate Medical Records
• Accuracy essential to patient care
• Critical to facility’s smooth functioning
• Important when referring patient to
outside specialists
• Essential in controlling costs
• May be needed in medical litigation
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or duplicated, or posted to a publicly accessible website, in whole or in part.
The Importance of
Accurate Medical Records
• Creating paper and electronic charts
– Chart prepared on or before day of patient’s first
visit
– Paper medical records require assembly of
appropriate file folders and forms
– Electronic medical charts prepared in much the
same manner except that all information stored
electronically
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or duplicated, or posted to a publicly accessible website, in whole or in part.
The Importance of
Accurate Medical Records
• Correcting medical records
– Paper medical record
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Draw single line using red ink pen through error
Make correction
Write Corr. or Correction above area corrected
Indicate your initials and current date
Never obliterate
Forensic experts able to determine when and how
corrections were made
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or duplicated, or posted to a publicly accessible website, in whole or in part.
The Importance of
Accurate Medical Records
• Correcting medical records
– Errors in EMRs
• Draw line through error (using “tracking” device in word
processing software)
• Correction made immediately after information lined out
• “Corr.” or “Correction” indicated with your initials and
date correction made
• EMR software locks out chart additions after specified
time
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or duplicated, or posted to a publicly accessible website, in whole or in part.
The Importance of
Accurate Medical Records
• Correcting medical records
– If information or chart sent elsewhere, make copy
of corrected information and send it as quickly as
possible
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or duplicated, or posted to a publicly accessible website, in whole 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 to
charting relevant to that problem number
– Each problem followed with the SOAP(ER)
approach for all progress notes
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Types of Medical Records
• Problem-oriented medical records
(POMRs)
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S: Subjective impressions
O: Objective clinical evidence
A: Assessment or diagnosis
P: Plans for further studies, treatment,
management
– E: Education for patient
– R: Response of patient to education and care
given
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or duplicated, or posted to a publicly accessible website, in 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 EMRs
– Various formats for POMR manual charts
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Types of Medical Records
• Source-oriented medical records
(SOMRs)
– Groups information according to its source
– Makes different types of information quickly
accessible
– Many providers use SOAP(ER) method to record
their chart notes
– SOMR does not have problem list
– Many EMR software packages use POMR or
SOMR format
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Types of Medical Records
• Strict chronological arrangement
– Data filed strictly with most recently charted
materials to top of folder
– Difficult for provider or MA to quickly assess
patient’s clinical picture
– May fit specialty office where patients seen on
short-term basis
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Equipment and Supplies
• Vertical files
• Open-shelf
lateral files
• Movable file
units
• File folders
• Identification labels
Open-shelf lateral file
cabinet >>
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Equipment and Supplies
• Guides and positions
• Out guides
An out guide indicating name
of person who has
possession of the file >>
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Basic Rules for Filing
• Alphabetizing is key to organizing files
and charts
• Indexing rules developed by Association
of Medical Records Administrators
(AMRA)
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Basic Rules for Filing
• Indexing units
– Unit identifies each part of a name
– Each unit identified according to unit 1
– Applied to individual names, organizations, clinics
• Filing identical names
– When names identical, address may be used to
order files
– Preferred methods include date of birth or Social
Security number
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Steps for Filing Medical
Documentation in Patient Files
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•
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Inspect
Index
Code
Sort
File
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Filing Techniques and
Common Filing Systems
• Color-coding technique used in three
major filing systems
• Patient charts use alphabetic system of
color coding
• Color coding can be used in numeric
filing
• Color coding makes retrieval of files
more efficient
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Filing Techniques and
Common Filing Systems
• Color coding
– Tab-Alpha system
– Alpha-Z system
– Customized color coding systems
• Colored File folders by first name
• Colored File folders by last name
• Color-coded numbers
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Filing Techniques and
Common Filing Systems
• Alphabetic filing
– Simplest filing methods; strictly maintained by
assigning label to each file
• Numeric filing
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Organized by number rather than by letter
Preserves patient confidentiality
Straight numeric
Terminal digit
Middle digit
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Filing Techniques and
Common Filing Systems
• Components of numeric filing
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Serially numbered dividers with guides
Miscellaneous (general) numeric file section
Alphabetic card file
Accession record
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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
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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
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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:
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Patient name
Tickler date when action should be taken
Required action
Additional relevant information
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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
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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
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Filing Procedures
• Filing chart data
– Types of reports
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Clinical notes
Correspondence
Laboratory reports
Miscellaneous
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or duplicated, or posted to a publicly accessible website, in whole or in part.
Filing Procedures
• Retention and purging
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Record purging
Active files
Inactive files
Closed files
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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
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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 do not
have enough in number to warrant individual
folder
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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
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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
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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)
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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
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or duplicated, or posted to a publicly accessible website, in whole or in part.