Ch 23 The Medical Reccord, Documentation, and Filing

Purposes of Medical Records

1. Continuity of care 2. Documentation for insurance reimbursement 3. Chronological record for subsequent care

HIPAA Privacy Rule

Provides standards for protecting patients’ confidential, personal information

HIPAA Security Rule

Primarily concerned with protecting electronic health information from invasion, accidental disclosure, or loss

Medicare Promoting Interoperability (PI) Program

The newer name (since 2018) for the Meaningful Use program, shifting focus to interoperability and patient access

Record Ownership vs. Patient Rights

The provider/hospital owns the physical record and can restrict it to the premises, but the patient has a right to complete confidentiality

Mandatory Reporting Exceptions

Providers must report certain information without consent, such as infectious diseases and specific crimes

Avoiding Patient Abandonment

A physician must notify patients in writing when wishing to discontinue care to legally sever the relationship

Subjective Information

Information supplied directly by the patient (e.g., chief complaint, symptoms)

Objective Information

Measurable data gathered by healthcare providers (e.g., vital signs, exam findings, lab results)

Progress Notes

Chronological documentation of a patient's progress, encompassing various encounters and communications

POMR (Problem-Oriented Medical Record)

A record organized by the source of the information (provider, lab, etc.) that begins with a standard database

SOAP Note

A data collection method standing for Subjective, Objective, Assessment, Plan

CHEDDAR

A detailed charting acronym: Chief complaint, History, Examination, Details, Drugs/dosages, Assessment, Return visit

Electronic vs. Paper Chart Dating

EHR software automatically dates and times entries; paper records require the patient's name and DOB at the top of every new page

Paper Chart Organization Layout

Opened flat: Progress notes/exams on the right; imaging/labs shingled on the inside right back; immunizations/meds/demographics on the inside left cover

5 Steps in Filing

1. Inspecting, 2. Indexing, 3. Coding, 4. Sorting, 5. Storing

Chronologic Filing

Filing documents according to date, with the most current date placed on top

5 Common Filing Systems

Alphabetic, Numeric, Geographic, Subject, Chronologic

Tickler File

A chronologically organized file used as a follow-up or reminder tool for tasks to be done on specific dates

EHR Human Error Vulnerability

While EHRs prevent lost physical charts, data or scanned documents can still accidentally be placed into the wrong patient's electronic chart

HIPAA Retention Requirement (General)

All medical records, signed consent forms, and HIPAA documents must be kept for six years

HIPAA Retention Requirement (Deceased)

Records of deceased patients must be maintained for at least two years

Federal vs. State Retention Laws

State laws can require longer record retention than federal laws, but they cannot require less than federal regulations