Medical assisting Administrative and clinical procedures (5e) Chapter 11

CHAPTER

11
Medical Records
and Documentation


11-2

Learning Outcomes (cont.)
11.1 Explain the importance of patient medical
records.
11.2 Identify the documents that comprise a
patient medical record.
11.3 Compare SOMR, POMR, SOAP, and
CHEDDAR medical record formats.
11.4 Identify the six Cs of charting, giving an
example of each.


11-3

Learning Outcomes (cont.)
11.5 Describe the need for neatness, timeliness,
accuracy, and professional tone in patient
records.
11.6 Illustrate the correct procedure for correcting
and updating a medical record.
11.7 Describe the steps in responding to a written
request for release of medical records.

11-4

Introduction
• Medical assistants role regarding patient
health records
– Documentation
– Maintenance

• Medical records – critical to patient care
– Evaluation
– Management
– Treatment


11-5

The Importance of Medical Records
• Past medical history and present condition
• Communication tool for healthcare team
• Legal documentation
• Patient and staff education
• Quality control and
research
• Documentation for
billing and coding


11-6

Importance of Patient Records (cont.)
• General information
– Contact information
– Occupation
– Medical history
– Current complaint
– Healthcare needs
– Treatment plan or services provided
– Radiology and laboratory reports
– Response to care


11-7

Legal Guidelines for Patient Records
• Support a malpractice claim
• Support defense for a malpractice claim
• Back up financial records
• Documentation
– Medical care, evaluation and instructions
– Noncompliant patient


11-8

Standards for Records
• Evidence of appropriate care
– Complete
– Accurate

• Everyone who documents in the patient
record has a responsibility to the patient
and physician


11-9

Additional Uses of Patient Records
Patient
Education
• Test results
• Health issues
• Treatment
instructions

Quality of
Treatment
Research

• Peer review

Source of data

• TJC review
• Health-care
analysis and
policy decisions


11-10

Apply Your Knowledge
What is the purpose of documentation in a patient’s
medical record?
ANSWER: Documentation in the medical record
provides evidence of appropriate care. If a
procedure is not documented, it is considered not
done.


11-11

Contents of Patient Medical Records
Patient Registration Form


Date



Patient demographic information


Age, DOB



Address, phone number



SSN



Insurance/financial information



Emergency contact


11-12

Contents of Patient Medical Records (cont.)
• Patient medical history
– Past medical history
– Family medical history
– Social and occupational history
– History of present illness (chief complaint)


11-13

Contents of Patient Medical Records (cont.)
• Physical examination results
– Review of systems
– Form ensures consistency

• Results of laboratory and other tests

• Documents from
Other Sources


11-14

Contents of Patient Medical Records (cont.)
• Doctor’s diagnosis and treatment plan
– Treatment options and plan
– Instructions
– Medication prescribed
– Comments or impressions

• Operative reports, follow-up visits, and
telephone calls


11-15

Contents of Patient Medical Records (cont.)
• Hospital discharge summary forms
• Consent forms
– Verify that the patient understands
procedures, outcomes, and options
– Patient may withdraw consent at any time


11-16

Contents of Patient Medical Records (cont.)

• Correspondence with or about the patient
• Information received by fax – request an
original copy
• Date and initial everything you place in the
chart


11-17

Maintaining Confidentiality
1. The right to notice of privacy practices.
2. The right to limit or request restriction on
their PHI and its use and disclosure.
3. The right to confidential communications.


11-18

Maintaining Confidentiality (cont.)
4. The right to inspect and obtain a copy of
their PHI.
5. The right to request an amendment to
their PHI.
6. The right to know if their PHI has been
disclosed and why.


11-19

Apply Your Knowledge

What section of the patient record contains
information about smoking, alcohol use, and
occupation?
ANSWER: Information about smoking, alcohol use,
and occupation is part of the patient’s past medical
history.


11-20

Types of Medical Records
• Source-Oriented Medical Records
– Information is arranged according to who
supplied the data
– Problems and treatments are on the same
form
– Difficult to track progress of specific events


11-21

Types of Medical Records (cont.)
• Problem-Oriented Medical Records
– Data Base
– Problem List
• Each problem numbered
• Sign vs. symptom

– An Educational, Diagnostic, and Treatment
Plan per each problem

– Progress Notes


11-22

Types of Medical Records (cont.)
• SOAP documentation
– Orderly series of steps for dealing with any
medical case
– Lists the following
• Patient symptoms
• Diagnosis
• Suggested treatment


11-23

SOAP Documentation
Information the patient tells you

ubjective data

bjective data

ssessment

lan

What the physician observes during
the examination

The impression of the patient’s
problem that leads to diagnosis

The treatment plan to correct the
illness or problem


11-24

CHEDDAR Format
• Expands on SOAP format
C

Chief complaint, presenting problems, subjective
statements

H

History – social and physical history

D

Examination


11-25

CHEDDAR Format
• Expands on SOAP format

D

Drugs and dosage

A

Assessment of diagnostic process and diagnosis

R

Return visit information or referral