Health Information ManagementRecords and Files

11.13 Differentiate between types and content of health records (patient, pharmacy, and laboratory). 11.14 Ensure that documentation in the health record reflects timeliness, completeness, and accuracy. 11.15 Adhere to information systems policies and procedures as required by national, state, local, and organizational levels.

Confidentiality What do you remember about patient

records and confidentiality? They are legal documents Records should not be released to other

parties without the written consent of the patient.

The records belong to the physician or health agency.

Does the patient have a right to obtain copies of his/her medical records?

Statistical Data Sheet Also called patient

or medical information form.

Contains name, personal data and insurance information.

Often filled out by hand and then typed into computer.

Some are online.

Medical Record Also called patient chart, medical

chart or patient record. Collection of documents pertaining to

a patient. Purpose of medical record:

Communication Documentation Legal protection

Who does a medical record protect?

What is in a Medical Record? MEDICAL HISTORY A process of questioning by a healthcare

professional for the purpose of gathering information used to help diagnose and care for a patient.

The history can vary based on circumstances. Who would take a longer medical history – a

paramedic responding to a patient with chest pain,

Or a psychiatrist who is evaluating a suicidal patient?

What is in a Medical Record?

PHYSICIAN’S ORDERS

Communicates patient treatment plan.

Can be handwritten,

Pre-printed and checked off,

Or printed electronically.

What is in a Medical Record?

DIAGNOSTIC TESTS Laboratory reports Radiology reports EKGs What other diagnostic

tests might be included in a medical record?

What is in a Medical Record? REPORTS Can include operative reports,

consultations, and other important information.

CONSENT FORMS Meet informed consent

requirements Signed by patient and

witness

What is in a Medical Record? MEDICATION RECORDS Documentation of all medication – drug,

dosage, time administered, and by whom

PROGRESS NOTES Healthcare workers document evaluation of

patient’s clinical status and achievements during a hospital stay, or over a span of time. Physicians will update findings after seeing patient. Therapists will note what was done and results. Nurses record treatment they perform and patient

response.

Problem Oriented Charting - SOAP

S - SUBJECTIVE Subjective information – sensed by the patient Chief complaint – reason patient is seeking

medical care O - OBJECTIVE

Objective information – observed by health care worker

A – ASSESSMENT Health care professional’s assessment of what is

wrong, based on signs and symptoms P – PLAN

Procedures, treatments and patient instructions

You Try It

A friend comes to you and says “I have a sore throat.”

What is S? “My throat is sore.” “It hurts when I swallow.”

What is O? You look in the throat and see redness.

What is A? Local throat irritation could be caused by a virus or

strep. What is P?

Get a throat culture. Gargle with warm salt water

Computerized Medical Records

It’s the wave of the future for medical records.

Where have you seen the use of computerized medical records?

Why?

Computerized Medical Records

ADVANTAGES Improved legibility of charting Quicker to record which increases efficiency Fewer errors Improved communication among health team

members Records easily transmitted to other hospital

departments and health care providers who need them.

Computerized Medical Records

DISADVANTAGES Possible system crash Cost of converting to a computerized system –

hardware, software and training costs Potential problems with confidentiality

What do you think is the biggest obstacle?

Insurance Forms and Statements Insurance card

usually photocopied Insurance

information on patient data sheet

Most agencies now file insurance claims electronically

All purpose electronic claim form is CMS-1500

Coding Systems International Classification of Diseases (ICD) Used for diagnosis coding

Coding Systems Current Procedural Terminology (CPT) Used for procedures and services

Health Careers What healthcare professionals work most

closely in health information management? Coder – certificate level Transcriptionist Medical records administrator RHIA – Registered Health Information

Administrator Degree levels from certification to Master’s

degree American Health Information Management

Association http://www.ahima.org/