MAAS 211G-Medical Insurance and Managing Medical Records, Chapter 23

Ownership of charts

Patient charts belong to the medical practice, not the patient.

What are the components of medical records?

Includes progress notes, prescription refills, calls, and test results.

How long is retention?

HIPAA requires medical documents to be retained for 6 years.

How should you make a correction in a emr chart?

Use the edit feature, never delete or scribble out.

Legal protection

Accurate records protect both patient and the provider.

Subjective

Patient reported findings.

Objective

Physical exam findings such as high or low bp.

Primary system

Most filing is alphabetical.

Tie-Breaker Rule

If names are identical, file by state, city, then street. Major to minor.

Numeric system

Spreads files evenly across storage space.

Coding

Marking index identifiers on items to be filed.

Storage equipment

Shelves, filing cabinets, barcodes, scanners, OUTguides.

Filing safety

Start filling bottom drawers in a new cabinet.

SOAP

Subjective, objective, Assessment, plan. Includes studies, treatments, and management strageties.

HPIP

History, physical exam, impression, plan. Assessment or diagnosis. History is subjective and physical exam is objective.

POMR

Problem, oriented, medical, record. Organizes charts by patient problems.

HIPAA

Protects patient privacy and regulates data retention and disclosure.

HITECH

Encourages electronic health record (EHR) adoption and improves care quality.

Progress notes

Found on the right side of the paper chart

Edit features

Used to correct EMRs without deleting entries.

Medical Assistant

First to review incoming reports.

HPIP method

History (subjective), Physical (objective), Impression (diagnosis), Plan (treatment).

SOAP method

Subjective, Objective, Assessment, Plan.