09th November 2021

At the end of this session students would be able to :

1. Define a patient’s medical file. 2. Identify the owner of the patient medical

file. 3. Explain the six 6 C’s in writing accurate

patient history. 4. Distinguish between and understand the

importance of confidentiality, safety and security of the patient medical file.

5. Validate the purpose of the patient medical file.

6. List the components of the patients medical file.

6. Identify key components of the medical file.

7. Express the importance of accuracy of data entry in patient medical files.

8. Discuss the advantages and disadvantages of paper based medical files vs. electronic medical files.

9. Distinguish between alphabetical and numerical filing systems.

10. Arrange files in both alphabetical and numerical order.

A medical chart is a complete record of a patient’s key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.

A medical chart is comprised of medical notes made by a physician, nurse, lab technician or any other member of a patient’s healthcare team.

Accurate and complete medical charts ensure systematic documentation of a patient’s medical history, diagnosis, treatment and care.

The physical medical record belongs to the physician who created it and the facility in which the record was created.

The information gathered within the original medical record is owned by the patient.

Hence, patients are allowed a COPY of their medical record, but not the original document.

The length of time records are kept differ on whether the records are held by private practice medical doctors or by hospitals. The length of time records are kept also depends on whether the patient is an adult or a minor. Generally, medical records are kept anywhere from five to ten years after a patient's latest treatment, discharge or death.

Medical records are legal documents. Notes must be properly maintained. Specifically, medical records must be

complete, legible, and timely. All information in records must be objective

and the information must be signed and dated.

Subjective statements made by patients may be included. These should be recorded in patients' exact words and quotation marks should surround them.

Client's (patient) words Record the patient's exact words rather than your interpretation of them. Often provides clues for the diagnosis. Clarity Use precise descriptions and accepted medical terminology when describing a patient's condition Completeness Fill out completely all the forms used in the patient record. Provide complete information that is understandable to others when making any notation in the chart Conciseness Brief and to the point. Abbrev. and specific med. terminology can often save time and space. Every member of your staff should use the same abbrev. Chronological order All entries must be dated to show the order in which they are made. Very important for patient care and in case of legal questions. Confidentiality Only the patient, attending physicians, and the medical assistant are allowed to see the charts without the patient's written CONSENT

Errors should never be erased or covered with correction fluid.

Instead, a single line should be drawn through an error so that the error is still readable, and initial.

E.G Mr. Jones weight was 358lb (csk) 258lbs.

Three important and related concepts are often used interchangeably in discussing protection of health information within the a healthcare system: confidentiality, privacy and security.

Yet, each of these concepts has a different fundamental meaning and unique role.

Confidentiality is recognized by law as privileged communication between two parties in a professional relationship. (Brodnik, Rinehart-Thompson, Reynolds, 2012).

Confidentiality refers to personal information shared with a health care provider, physician, therapist, or other individual that generally cannot be divulged to third parties without the express consent of the client.

Privacy refers to the freedom from intrusion into one's personal matters, and personal information.

Privacy, as distinct from confidentiality, is viewed as the right of the individual client or patient to be let alone and to make decisions about how personal information is shared (Brodnik, 2012).

Even though the Constitution does not specify a “right to privacy”, privacy rights with respect to individual healthcare decisions and health information have been outlined in court decisions, state Laws, patients' rights, accrediting organization guidelines and professional codes of ethics.

Security refers directly to protection, and specifically to the means used to protect the privacy of health information and support professionals in holding that information in confidence.

The concept of security has long applied to health records in paper form; locked file cabinets are a simple example.

As use of electronic health record systems grew, and transmission of health data to support billing became the norm, the need for regulatory guidelines specific to electronic health information became more apparent.

NB. Laws against cyber crimes.

The purpose of complete and accurate patient record documentation is to foster quality and continuity of care.

Medical record is the legal record of the medical practice used in litigation and are thus subject to the laws of the country/state in which they are produced.

It creates a means of communication between providers and members about health status, preventive health services, treatment, planning, and delivery of care.

Provides evidence of care received.

Support reimbursement for health services provided

Provide evidence of injury and treatment for workers’ compensation

Provide evidence of disability for disability insurance

Identify people who have had a specific treatment when it has been discovered that this treatment caused some adverse events

Study disease trends to identify potential environmental or genetic causes

Track changes in physical findings such as growth of a mole. Baselines are recorded so changes are recognized

A patient's individual medical record identifies the patient and contains information regarding the patient's case history at a particular provider.

The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient.

Further information varies with the individual medical history of the patient.

Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically.

Active records are usually housed at the clinical site, but older records are often archived offsite.

Includes information such as the client’s: Name Age Address Date of birth (D.O.B.) Marital status Next of Kin (N.O.K) occupation Religion Ethnicity

Medical history A longitudinal record of what has happened

to the patient since birth.

It chronicles diseases, major and minor illnesses, as well as growth landmarks.

It gives the clinician a feel for what has happened before. As a result, it may often give clues to current disease state.

Surgical History The surgical history is a chronicle of surgery

performed for the patient.

It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did.

Obstetric History The obstetric history lists prior pregnancies and

their outcomes. It also includes any complications of these pregnancies.

Family history

The family history lists the health status of immediate family members as well as their causes of death (if known).

It may also list diseases common in the family or found only in one sex or the other.

Social History Such as tobacco use, alcohol intake, exercise,

and diet. This section may also include more intimate details such as sexual habits and sexual orientation.

It may explain the behavior of the patient in

relation to illness or loss. It may also give clues as to the cause of an illness (e.g., sexual exposure, lifestyle practices).

Helps the physician to know what sorts of community support the patient might expect during a major illness.

The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies.

Immunization History

The history of vaccination is included. Any blood tests proving immunity will also be included in this section.

For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time.

Many diseases and social stresses can affect growth, and longitudinal charting can thus provide a clue to underlying illness.

Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.

May contain:

Consent for surgery

Ultrasound Report

CT Report

Discharge Summary

Usually contain these key information:

Patient Database Form

Clinical Chart

Nurses Notes

Progress Notes

Intake/Output Chart

Diabetic Chart

Lab Results

Accountable Care

When data is accurate, physicians at any practice are thoroughly informed of patient history, tendencies, previous complications, current conditions and likely responses to treatment.

Data accuracy allows relevant healthcare staff to treat patients promptly and in the most effective and appropriate way possible.

Data aggregated through digital, cloud-based apps allows physicians to spend time with patients more effectively; when data is uploaded accurately, they can see who needs to come in for appointments and who is making comfortable progress at home, reducing time wasted visiting with healthy patients.

Reducing Complications

Complications can be avoided when accurate data shows physician and surgeon tendencies of treatment failure or future side effects.

Accurate aggregated data shows the bigger picture of patient outcomes, pointing to steps in treatment to avoid and potentially harmful attempts of patient care.

Knowing it is accurate, physicians and surgeons are more willing to look at individual cases and a larger, collective picture to work out new treatments, side effects to prevent and ways to avoid certain medical complications entirely.

Accurate patient data makes for a smooth day to day practice.

Physicians treat patients accurately and staff can constantly evaluate the practice from a larger perspective, implementing initiatives and new systems that optimize the practice’s efforts.

When patients are accurately diagnosed and treated promptly, the measures taken to treat their conditions are fewer, reducing time and resources allocated by the healthcare industry.

Physicians can monitor their progress through digital

apps and insurance companies can swiftly process minimal accurate information.

By reducing money spent by patients, insurance providers, private practices and hospitals, money is more readily available and in greater amounts to further treatment research, treat more patients, and push healthcare initiatives beyond their potential.

An electronic health record (EHR) is the

systematized collection of patient and population

electronically stored health information in a digital format.

Records can be shared across different health care settings.

Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges.

Benefits EHR systems are designed to store data

accurately and to capture the state of a patient across time.

It eliminates the need to track down a patient's previous paper medical records and assists in ensuring data is accurate and legible.

It can reduce risk of data replication as there is only one modifiable file, which means the file is more likely up to date, and decreases risk of lost paperwork.

With EHRs, information is available whenever and wherever it is needed.

Improved Patient Care

Increase Patient Participation

Improved Care Coordination

Improved Diagnostics & Patient Outcomes

Practice Efficiencies and Cost Savings

Disadvantages

Threats to health care information can be categorized under three headings:

Human threats, such as employees or hackers

Natural and environmental threats, such as earthquakes, hurricanes and fires.

Technology failures, such as a system crashing

These threats can either be internal, external, intentional and unintentional.

Technical Issues

In recent years, there has been a trend in health care facilities to convert all medical records from paper form to electronic form.

EMR creates many security and privacy issues. As a result, HIPAA provides regulations to make sure that confidential records are kept secure.

This is called the Security Rule.

According to the Security Rule, health care facilities must provide three types of safeguards when using electronic records:

Physical

Technical

Administrative

Physical Safeguards include rules for providing a safe and hazard-free environment in which to store medical records.

For example:

Doors should be locked.

Computer server rooms should be locked and accessed by authorized personnel only.

Any paper records should be stored in locked, fireproof cabinets

Technical Safeguards include rules for protecting electronic information.

For example:

All medical records should be password-protected, and passwords should be updated regularly.

Information that is transmitted electronically should be encrypted.

All computer systems must have effective anti-virus software

Administrative Safeguards include rules for managing employees who have access to protected health records.

For example:

Policies must be in place regarding which employees are allowed to access information.

All employees should complete security awareness training.

Arrange the following files in alphabetical order

Arrange the above files in numerical order

Last Name First Name Patient Reg.#

Weiler Rott P. A258654

Redeemer May S. A249361

Hart-Red Bigg A472408

Maker Way A192695

Redeemer My C. B054260

Last Name First Name Patient Reg.#

Hart Bigg A472408

Maker Way A192695

Redeemer May S. A249361

Redeemer My C. B054260

Weiler Rott P. A258654

Last Name First Name Patient Reg.#

Maker Way A192695

Redeemer May S. A249361

Weiler Rott P. A258654

Hart Bigg A472408

Redeemer My C. B054260

Write legibly

Include details of the patient, date, and time

Avoid abbreviations

Do not alter an entry or disguise an addition

Avoid unnecessary comments

Check dictated letters and notes

Check reports

Be familiar with the Data Protection Act 1998

1. Discuss the 6C’s for writing an accurate patient history.

2. Name three (3) components of a medical record

with examples

3. Identify three (purposes of the Patient Medical File.

4. What are the steps for correcting an error on the

Patient’s Medical File? 5. Subjective data should be included in the Patient’s

Medical File:

a) True b) False

6.Each patient is the owner of his/her medical file: a) True b) False

Brodnik, M., L. Rinehart-Thompson and R. Reynolds (2012). Fundamentals of Law for Health Informatics and Information Management Professionals. Chicago: AHIMA Press. Chapter 1.

HealthIT.gov. What is an electronic health record (EHR)? https://www.healthit.gov/faq/what-electronic-health-record-ehr

Hicks, J. (2019).The Basic Components of a Complete Medical Record https://www.verywellhealth.com/importants-parts-of-a-medical-record-2317249

QTS (2019). 5 Benefits of EMR vs. Paper Medical Records

Valerie S. Prater (2014). Biomedical and Health Information Sciences University of Illinois at Chicago

https://www.youtube.com/watch?v=M7qb2rmuIZs&ab_channel=TheAudiopedia

https://obgyn.onlinelibrary.wiley.com/doi/full/10.1576/toag.9.4.257.27356

https://www.asha.org/practice/ethics/confidentiality/

https://www.who.int/goe/policies/tnt_strategic_plan2012-2016.pdf