The Medical Record

Accountability: The Medical Record

• Adversity is the most powerful sustainer of accountability.

Chapter Objectives

• Details regarding the definition and purpose of medical records
• Describes characteristics of proper documentation (FLOAT)
• Describes the information that should be contained in medical records
• Details medical record ownership
• Mentions the Privacy Act of 1974
• Includes the advantages of medical record information
• Outlines the advantages and disadvantages of a national electronic medical records system
• Includes two types of 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

• The medical record is a written story of a patient's medical history.
• It enables the physician to assess family medical history.
• Allows comparison of progress or regression in treatment.
• Permits prescription of appropriate treatment plans.
• Allows physician to offer appropriate advice.
• Enables referrals to specialists.
• Allows for management of hospitalization, if necessary.
• Manages information that could be used in the legal system.

Factual

• Medical records must be factual because they may be reviewed and presented as evidence in legal cases.
• The phrase "not recorded . . . did not happen” will be enforced.
• Record procedures only after they have been completed.

Legible

• Medical record entries should be done in blue or black ink only.
• Writing should be legible to ensure patient information is accurately assessed.
• Physicians often use preprinted forms to save time and improve legibility.
• Physicians must provide the time, date, and authenticate the information for preprinted forms.
• Authentication of electronic medical record entries may include written signatures, initials, computer key, or other code.
• Electronic Medical Records (EMR) have largely eliminated illegible handwriting.

Objective

• Information in medical records should be impartial and fair.
• Personal opinions have no place in the medical record.
• Proper documentation should state what was offered and whether it was accepted.
• Terms such as “disagreeable” are subjective and should not be used.
• Terms such as “every” or “never” are rarely true.

Accurate

• Medical record accuracy could mean the difference between improved health and a life-threatening situation for a patient.
• Always double-check to assure that you have the correct medical record before beginning to document.
• The use of abbreviations is a controversial issue in charting as many abbreviations can be confused.
• Healthcare facilities should have an approved list of abbreviations on file.

Timely

• Documenting notes immediately ensures the most accurate information.
• According to the American Health Information Management Association, a late entry or addendum may be added if information cannot be entered in a timely manner.
• Do not confuse a late entry or addendum with unethical information added to enhance a medical record for court use.
• Unethical practices of adding information can result in punishment.

The Joint Commission

• The Joint Commission (TJC) is a not-for-profit agency established in 1951.
• It is an accreditation agency in the United States that reviews patient documentation.
• The mission is to improve healthcare for the public by evaluating health care organizations.
• TJC evaluates dental offices, nursing homes, clinics, surgery facilities, and urgent care facilities.
• An organization must undergo an on-site survey by a Joint Commission survey team at least every 3 years to earn and maintain TJC's “Gold Seal of Approval."
• Laboratories must be surveyed every 2 years.
• A TJC representative is there to suggest improvements according to Gold Seal of Approval standards.

Contents of the Medical Record

• Each entry is dated and initialed by the person recording the information.
• Insurance information including provider name and contact information
• The patient's personal information including address, phone number, and social security number
• HIPAA forms
• X-rays, lab work, and surgery records
• Medical history including chief complaints and family medical history
• Notes and charts recorded by the physician, physician assistant, nurse practitioner, or nurse
• Communications between healthcare providers
• Dates and times of appointments, and a record of missed appointments
• Dated telephone conversations between office staff or physician
• Plans of actions/treatment plans relating to diagnoses, hospitalization, referrals, treatments, therapy, prescriptions, etc.

Correcting the Medical Record

• When making a mistake in a traditional medical record, never use correction fluid or erase the entry.
• Instead, draw a thin line through the mistake, write initials, and date above the line.
• Corrections on electronic medical records depend on the specific system being used.

Types of Medical Record Charting

• Two common methods of medical charting are the narrative method and the SOAP method.

The Narrative Method

• It consists of thorough but concise documentation.
• This method can be difficult to decipher patient information and to fit all the information together to make decisions about patient care.
• Progress notes are often a part of this method.

The SOAP Method

• It often produces a more consistent record.
• SOAP is a mnemonic for the sections included in the record:
  • Subjective: The patient's chief complaints.
  • Objective: The healthcare professional's observations and findings through examination and conversation.
  • Assessment: Conclusions based on the subjective and objective information.
  • Plan of action: The treatment that is advised based on the conclusions.
• Entries are easy to track throughout the record, which saves time for the physician(s) reviewing it.

Sending Out Medical Information

• A patient's medical record should be carefully handled to protect the confidential nature of information contained in it.
• The preferred delivery method is through registered mail or a reliable delivery service where a signature is required.
• Faxing should only be used when information is needed immediately or when other communication avenues are not feasible.
• Faxing should be used only with proper documentation of permission.
• Some states prohibit faxing medical information.
• Sending medical information by e-mail is risky, as unauthorized persons may view it.
• Tips for faxing medical information:
  • Verify if the information is going to a healthcare provider or is being sent because of a court order.
  • Ensure information has a release of information signed by the physician and the patient. -Ensure the recipient will be at the fax machine to receive the information.
  • Only send the portion of the record requested, also known as subpoena duces tecum.
  • Always verify that the fax number is correct.
  • Include a cover sheet marked “Confidential” with the date and time of transmission, number of pages, sender and recipient information, request for notification of receipt, and the patient's name on each page.

Sharing a Patient's Medical Information

• Every patient has the right to medical information protection, as specified by the Health Insurance Portability and Accountability Act (HIPAA).
• Exceptions exist, but the patient decides who sees their medical information.
• If a patient has a contagious condition listed by the Centers for Disease Control and Prevention (CDC) as sharable, details of the condition must be shared with the local Health Department.
• There are times when it is not good for the patient to have access to his or her own medical record.

Ethical Considerations of the EMR

• Autonomy: In emergency cases where EMR is accessible to all hospitals, does the patient still have the autonomy to decide who can view the EMR?
• Trust: If a patient fears the EMR might fall into the wrong hands, that patient might be less likely to fully disclose health information.
• Justice: Should EMRs consider equity among all patients, including those of lower socioeconomic status and those who do not speak English?
• Fidelity: Is fidelity to be questioned if the record is susceptible to documentation mistakes and thievery (hackers)?
• If the patient feels compromised in regard to the above ethical principles, might they hesitate in seeking medical treatment?

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

• Physicians must retain patient records that may be of value to a patient.
• Medical considerations are the primary basis for deciding how long to retain medical records.
• Check state laws to see if there is a requirement that records be kept for a minimum amount of time, if a particular record is no longer needed for medical reasons.
• Medical records should be kept for as long as the statute of limitations for medical malpractice claims.
• A physician should measure time from the last professional contact with the patient.
• The statute of limitations for medical malpractice claims may not apply until a minor patient reaches the age of majority.
• Immunization records always must be kept.
• Records of any patient covered by Medicare or Medicaid must be kept for at least five years.
• All documents should be destroyed to preserve confidentiality when discarding old records.
• Before discarding old records, patients should be given an opportunity to claim the records or have them sent to another physician.

Electronic Health Records Incentive Programs

• Medicine and Medicaid, through the centers for Medicare and Medicaid services (CMS), offer financial incentives to healthcare providers and facilities to become certified in electronic/online records (EMR).
• The goal is to teach the facility to provide and maintain a high standard of electronic data entry and usage through Meaningful Use Regulations (MUR).
• Three stages to MUR certification:
• Stage 1: Data acquisition and providing patients with electronic copies of their health information.
• Stage 2: Advancing clinical processes, ensuring the meaningful use of EHRs supports the aims and priorities of National Quality Strategy, and exchange of information.
• Stage 3: Addresses health outcomes.
• Participation must meet Stage 1 requirements of meaningful use for 90 days of the first year and a full year of the second year.
• Participants must meet Stage 2 requirements for two full years.
• Stage 3 requires demonstrating advanced use of EHR technology to promote health information exchange and improved outcomes for patients.

Putting It All Together

• The medical record contains vital information about the patient and aids the healthcare team in providing the care.
• A well-maintained medical record includes:
  • factual
  • legible
  • objective
  • accurate
  • timely
• Never erase original entries.
• Instead, draw a line through the entry and make the correction, then date and initial the new entry.
• Always use black or blue ink.
• The medical record is considered a legal document. The EMR has largely eliminated the issues with legibility, however human error can still affect the EMR.