Chapter 8: Medical Record Management

electronic health records (EMR)

an electronic version of a patient’s medical record that is used by a single healthcare facility

information in an EMR

medical history; diagnoses; treatment plans; medications; immunization records; vital signs measurements; imaging, test, and lab results

centers for medicare & medicaid services (CMS)

a federal agency within the US Department of Health and Human Services that is responsible for Medicare and Medicaid, among other responsibilities

meaningful use

standards established by CMS to create incentives for the use of electronic health records

information in a patient’s medical record

demographic information; administrative records; medical history; social history; family history; known allergies to medications, food, or substances; current health conditions, diagnoses, treatments/medications, and procedures; consent forms (general and for procedures); provider notes describing assessments, diagnoses, and treatment plans; test results

demographic information

name; date of birth; contact information

administrative records

health insurance; billing records; appointments; referrals; information requests; letters

medical history

history of illnesses, injuries, diseases, and surgeries

social history

history of education, living conditions; health heabits; alcohol/tobacco use

family history

history about diseases and conditions of close relatives

types of record-keeping systems

electronic medical records; electronic health records; paper charts

electronic medical records

digital record of a patient’s medical information; can be assessed by multiple users simultaneously; reduces the chance of errors due to handwriting; allows for searches, report-creating, and easier coding; can be easily stored/maintained; EMRs are facility-specific and cannot be accessed by outside providers

electronic health records

can be accessed by multiple users simultaneously'; can be accessed across many healthcare systems; most accessible type of patient record available; allows for searches, reports, billing, and scheduling functions; systems are expensive; increased security requirements under HITECH; CMS provides incentives to medical practices who can prove they are using EHRs to improve care and health outcomes

paper charts

only available to one person at a time; require large space for storage; must be physically kept secure; inexpensive; possible to lose or misfile; easier to overlook information; are filed alphabetically or numerically and are color-coded; facilities have individualized systems and will provide training

guidelines for paper file indexing

use the patient’s last name, first name; and middle initial for alphabetical filing; follow office procedure for numerical filing; follow facility procedure for using a placeholder when removing file; do not file vendor, maintenance, or other types of records with patient files

source-oriented medical record (SOMR)

a method of organizing paper medical records according to source or category

problem-oriented medical record

a method of organizing paper medical records according to the patient’s problems and diagnoses

personal health record (PHR)

an electronic collection of a patient’s health history and medical information

guidelines for protecting patient privacy

using features that help protect a patient’s data (encryption, firewalls, etc.); following HIPAA requirements for backing up electronic medical information; keeping user names and passwords private and making sure information on screens is not visible to others; keeping paper records in a secure area/locked when not in use; following facility policy regarding how long medical files are kept and how they must be destroyed after the required period has expired

patient rights regarding their records

patient must authorize release of information to any other party, including their insurance company; patient has the right to access medical records; patient may request that records be changed to correct any errors; patient may request copies of their medical records which should be free or at a “reasonable” fee

computerized provider order entry (CPOE)

a method of entering orders for healthcare services, such as laboratory or diagnostic tests, within a patient’s EHR; also called computerized physician order entry

requisition

an order for diagnostic tests to be completed

superbill

a document listing diagnosis and treatment codes, charges for treatment provided, and any payment made by the patient

management functions in an EHR

patient scheduling; insurance billing; payment tracking; appointment reminders

ways to use EHR/Computerized Provider Order Entry (CPOE)

entering provider orders for diagnostic tests or other services (CPOE); entering prescriptions/transmitting them to the patient’s pharmacy; maintaining consent forms, both general consent forms and informed consent forms for procedures; printing instructions for procedures/preparation and reviewing them with the patient; generating bills documents; creating return-to-work/return-to-school forms for a patient

benefits of using EHR for prescriptions

reduces errors due to handwriting; allows provider and pharmacy to view all medication information in one place; may generate drug information sheets for the patient

administrative functions that use EHR/practice management

generating a superbill; completing and transmitting claims to insurance companies; creating reports to track specific things such as patient appointments, demographics, and medical conditions; accounting tasks such as sending bill to patient and posting payments