2. Patient’s personal information
Demographic information
Marital status, children, and living arrangements
Social habits
Occupation information
Medical history and family history
Medications
Testing performed
3. Maintains and documents the course of
patient care
Provider’s evaluation
Prescribed treatment
Responses to treatment
Provides for a continuity of care
Eliminates incompatible therapies, duplication of
efforts, or unnecessary expenses
Provides legal protection
Maximizes reimbursement
Helps conduct research
4. HIPAA Privacy Rule
HIPAA Security Rule
Ensures confidentiality of patient’s medical
record
Protects against use or disclosure of information
without the patient’s consent
All employees must comply with HIPAA
5. EMR
Electronic medical record
Electronic record of health-related information
for an individual that is created, gathered,
managed, and consulted by licensed clinicians
and staff that is maintained through a single
organization
6. EHR
Electronic health record
Aggregate electronic record of health-related
information on an individual that is created and
gathered cumulatively across more than one
health care organization
Often used interchangeably with “EMR”
7. PHR
Personal health record
Collection of medical records compiled and
maintained by the individual
8. Searchable databases
Results can be transmitted to different
providers and departments immediately
Legible prescriptions sent to pharmacy
immediately
Reminder systems for routine maintenance
and testing
9. Encourages coordination of care between
providers and departments
Plug-ins for voice recognition software to
decrease transcribing needs
Automatic CPT/ICD code assignment
Photo upload capabilities to ensure correct
patient is selected
10. Administrative Clinicaldata
data Progress notes
Financial and
Diagnostic information
insurance
Lab information
information
Medications
Correspondence
Referrals
Past medical
records
12. Subjective Objective
Provided by the Provided by the provider
patient and health care team
Routine information Vital signs
about the patient Exam findings
Chief complaint Diagnostic tests
14. All correspondence received by the medical
office
Referral or follow-up letters from specialists
In an EHR, these are scanned and uploaded
into the patient record
15. Records from previous providers or facilities
Release of information form
Ensures continuity of care
16. Arranged chronologically
Most recent note on top
Each entry is timed, dated, and signed
Medical office or provider will indicate
preferred format for progress notes
17. Imaging information
X-rays, MRIs, and many others
Lab reports
Critical values should be highlighted and
presented to the provider for review
18. Medications administered in the office
Complete documentation
Prescriptions
19. Problem-oriented medical record (POMR)
SOAP
Subjective, objective, assessment, plan
HPIP
History, physical exam, impression, plan
CHEDDAR
Chief complain, history, examination, details,
drugs/dosages, assessment, return visit
20. Generally the medical assistant files
three types of items:
Individual Previously
New
documents filed
patient
for patient
record
existing record
folders
folders folders
21. Place the files in the appropriate location for easy retrieval when
needed Storing
Place files in order to save time when storing Sorting
Add an identifying mark to ensure that Coding
the file is put in the correct place
Name the file using the office
classification system
Indexing
Make sure
document is
Inspecting
ready to
be filed
23. With alphabetic filing systems
Each letter is assigned a color
The first two letters of the last name are color-
coded with colored tabs
Can easily tell if files are filed correctly
File these in the correct order:
Allen, E.S.
Allen, William C.
Allard, Wm.
Allens, M.R.
Allen, Edna
24. With numeric filing systems
Numbers 1 to 9 assigned a distinct color
Helps identify numeric files that are out of place
File these in the correct order:
02-17-25
12-25-35
08-17-35
10-07-25
26. Tickler files
Reminder files
Check on a regular basis
Organizedby month, week
of month or day of week
Computers systems offer tickler files in
the form of a calendar
Reminders set to alert prior to event
27. Take a close look at the contents of patient
records each time you pull or file them
Keep files neat
Do not overstuff file folders
Papers should not extend beyond edge of folder
Remove file from drawer when adding
documents
Prevents damage to documents
28. Determine where the file was when last seen or used
Look for the file while retracing steps from that
location
Check filing cabinet where it belongs
Check neighboring files
Check underneath files in drawer or on shelf
Check items to be filed
Check with other staff members
Check other file locations
Similar indexes
Under patient’s first name
Misfiled chart color
29. Ask if someone inadvertently picked up the
file with other materials
Haveanother person complete the steps to
double-check your search
Straighten the office, carefully checking all
piles of information
30. Active files are files that you use frequently
Inactive
files are files that you use
infrequently
Closed files
Files of patients that no longer consult the office
The physician determines when a file is deemed
inactive or closed
31. Certain records have legal criteria for the
length they must be maintained in the
office, such as
Immunizations
Employee health records
Medical office financial records
Criteria from
IRS – financial records
AMA, American Hospital Association
HIPAA law
Federal and state laws
32. Paper Microfilm Computer
Storage Storage
Basic
Storage
Options
Microfilm, microfiche and filmformat
Files remain in their original cartridges offer
Patient records can be scanned and saved on
a paperless way of storing records. DVDs, flash
computer boxes recordable CDs even stacking
Labeled tapes, with lids to allowor
drives, paper becomes brittle, transfer
If theor external hard drives.
documents to
another storage medium.
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33. Some offices have extra storage space on-site
Smaller offices require the use of off-site storage
Use a facility that takes precautions against fires and
floods
Maintain a list of all files stored at off-site locations
Inactive and closed files must remain safe and
secure
Evaluate storage sites carefully
Preferably place files in fireproof and
waterproof containers
The storage site should be safe from
Fire and floods
Vandalism and theft
Extremes of temperature