Medical Record Management
Understanding EMR, EHR, and Filing Systems
Definition of Electronic Medical Records (EMR):
An EMR is an electronic version of a patient’s medical record used within a single healthcare facility.
Typical contents include medical history, diagnoses, treatment plans, medications, and immunization records.
It may also capture vital signs measurements, imaging results, test results, and laboratory data.
Definition of Centers for Medicare & Medicaid Services (CMS):
A federal agency residing within the US Department of Health and Human Services.
CMS is responsible for the administration of Medicare and Medicaid and oversees many other healthcare responsibilities.
Definition of Meaningful Use:
Standards established by CMS to incentivize the adoption and effective use of electronic health records (EHR).
Importance of Record Management:
Record management is a critical responsibility for the Medical Assistant (MA).
Accurate and up-to-date records are essential for providers to deliver high-quality patient care.
Components of the Patient Medical Record
Demographic Information:
Includes the patient’s full name, date of birth (), and contact information.
Administrative Records:
Health insurance information.
Billing records.
Schedules and appointments.
Referrals and information requests.
Correspondence/letters.
Medical History:
Historical illnesses and injuries.
Documented diseases and previous surgeries.
Social History:
Education level and living conditions.
Health habits, including alcohol and tobacco use.
Family History:
Documented diseases and conditions of close relatives, specifically parents and siblings.
Known Allergies:
Allergies to medications, food, or other substances.
Current Health Status:
Current conditions and diagnoses.
Current treatments, medications, and medical procedures.
Consent Forms:
General consent forms.
Specific consent forms for procedures.
Provider Notes:
Detailed descriptions of clinical assessments, diagnoses, and treatment plans.
Test Results:
All relevant laboratory and diagnostic test outcomes.
Comparison of Record-Keeping Systems
Electronic Medical Records (EMR)
Digital records of patient medical information.
Supports simultaneous access by multiple users.
Reduces the risk of errors associated with illegible handwriting.
Facilitates digital searches, report generation, and streamlined coding.
Storage and maintenance are generally easier than physical files.
Limitation: EMRs are facility-specific and cannot be accessed by outside providers.
Electronic Health Records (EHR)
Supports simultaneous access by multiple users.
Accessible across multiple different healthcare systems and facilities.
Characterized as the most accessible type of patient record available.
Includes integrated functions for searches, reporting, billing, and scheduling.
Drawbacks/Requirements:
Implementation of these systems is expensive.
Subject to increased security requirements under the Health Information Technology for Economic and Clinical Health () Act.
CMS provides financial incentives to practices that demonstrate the use of EHRs to improve care and health outcomes.
Paper Charts
Access: Only available to one person at a single time.
Space: Requires significant physical space for storage.
Security: Must be physically secured (e.g., locked cabinets/rooms).
Cost: Initial costs are inexpensive compared to digital systems.
Risks: High potential for losing files or misfiling; easier to overlook specific information.
Filing Logic: Most commonly filed alphabetically; larger practices may use numerical filing.
Organization: Files are often color-coded; facilities typically provide individualized training on their specific system.
Paper File Indexing and Organization
Guidelines for Paper File Indexing
Alphabetical Filing: Use the patient's last name, then first name, then middle initial (standard unless the facility dictates otherwise).
Numerical Filing Varieties:
Straight Numerical: Files are ordered from lowest number to highest number.
Middle Digit: Files are ordered according to the middle digit of the assigned number.
Terminal Digit: Files are ordered according to the final digit of the assigned number.
Placeholders: Always follow facility-specific procedures for using placeholders when a file is removed.
Separation of Records: Do not mix vendor records, maintenance records, or other non-patient records within the patient files.
Methods of Organizing Paper Records
Source-Oriented Medical Record (SOMR): Organizing records based on the source or category of the information.
Problem-Oriented Medical Record (POMR): Organizing records according to the patient’s specific problems and diagnoses.
Personal Health Record (PHR): An electronic collection of a patient’s health history and medical information maintained by the patient themselves.
Patient Portals and Electronic Access
Functions and Benefits:
Patient portals involve the patient directly in their own healthcare management.
Common functions include viewing test results, messaging providers, and scheduling appointments.
Discussion Points on Access (Critical Thinking):
Patients may receive information through portals they might not get as quickly elsewhere.
Consider alternative methods for patients who lack reliable internet or computer access to ensure they receive their health information.
Legal Issues and Privacy in Record Management
Protecting Patient Privacy
Use technical features such as encryption and firewalls to protect data.
Follow requirements for backing up electronic medical information.
Maintain privacy of usernames and passwords.
Ensure computer screens containing patient information are not visible to unauthorized persons.
Keep paper records in secure, locked areas when not in use.
Adhere to facility policies regarding file retention periods and the proper destruction of records after expiration.
Medical Assistants must be able to recognize and report any breaches of confidentiality.
Patient Rights Regarding Medical Records
While the medical facility owns the physical or electronic record, the patient has specific rights:
The patient must authorize the release of information to any third party (including insurance companies).
The patient has the right to access their own medical records.
The patient may request corrections to errors in their records.
The patient may request copies of records; these should be provided for free or for a "reasonable" fee (covering the cost of making the copies).
Software Functions and Practice Management
Key Terms
Computerized Provider Order Entry (CPOE): A method for entering orders for healthcare services (labs, diagnostics) directly into the patient's EHR; also known as computerized physician order entry.
Requisition: A formal order for diagnostic tests to be completed.
Superbill: A document that lists diagnosis codes, treatment codes, charges for services, and any payments made by the patient.
Electronic Health Record Functions
Practice Management:
Patient scheduling.
Insurance billing and tracking payments.
Appointment reminders.
Medical Assistant Responsibilities:
Learn the specific capabilities of the facility's EHR.
Manually add information through scanning and proper indexing according to policy.
Clinical and Administrative Tasks in EHR/CPOE:
Entering orders for diagnostic tests.
Entering and transmitting electronic prescriptions (e-prescribing) to pharmacies.
Maintaining general and informed consent forms.
Printing and reviewing procedure preparation instructions with patients.
Generating/transmitting referral forms and billing documents.
Creating return-to-work or return-to-school forms.
Benefits of E-Prescribing
Reduces errors caused by poor handwriting.
Allows both the provider and the pharmacy to view all medication data in one centralized location.
Can automatically generate drug information sheets for the patient.
Administrative and Accounting Functions
Generating superbills and transmitting insurance claims.
Creating reports to track appointments, patient demographics, and medical conditions.
Executing accounting tasks such as posting payments and sending bills to patients.
Questions & Discussion
Case Study Prompts (Textbook References):
Reference the case study on page as a baseline for the chapter discussion.
Use specific information from the chapter to answer evaluation questions found on page , page , page , and page .
Patient Portal Conversation Starters:
Have you used a patient portal? What are the pros and cons?
How do we bridge the gap for patients without digital access?