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The Medical Record, Documentation,
             and Filing
 Patient’s   personal information
     Demographic information
     Marital status, children, and living arrangements
     Social habits
     Occupation information
 Medical    history and family history
     Medications
     Testing performed
 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
 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
 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
 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”
 PHR
    Personal health record
    Collection of medical records compiled and
     maintained by the individual
 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
 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
 Administrative    Clinicaldata
  data              Progress notes
 Financial and
                    Diagnostic information
  insurance
                    Lab information
  information
                    Medications
 Correspondence
 Referrals
 Past medical
  records
Ch. 13ppt
 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
 Demographics
 HIPAA Notice of Privacy Practices
 Insurance information
 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
 Records   from previous providers or facilities
    Release of information form
    Ensures continuity of care
 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
 Imaging   information
    X-rays, MRIs, and many others
 Lab   reports
    Critical values should be highlighted and
     presented to the provider for review
 Medications   administered in the office
     Complete documentation
 Prescriptions
 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
Generally the medical assistant files
 three types of items:


               Individual    Previously
     New
               documents        filed
    patient
                   for        patient
    record
                existing       record
    folders
                 folders      folders
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
 Alphabetic
 Numeric
 Subject
 Geographic
 Chonologic
 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
 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
 Inventory
 Copies of orders
 Financial Records
 Tax records
 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
   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
   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
 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
 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
 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
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.
                        10-32
 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

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Ch. 13ppt

  • 1. The Medical Record, Documentation, and Filing
  • 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
  • 13.  Demographics  HIPAA Notice of Privacy Practices  Insurance information
  • 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
  • 22.  Alphabetic  Numeric  Subject  Geographic  Chonologic
  • 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
  • 25.  Inventory  Copies of orders  Financial Records  Tax records
  • 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. 10-32
  • 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