Medical Records and Office Emergencies

Medical Records

Learning Objectives

• Explain the parts of a medical record.
• Describe the importance of documentation in medical records.
• Identify similar information in different medical records formats.
• Explain how healthcare personnel manage medical records.
• Describe the electronic record, including its history and goals.
• Discuss electronic data management systems.

Lesson Preview

• A medical record contains all of a patient’s medical history related to a specific provider.
• The medical record includes:
  • Charts
  • Notes
  • Information to identify the patient
  • Support for diagnosis or reason for appointment
  • Justification for treatment
  • Accurate documentation of results
  • Past and present illnesses and treatments
• The medical record provides a complete picture of the healthcare a patient has received.
• Electronic records are now commonplace in the medical industry.

Medical Records: Common Parts

• Common parts of a medical record:
  • Questionnaire
  • Registration/admission
  • Consent for treatment
  • Patient history
  • Plan of treatment
  • Progress report forms
• Ensure required intake forms are complete and pertinent information is entered into the electronic record.

Questionnaire

• A medical record starts with a questionnaire or patient data sheet, gathering:
  • Medical history
  • Insurance coverage
  • Other important facts
• Sexual Orientation and Gender Identity (SOGI) data:
  • Crucial to providing competent care to LGBTQ+ patients.
  • Sexual orientation: pattern of emotional, romantic, and sexual attraction.
  • Gender identity: inner sense of belonging on a continuum of masculine to androgynous to feminine traits.
  • Can reduce health disparities among sexual and gender minority populations.
  • Helps improve culturally sensitive care.
  • Documenting gender identity and preferred pronouns avoids misgendering patients.
  • Helps identify appropriate preventive screenings.
  • Providers need this information to recommend appropriate preventive care.

Registration/Admission

• Used to record important information, such as:
  • Patient's name
  • Address
  • Insurance information
• May be completed every visit or kept on file and updated as needed.

Consent for Treatment

• Completed when a patient agrees to a suggested treatment.
• Includes a statement indicating the patient has been informed of the treatment plan, including possible side effects and negative outcomes.
• The patient signs the form, indicating agreement to the treatment and awareness of all possible consequences.

Patient History

• Filled out when a patient sees a provider for the first time or hasn’t seen a particular doctor for a long time.
• Contains critical questions regarding the patient’s health history.
• Enables the provider and medical staff to give the patient the best possible care.

Plan of Treatment

• The provider records the orders given to the patient regarding treatment.
• Completion of this form helps establish a plan for recovery and provides the patient with clear instructions to follow.

Progress Report

• Information is recorded on the progress report form as a treatment plan moves along or a patient’s condition changes.
• Used to chart changes of all kinds in patients’ conditions, including:
  • Worsening conditions
  • Improvements

The Flow of Medical Information

• The medical record provides patient information for the different segments of the patient’s care.
• Practitioners involved in treating the patient can communicate with one another.
• The medical record keeps current healthcare providers abreast of the patient’s treatment and progress.
• It depicts an accurate picture of the patient’s previous care for future providers.
• Enables one doctor who takes over for another to continue to treat the patient without interrupting care.
• Used for reimbursements.
• Supplies information so the patient and third-party payers can be billed for services and expenses.
• Substantiates laboratory tests, medications and other services listed on an insurance claim.
• Serves as a legal business record for the healthcare provider.
• Gives the patient documentation for legal claims.
• Used to analyze and review the quality of patient care.
• Can be used for research and education, or for healthcare facility planning and market research.
• Helps determine problems that the healthcare delivery system needs to address.
• Complete files are necessary to verify medical expenses, validate the healthcare provided and meet government requirements.
• All records contain similar information, even if the format differs.

Medical Records: Purposes

• Identify the patient.
• Record results of tests and treatments.
• Justify diagnoses and treatments.
• Offer information to all providers involved in the patient’s care.
• Detail the patient’s previous care for future providers.
• Maintain a record of services for billing third-party payers.
• Provide the healthcare facility with a legal business record.
• Provide tools for evaluating patient care.
• Provide documentation for study and research.
• Give healthcare providers data for planning delivery of services and marketing.

Documentation

• Medical records act as an important resource for:
  • Legal protection
  • Financial reimbursement
  • Education
  • Quality assurance
  • Medical research
• Documentation is the written record of the services that the provider performs.
• Patients are charged for services received based on what the physician documents.
• A physician’s documentation substantiates the charges on the medical bill.
• Contains the information used to assign the correct medical codes for reimbursement purposes.
• Represents a database for reimbursement decisions for insurance payments, such as:
  • Medicare
  • Medicaid
  • Private insurance coverage
  • Workers’ compensation
• If services are provided but not documented, the healthcare provider will not be reimbursed.
• If it’s not documented, it didn’t happen.
• Medical records must be secure.
• Someone who is able to order, provide, or evaluate service must authenticate all entries into the record.
• Authentication means that an author to an entry in a medical record signed the record.
• Only the author of the entry can authenticate it.

Types of Documentation

• The type and format of a physician’s dictation vary among facilities.
• All dictation contains:
  • Date and time the entry was written
  • Patient’s complaint
  • Problem
  • What the physician did during the service
• Chief complaint: a concise statement that describes why a patient is seeking treatment

Commonly Used Narrative Formats

• SOAP Report (Chart Note):
  • Subjective
  • Objective
  • Assessment
  • Plan

SOAP Format

• S - Subjective:
  • The patient’s point of view or complaint.
• O - Objective:
  • Refers to the clinical findings.
• A - Assessment:
  • The examiner’s diagnosis based on the clinical findings.
• P - Plan:
  • Refers to the provider’s order.
• Other Formats:
  • CC (Chief Complaint) - same as Subjective
  • Px (Physical Examination) - same as Objective
  • Dx (Diagnosis) - same as Assessment
  • Rx (Prescription) - same as Plan
• The medical record is the property of the provider, but the patient has the right to review the information inside the record.
• The patient has the right to release medical records to third-party payers or different healthcare providers.

The Business of Managing Medical Records

• Standards exist for the documentation of medical information.
• The American Health Information Management Association (AHIMA) provides a list of documentation guidelines.

AHIMA Documentation Guidelines

• Anyone who documents the health record should be credentialed or have the authority and right to document the record.
  • Individuals must be trained and competent in documentation practices and legal documentation standards.
• All medical facilities should ensure that the content and format of their medical records are uniform.
  • Accreditation standards, federal and state regulations, insurance requirements and professional practice standards should be the basis for these policies.
• Medical records should be systematically organized to make compiling and retrieving of information as simple as possible.
• Only the healthcare organization’s authorized individuals may record information into a medical chart.
• The healthcare organization’s policies or medical staff rules should state who can receive and transcribe doctors’ orders.
• Information should be added to the medical record at the time services are provided.
• Authors of patient information must be clearly identified in the medical record.
• A healthcare organization’s or medical staff ’s rules must provide a list of approved symbols and abbreviations to be used in medical records—no other symbols or abbreviations may be used.
• All entries into a medical record must be permanent.
• Errors in medical records must be corrected through a specific process.
• Any patient corrections or information a patient wants added to his medical record should be done so as an addendum, or separate note, and must be clearly identified as such.
  • No changes should be made to the original medical record.
• Policies and procedures for analysis of medical records is the responsibility of a medical facility’s health information management professionals.

Good Recording Practices

• Activities and procedures healthcare professionals do to ensure a patient’s medical record is:
  • Legible
  • Understandable
  • Timely
  • Error free
  • Reproducible
• Legible: Doctor might have to rewrite the entry if key elements of a written health record cannot be deciphered.
• Understandable: Abbreviations and arrangement of forms must be consistent with the medical facility’s standards and procedures.
  • Personnel should have an official list of acceptable abbreviations and their meanings.
• Timely: Timeliness of entries is critical to the accuracy of the health record.
  • Medical record must be coded in a timely manner, and the bill must be submitted in a reasonable amount of time.
  • Patient records should be updated as soon after each healthcare encounter as possible.
  • To be admissible in a court of law, medical records must be dated in the mm/dd/yyyy format, and the time must be recorded on the record in military time.
  • The Joint Commission’s accreditation standards require medical records to be updated within 30 days of a patient’s discharge.
  • If the 30 days pass, and the record is not updated, it becomes delinquent.
• Error Free: When an error is made in the medical record, several protocols must be followed.
• Reproducible: A medical record must be correctly formatted and clear.
  • Handwritten entries must be made in black ink, and computer-generated reports must be reproducible.
• It is unlawful to delete information from the patient’s medical record.
• Incorrect entries must remain, with the new or corrected information appearing as an addendum or correction note.
• An addendum is the addition of information that was left out of the original entry.
• An amendment is made to add clarification or missing details from an initial documentation.
  • Amendments should clarify the original notes, but not change the general information in the record.
• Late entries are documentation added to the patient record after the care was provided.
• The Joint Commission’s accreditation standards require that a doctor must enter a discharge summary.
  • Reason for patient’s hospitalization
  • Significant findings
  • Procedures performed and treatment rendered
  • Patient’s condition when discharged
  • Instructions to the patient and family

Correcting a Written Medical Record

• The entry should be crossed out with a single line.
• The correction should be noted, such as indicating that the entry pertains to another patient or noting another specific reason for the error.
• The initials of the person making the correction should be noted.
• The date and time the error was discovered should be noted.

Correcting an Electronic Record

• The system must have the ability to track corrections or changes to the entry once entered or authenticated, which is known as an audit trail.
• The original entry should be viewable.
• The current date and time should be entered.
• The person making the change should be identified.
• The reason should be noted.
• In situations where there is a hard copy printed from the electronic record, the hard copy must also be corrected.
• Falsifying or tampering with a record is illegal.
• Healthcare professionals should routinely review medical records after a patient is discharged.
  • Information must be added within 15 days of the patient’s discharge.

Electronic Records

• Electronic medical record (EMR):
  • A description that is widely used for computerized records.
• Electronic health record (EHR):
  • A more accurate term for the actual electronic record.
• The electronic health record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.
• Includes:
  • Patient demographics
  • Progress notes
  • Problems
  • Medications
  • Vital signs
  • Past medical history
  • Immunizations
  • Laboratory data
  • Radiology reports
• The electronic record provides a completely electronic system to create, store and access medical records.
• Patient information goes directly into an electronic database.
• The electronic record incorporates special data-management functions to:
  • Assist healthcare providers with decision-making
  • Prevent medical errors
  • Enhance medical research
• The hope is that electronic records will:
  • Make all medical records universally portable
  • Provide continuity of care for patients
  • Support administrative functions

History of the Electronic Record

• The first electronic records appeared in the mid-1960s.
• The use of electronic data management became a necessity when the government instituted Medicare in 1965.
• For the next two decades, computerized healthcare data systems were used in areas of health care where the captured information was mostly numerical and inherently structured.
• Discrete data: information that consists of separate and limited values
  • Quantifiable information, which can be determined, indicated, or expressed.
  • A patient’s age, height and weight are examples of discrete data.
  • Structured because it can be sorted into categories and hierarchies.
• Early computerized healthcare data systems could really only capture discrete data.
  • Billing
  • Laboratory results
  • Pharmacy records
  • Radiology records
• One drawback to these original computerized health records was that they were specific to single institutions.
  • Healthcare providers couldn’t easily share the data the electronic records contained.
• Much of what goes into a patient’s medical record is not discrete data.
  • Unstructured narrative—clinical information
• In 1991, the Institute of Medicine (IOM) issued a report: The Computer-based Patient Record: An Essential Technology for Health Care.
  • Focused on the patient as the primary beneficiary of the computerized record.
  • Made specific recommendations for building a nationally coordinated system of electronic records.
• The U.S. Department of Defense created a clinical care patient record system, the Composite Health Care System (CHCS), implemented worldwide.
• The Veterans Administration developed its Decentralized Hospital Computer Program (DHCP), used for medical care of veterans nationwide.
• In 2003, the IOM released another report that outlined what the electronic health record should be and the capacities it should have.
• In 2010, the U.S. government renewed a national commitment to the electronic record, making it a priority.
  • A national goal in the United States for healthcare providers to replace all paper records with computer-based systems.
  • Financial Medicare incentives for healthcare entities that transitioned to the electronic record.
  • From 2015 to 2018, Medicare payments were adjusted to those healthcare providers that were not meaningful users of electronic records technology.

Computer-based Patient Record

• Health information management is the backbone of patient care.
• Transcriptionists, coders, billers and administrators keep the gears of the health system spinning.
• Health information exchange (HIE) allows healthcare professionals and patients to appropriately access and securely share a patient’s medical information electronically.
• The goal of HIE is to provide safe, timely, efficient and effective access to and retrieval of patient information for providers.
• The Institute of Medicine (IOM) originally created the term CPR (computer-based patient record) to describe the computerized version of a medical record.
• In 2003, the IOM report established eight core functions that a computer-based patient record should be capable of performing.

Eight Core Functions

1. Health Information and Data
   • Should contain the same items that are found in the paper chart, including problem lists, medications and test results.
   • A well designed interface to enable the provider to review the information efficiently.
2. Result Management
   • Refers to accessing information easily when and where it is needed.
   • Availability, convenience, reliability and ease of use.
3. Order Management
   • Computerized entry and storage of data on all medications, tests and other services.
   • Computerized provider order entry (CPOE) refers to any system in which clinicians directly enter medication orders, tests and procedures electronically, with the orders transmitted directly to the recipient.
   • Advantages of CPOE include standardized, legible and complete orders, which will reduce medical errors.
4. Decision Support
   • Alerts providers and patients to vaccines, screenings and/or preventative measures.
   • Provides warnings and reminders to assist providers in making decisions in patient care.
5. Electronic Communications and Connectivity
   • Focuses on patient safety and quality of care.
   • Allows multiple providers in multiple setting to communicate and coordinate care.
6. Patient Support
   • Home monitoring and educational materials are directly related to improving the control of a chronic illness, such as diabetes.
7. Administrative Processes
   • Computer-based patient records assist with billing and claims management.
   • The provider can immediately validate insurance eligibility, as well as obtain authorizations.
   • Results in more timely payments and less paperwork.
8. Reporting and Population Health Management
   • Computer-based patient records provide a standardized system for reporting requirements for safety and quality that are necessary for state, federal and local entities.

Future Goals for the Electronic Record

• To improve the accuracy, organization, management and accessibility of patient records.
• Electronic records allow interactive functions, such as the ability to generate alerts to healthcare providers, like warnings about dangerous medication interactions.
• Electronic records make it possible for all agencies and providers involved in patient care to communicate quickly and accurately.
• The patient’s information, both clinical documentation and discrete data, is collected once, and then shared—so it’s used multiple times.
• Interoperability: the ability for different electronic record software to communicate among multiple machines.
• Standards for electronic records: consistent information provided to and from the electronic record software.
• The electronic record must be private and secure.

Goals of Electronic Records

• Improve accuracy, organization and management of medical information
• Improve accessibility to medical information
• Reduce medical errors
• Improve patient care
• Reduce costs

Qualified EHR

• According to the Health Information Technology for Economic and Clinical Health (HITECH) component of the American Recovery and Reinvestment Act (ARRA) of 2009:
  • “includes patient demographics and clinical health information, and has the capacity to provide clinical decision support; support physician order entry; capture and query information relevant to healthcare quality; and exchange electronic health information with and integrate such information from other sources.”
• Data comparability standards are necessary to ensure quality payment.
  • Standard vocabulary helps achieve data comparability.
• HITECH requirements demand the use of controlled vocabulary to allow for electronic exchange of health information.
  • Controlled vocabulary: a specific set of terms in the electronic record’s data dictionary must be used.

National Standard Terminologies

• Recommended by The National Committee on Vital and Health Statistics (NCVHS):
  • SNOMED CT—Systematized Nomenclature of Medicine - Clinical Terms
  • LOINC—Logical Observation Identifiers Names and Codes
  • RxNorm—Federal drug terminologies
• SNOMED CT presents data in a completely machine-readable format to capture, encode and use data for clinical care of patients and research.
• Health Level Seven (HL7) develops specifications for electronic healthcare information to increase the effectiveness and efficiency of healthcare information.

HL7 Scenarios

• To create an addendum:
  • Author dictates additional information as an addendum to a previously transcribed document.
  • A new document is transcribed.
  • The addendum has its own unique document ID that is linked to the original document via the parent ID.
  • Addendum document notification is transmitted to create a composite document.
• To correct errors that were discovered in the original health document that haven’t been made available for patient care:
  • The original document is edited, and an edit notification is sent.
• Personal health record (PHR): medical information that the patient maintains.
  • Puts control in the consumer’s hands.
  • A tool for the patient.

Electronic Data Management System

• Hybrid medical records system.
• Uses standard word-processed documents in conjunction with the electronic record.
• An individual patient’s free-form clinical narrative is available electronically, but in the familiar document form.
• Healthcare professionals can electronically access those documents in the same way that they can access a patient’s laboratory and radiology results.
• Information included in the word-processed document is not “visible” to the facilities that share the electronic record.

Emergencies in the Medical Office

Learning Objectives

• Describe how to properly wash and glove using the virtual lab.
• Explain the purpose of triage in today’s medical office.
• Explain what a medical emergency is and describe the equipment used in an emergency, including the enhanced 911 system.
• Discuss the role of a healthcare professional in an emergency situation, the provisions that a medical office should have in its emergency kit and how to document an emergency procedure.
• Describe the symptoms and course of action to treat the most common emergencies in the medical office.
• Illustrate how to prevent disease transmission when providing first aid.

Lesson Preview

• Individuals working in health care expect to encounter many types of emergencies.
• Acquire first-aid skills and have a working knowledge of appropriate actions to take in common accident or illness situations.
• This lesson explores several of the most common medical emergencies you could encounter as a healthcare professional.
• This lesson alone is not enough to prepare you to deal with emergencies.
• Two certification courses are Basic Life Support and First Aid by the Red Cross or the American Heart Association (AHA).
• These first-aid courses also teach cardiopulmonary resuscitation (CPR).
• When you are working in a physician’s office, you must always be ready to react to an emergency situation.
• Swift and appropriate action can affect the outcome of the situation.
• As a medical administrative assistant, with the knowledge and skills gained from this lesson and your certification classes, you will be able to help in case of emergency.

Hand Washing and Gloving

Proper Hand Washing

• The single most important means of preventing the spread of infection.

Steps to Take: Proper Hand Washing

1. Remove any jewelry other than a plain wedding band.
2. Don’t allow your clothing to touch the sink.
   • Never touch the inside of the sink with your hands.
3. Turn on faucet with dry paper towel, adjust temperature, then discard towel.
   • Lukewarm water is best for your skin.
4. Wet hands and apply soap using a circular motion and friction.
5. Interlace fingers to clean between them.
   • Also scrub up to and including the wrists.
   • Scrub for 2 minutes at beginning of day, then for 30 seconds following each patient contact throughout the day.
6. Use a brush on your nails at the beginning of each day.
7. When you rinse your hands, keep them pointed downward under the water.
8. Blot hands and wrists dry with disposable paper towel; do not touch the towel dispenser following hand washing.
9. Turn faucet off with clean paper towel.
10. Apply antibacterial lotion to prevent chapped skin.

Proper Gloving

• Offers additional protection from germs for both you and the patient.
• Wear gloves whenever you expect to be in contact with any body fluids, a contaminated surface, open wounds or whenever performing any kind of procedure involving blood or any other body fluids.
• The latex glove is the norm in the healthcare field; however, you can also use vinyl gloves if you find that you are allergic to latex.

To Put On

1. Wash hands.
2. Grasp the gloves by the cuff and slip them on without any special technique.

To Take Off

1. Grasp the palm of a used glove with one hand to begin removing the first glove.
2. Keep your hands away from the body and pointed downward.
3. Turn the used first glove inside out and hold it in the other hand.
4. Holding the removed glove in the palm of the still-gloved hand, insert two fingers of the ungloved hand inside the dirty glove.
5. Peel the dirty glove downward, turning it inside out over the balled glove in your palm.
6. Note that one glove is inside the other with all contaminated surfaces inside.
7. Throw the gloves away.
8. Wash hands.

Proper Sterile Gloving

• Sterile gloves are free from all microorganisms.
• Required for any invasive procedure and when contact with any sterile site, tissue or body cavity is expected.
• Help prevent surgical site infections and reduce the risk of exposure to blood and body fluid pathogens for the healthcare professionals.

Steps to Take: Proper Sterile Gloving

1. Perform surgical handwash.
2. Inspect glove package for tears or stains.
3. Place glove package on open sterile surface above waist level.
4. Peel open the package, pulling it flat.
   • Do not touch inner sterile surface.
   • Be sure cuffs are toward you, palms up.
5. Grasp the inner cuff of one glove with index finger and thumb of the nondominant hand.
6. Pick the glove straight up without dragging it over any surface that is not sterile.
7. Slide dominant hand into glove, palm up and touching only the cuffed surface of the glove.
   • Keep hands above the waist.
8. With the newly gloved hand pick up the other glove by slipping fingers under the outside of the cuff.
   • Lift it up, keeping it away from the body.
9. Slip the second hand, palm up, into the glove.
10. Adjust gloves as needed without touching the wrist area.
    • Keep hands above the waist and away from the body.

What Is a Medical Emergency?

• An emergency describes any instance in which someone becomes ill or injured suddenly and requires immediate attention.
• Emergency medical care refers to the immediate care given to a sick or injured person.
• Your assistance could even help the patient to recover with only a temporary disability instead of a permanent injury!
• If an emergency occurs in your medical facility, it will be the responsibility of your team of healthcare professionals to help the patient recover, or to care for the patient until an ambulance or rescue squad arrives.

Basic Life Support Measures

• Basic Life Support (BLS) measures help a person who is at risk for respiratory arrest, cardiac arrest or both.
• Includes CPR, which stands for cardiopulmonary resuscitation; the primary method used to support blood flow to the heart and brain in cardiac arrest victims.
• BLS is used to keep a person alive until advanced medical assistance arrives.
• It is not a substitute for a doctor’s care. The American Heart Association made a change in the sequence of steps for CPR in 2010.