Medical Records: Documentation and Importance

• Accountability sustained by adversity.

Chapter Objectives

• Definition and purpose of medical records
• Characteristics of proper documentation (FLOAT)
• Information within medical records
• Medical record ownership
• The Privacy Act of 1974
• Advantages of medical record information
• Advantages and disadvantages of a national electronic medical records system
• Two medical charting methods

Key Terms

• Electronic Medical Record (EMR)
• Fidelity
• FLOAT
• Hopper
• The Joint Commission (TJC)
• Meaningful Use
• Regulations
• Medical Record
• Narrative Charting Method
• SOAP Charting Method
• Subpoena duces tecum

The Medical Record

• A medical record is a written story of a patient's medical history.

• Medical records let physicians:

• Assess family medical history

• Compare progress in treatment

• Prescribe treatment plans

• Offer advice

• Refer to specialists

• Manage hospitalization

• Manage information for legal system use

• Patient history includes:

• Introductions

• Explanations of provider roles

• Questions include:

• What brings you in today?

• When did it start?

• Was the onset sudden or gradual?

• Have you ever had this before?

• Can you describe it?

• Does anything make it worse?

• Does anything make it better?

• Do you have shortness of breath?

• Any fever or chills?

• Any headache or sinus congestion/pressure?

• Any visual changes?

• Any ear pain?

• Do you have a cough?

• Other medical conditions?

• Information on:

• Medications

• Allergies

• Social history

• Menstrual history

• Surgical/Hospital history

• Physical exam:

• Includes the information that the exam is about to begin

• Practitioner washes hands for 15 seconds

• Vitals:

• Include repeated measurements if needed

• General health:

• Assessment

• Skin conditions

• Head/Sinuses:

• Involves inspection and palpation

• Eyes:

• Inspection

• Nose:

• Inspection

• Ears:

• Inspection

• Mouth/Throat:

• Inspection

• Neck/Lymph:

• Inspection and palpation

• Lungs:

• Auscultation to check for clear sounds

• Cardiac:

• Auscultation to check aortic, pulmonic, tricuspid, and mitral functions

• Abdomen:

• Palpation

• Assessment:

• Gives three things in the differential diagnosis, including URI

• Plan:

• Explains likely etiology

• Includes supportive therapy, throat culture, increase fluids, and rest

• Doctors ask patients and family members for more suggestions or questions

• Display professionalism and empathy with patients

The Hopper

• "Hoppers" switch between doctors
• This could be due to dissatisfaction, because of money owed, or to seek prescriptions
• Standardized electronic medical records could eliminate hoppers

Medical Records as Legal Documents

• Used as primary evidence in lawsuits.
• Documentation can win or lose legal cases

Qualities of a Medical Record (FLOAT)

• Factual:

• The information must be fact-based.

• Information is reviewed and may be presented as evidence.

• If something is not documented, then it did not happen.

• Waiting to record a procedure until after it is completed

• Legible:

• Poor handwriting can lead to misinterpretations.

• Medical record entries should be in blue or black ink.

• Never use pencil or colored/erasable ink.

• Physicians are using preprinted forms for saving time and addressing legibility issues

• Objective:

• The word objective means impartiality and fairness.

• Personal opinions have no place within the medical record.

• Instead, state what was offered and whether it was accepted

• Accurate:

• Health can improve/decline depending on the accuracy within the record

• Spelling and grammar are just as crucial as information

• Always double-check records before documenting anything

• There are numerous abbreviations that some may confuse

• Timely:

• Timeliness is essential in medical accountability

• Notes should be made immediately to ensure the most accurate information.

• A late entry/addendum may be needed if one cannot enter the information in a timely manner

The Joint Commission (TJC)

• The Joint Commission accredits US healthcare organizations since 1951.
• Continually improves healthcare by reviewing organizations and inspiring excellence.
• It has a "Gold Seal of Approval"
• It reviews hospitals, dental offices, nursing homes, clinics, surgery facilities, and urgent care facilities.
• Organizations undergo on-site surveys every 3 years (laboratories every 2 years)

Contents of Medical Records

• Entries should be dated and initialed.
• Includes insurance details such as the provider name and contact information
• Contains patient's personal information (address, phone number, etc.)
• HIPAA forms
• Imaging, lab work, and surgery records
• Complete medical history
• Notes and charts by healthcare providers
• Communication logs
• Dates of appointments and missed appointments
• Dated telephone conversations
• Plans of action (diagnoses, hospitalization, referrals, therapy, prescriptions, etc.)

Correcting Medical Records

• When a mistake is made, draw a line through it, then initial and date it.
• This allows for a former statement to still be seen if there is any discrepancy.
• Correction methods depend on employer

Types of Medical Charting

• The Narrative Method:

• Thorough but concise documentation.

• May present difficulties in deciphering information.

• Progress notes are a part of this method

• The SOAP Method:

• Produces a consistent record

• Subjective: The patient’s chief complaints

• Objective: Healthcare professional’s findings through examination and conversation

• Assessment: Conclusions based on subjective and objective information

• Plan of Action: Treatment based on conclusions

• Records are easily categorized.

Sending Medical Information

• Medical records should be protected.

• The preferred method is through registered mail/reliable delivery with signature.

• Faxing requires great care for medical information

• E-mail is like faxing

• Some states prohibit faxing

• Sending e-mail is risky

• Verify request legitimacy when information is requested

• Have a release of information signed by both physician and patient

• Those receiving should be available at the fax machine

• Only send what is requested

• "Subpoena duces tecum" means "bring with you under penalty of punishment"

• Confirm the fax number before sending

• Use a cover sheet marked "Confidential" with:

• Date and time, and number of pages

• Sender information

• Recipient information

• Request for receipt notification

• Patient's name on each page

Sharing Medical Information

• HIPAA protects patients medical information

• Some exceptions exist, but the patient usually decides on personal medical information sharing

• Employers only need a doctor's note, not details

• Contagious diseases are an exception:

• The CDC has a list for sharable contagious conditions

Infections Diseases Designated as Notifiable at the National Level During 2015

• Anthrax
• Arboviral diseases
• Babesiosis
• Botulism
• Brucellosis
• Campylobacteriosis
• Chancroid
• Chlamydia trachomatis infection
• Cholera
• Coccidioidomycosis
• Cryptosporidiosis
• Cyclosporiasis
• Dengue virus infections
• Diphtheria
• Ehrlichiosis and anaplasmosis
• And numerous other infections

Electronic Medical Records (EMR)

• Electronic version of a medical record available by computer

• Digitalizing medical records was controversial initially, but is now commonplace

• Healthcare providers take preventative measures to ensure security and confidentiality

• National medical registry not yet established

• The CDC states 87% of office based physicians use electronic medical records

• This is now seen as a convenient, legible way to document patient information.

• This allows healthcare professionals to easily share information in real time.

• The EMR System has Vulnerabilities:

• Altered records can jeopardize patient health.

• Computer systems could fall prey to intruders.

• Spelling mistakes/ innacurate entries

• EMRs are required for all healthcare facilities

• The US federal government mandated “meaningful use” in 2015

Ethical Considerations of the EMR

• Autonomy:

• Patients can make their own healthcare decisions.

• In an emergency, can the patient decide viewers of the EMR?

• Trust:

• Patients might withhold information if they are afraid it will be leaked

• The type of withheld information is pain level and disability

• Justice:

• Will all people have access to EMRs?

• What about the poor or non-English speakers?

• Fidelity:

• It means loyalty.

• Is fidelity questioned if records are mistaked or hacked?

• The patient might hesitate when seeking medical treatment

American Medical Association Statement: E-7.05 Retention of Medical Records

• Physicians must retain patient records that may reasonably be of value.

• Medical considerations are the primary basis for deciding how long to retain medical records.

• Guidelines Include:

• Operative notes and chemotherapy records should be part of the patient's chart

• State laws and state licensing board regulations regarding record keeping must be obeyed

• Records should be kept for the length of time of the statute of limitations for medical malpractice claims.

• Time should be measured from the last professional contact with the patient.

• The statute of limitations for minors may not apply until they reach the age of majority.

• Immunization records must always be kept.

• Patient records need to be kept if covered by Medicare or Medicaid for at least five years.

• Documents should be destroyed and patients should have a chance to retrieve records.

Electronic Health Records Incentive Programs

• Medicare and Medicaid offer financial incentives to become certified in electronic or online records (EMR).

• Otherwise called MUR, or Meaningful Use Regulations, goals are focused on providing and maintaining electronic data

• Three Stages to MUR certification:

• Stage 1: Addresses requirements for data collecting. Also covers providing patients electronic copies of their health information.

• Stage 2: Addresses clinical processes and ensures EHR use is used to support aims and priorities of national quality strategy.

• Stage 3: Addresses Health Outcomes

• Requirements of meaningful use must be met for 90 days for the first year and the whole second one. Then the standards from stage 2 must be met for another 2. Stage 3 demonstrates expanded EHR.

Putting It All Together

• Key mnemonic for the medical record is FLOAT: Factual, Legible, Objective, Accurate, and Timely.
• Never blot out and alter entries: instead, use a single line through the word, then date and initial as per company policy
• Never use red ink, other colors, or pencils
• Altering official medical records is illegal
• As most records are now digital, readability is a lesser concern
• Remember, everyone makes mistakes!