OA: Medical Records Management

Medical Records

Permanent account of client interactions and services.

Legibility

Records must be readable by all team members.

Computerized Records

Digital records accessible from any computer.

Legal Document

Medical records must be inked, not pencil.

Ink Requirements

Use blue or black ink only for records.

Record Correction

Cross out mistakes, correct, and initial error.

Filing Systems

Organize paper records alphabetically or numerically.

Color-Coding

Use colors to identify misfiled charts.

Warning Stickers

Indicate special conditions like 'Will Bite!'.

Records Release

Confidential; requires owner's consent for sharing.

Privacy Act of 1974

Protects client records from unauthorized disclosure.

Client Copy Rights

Clients can request copies; originals stay with practice.

SOAP Format

Structure for organizing patient medical records.

Medical Record Components

Includes history, exam, diagnosis, and treatments.

History Taking

Summarizes client information for accurate diagnosis.

Problem-Oriented Records

Organized by problems, using SOAP method.

Drug Documentation

Must specify dosage and administration route clearly.

Fluid Administration

Document type and rate of fluids given.

Record Retention

Maintain records for at least three years.

Inactive Records

Records of clients not seen in one year.

Discharge Instructions

Clients receive written and verbal care instructions.

Medication Information

Includes type, dosage, frequency, and side effects.

Common Abbreviations

Includes PO, IM, IV, SID, BID, etc.

Radiographs

Must include client and patient identification details.

Radiograph Checkout Log

Tracks loaned radiographs to prevent loss.

Backup System

Daily backups using multiple methods for data safety.

Master Problem List

Comprehensive list of patient issues for reference.

Laboratory Flow Sheet

Tracks diagnostic tests and results systematically.