Medical Office Administration 2nd edition

Medical Office Administration2nd edition Brenda A. Potter, CPC

Chapter 9 Health Information Management

What is Health Information Management? • Directing activities that relate to keeping patients’ medical information • Maintaining medical records • Preparing medical reports • Releasing medical information • Compiling statistics • Coding for billing and insurance

Purposes of Recordkeeping • Documentation of care given to patient • Legal purposes • Documentation for insurance claims • Data used in planning for healthcare services • Education and research

Types of Records • Paper • Electronic • EHR – electronic health record (preferred by AHIMA) • CPR – computerized patient record • EMR – electronic medical record • EPR – electronic patient record

Confidentiality • All information seen, heard, and done must be kept confidential • Releasing information without permission is breach of confidentiality

Confidentiality Agreements • All employees and volunteers should be required to sign confidentiality agreements

Confidentiality and Computerized Records • Portion or entire record can be stored on a computer • Computer systems must be protected

Health Insurance Portability and Accountability Act of 1996 (HIPAA) • Regulation includes • Requirements for protecting information • Patient’s right to know how information is used • Patient’s right to a copy of his/her record • Restrictions on using information • Civil and criminal penalties for violations

Notice of Privacy Practices • Written notice detailing how the healthcare provider responsibilities pertaining to the patient’s health information • Sign and dated by patient and retained by provider

Components of the Medical Record in a Medical Office • Summary sheet • Medical history • Progress notes • SOAP note • Chart note • Chart entries • Medication list • Immunization record

Laboratory report • Pathology report • Radiology report • Other specialized documents • Pediatric growth chart • Pregnancy flow sheet • EKGs, EEGs, EMGs • Photographs, CDs, DVDs • Correspondence

Entering Information in a Patient’s Record • Specific guidelines should detail • Who may document information in a patient’s record • What type of information should be documented • In a paper record • Do not leave large gaps in progress notes section • Handwritten entries done in black ink

Hospital Records • History and Physical (H&P) • Operative report • Discharge summary

Corrections in Records • Person making the mistake should correct the entry • Do not obliterate information • Electronic records may require an entirely new entry to correct a mistake

Medical Transcription • Production of a typewritten report from physician’s dictation • Dictation saves time for a physician • Transcription is more legible compared to handwriting • Transcriptionists are medical language experts

Transcription Equipment • Digital equipment is the norm • Tapes are outdated

Signature • Reports and other documents placed in a patient’s chart must be signed or initialed by patient’s physician • Signature or initials verify that physician has reviewed documents • Electronic signatures used for electronic reports

Organizing Medical Record • Source-oriented (SOMR) • Similar information is kept together • Most commonly used • Problem-oriented (POMR) • Information pertaining to a specific problem is grouped together

Chart Order • Dividers can separate sections of a chart • Each office should establish specific chart order

Documentation Guidelines • A Joint Commission requirement • Medicare 1995 documentation guidelines • Use of abbreviations • Dangerous abbreviations

What Does Not Belong in the Record • A report without a physician's signature or initials – EVEN normal lab results • Information regarding a patient’s financial status • Callous remarks about a patient

Records Flow • Chart is pulled for appointment • When patient is placed in exam room, chart is placed outside door • Nurse records vital signs in chart • Physician brings chart into exam room • Chart returned to records room after visit

Quantitative Analysis • Verifies that all essential information is in chart • Incomplete records should not be filed • Deficiency form

Filing Supplies • Charts – durable heavy-stock folder • Labels – numeric or alpha • Outguides – hold place of record

Filing Methods • Filing should be kept up-to-date for easy retrieval of records • Numerical system • Accession ledger – tracks each chart number as assigned • Alphabetical system • Alphanumeric system

Consecutive Number Filing • Charts filed from lowest to highest number • Easy to learn • Numbers may be transposed • Master patient index for numeric systems requires knowledge of alpha filing rules

Terminal Digit Filing • Chart number broken into groups of numbers • Chart #145365 becomes 14 53 65 • 65 – primary unit • 53 – secondary unit • 14 – tertiary unit

Alphanumeric System • Combination of letters and numbers

Alphabetical Filing • Offices should adopt one set of rules • Every name indexed: last name, first name, MI • Complete legal name should be obtained – no nicknames • Abbreviations indexed as spelled out • Identical names filed with oldest DBO first • Nothing comes before something • Prefixes are included with name • Punctuation is disregarded • Professional and religious titles disregarded • Entry of names in computer system should be consistent • Cross-references important

Color Coding • Assigning a color to a letter or number • Reduces misfiles • Saves time when locating chart

Locating Missing Files • Check before and after the chart’s location and inside other nearby charts • Check all areas of office • Determine last department or individual who used the chart • Scan shelves for color out of place • Check areas behind shelves or drawers • If alpha filing, check other possible spellings for patient’s last name

Records Retention and Disposal • Verify state requirements for retention • Medicare requirements – minimum of 5 years after last visit • Minor records may have special requirements • Active record – current patient • Inactive record – patient has not received treatment in a specific period of time • Closed record – patient has died or moved away • Local obituaries should be checked with office’s patient database • Disposed records should be properly destroyed

Tickler File • File that reminds assistant of specific tasks • Electronic tickler files available in many computer calendar packages

File Storage and Protection • Lateral shelving is common and often works best • Shelving with pull-out drawers or file cabinets also used • Be aware of fire codes • Duty of medical office to protect records from destruction

Disaster Plan • Medical office is responsible for protecting records from destruction • Fire codes must be considered when setting up a records room • Fire suppression system • Computer backups

Multiple Locations • One chart may be shipped between locations • Each location may have separate chart • Electronic record ideal for multiple sites

Release of Information • Written documentation necessary to release information • In most instances, patient must authorize release information • Copy of release kept with patient’s record • Photocopies of records, not originals, are sent • Fax machines not encouraged for releasing information • Redisclosure – office cannot copy and release records received from another office • Release not required in some instances (small number of exceptions)

Ownership of Medical Record • Physician owns the paper • Patient owns the content • HIPAA standards – patient has a right to a copy of his or her record • Psychiatric records may not be released to patient

HIV and AIDS Records • Patients may be required to sign consent form for HIV testing • Take great care to protect record privacy • Patients may have to authorize listing the diagnosis on an insurance claim

Future of Health Records • Increased use of computers for health information activities

Medical Office Administration 2nd edition