Module 3 Understanding Medical Records

Learning Objectives

• Participants will be able to define medical records.
• Participants will be able to state the key purposes of patient records.
• Participants will be able to identify the main sections of medical records, and practice patient identification.
• Participants will understand the correct procedure for issuing medical record numbers
• Participants will understand the content of a medical record

Medical Record Definition

• A chronological written account of a patient's examination and treatment including the patient's medical history and complaints
• Physician's physical findings
• The results of diagnostic tests and procedures
• Medications and therapeutic procedures are recorded in a medical record.
• Medical Dictionary 2007

Key Purposes of Patient Records

• They provide the documented basis for planning patient care and treatment
• They offer a means of communication between various providers
• They are the primary evidence for what took place during the episode of care.
• "If it was not documented, it was not done."
• They are used for billing and reimbursement
• Provide documentation patients and payers use to verify billed services
• Insurance companies and other third-party payers use them
• They are used for research purposes and monitoring the quality of care provided
• Records monitor population health.
• Measure utilization of services, and evaluate adherence to evidence-based practice guidelines

Main Sections of Medical Records

Administrative

• Includes demographic and socioeconomic data, such as the patient's name (identification), date of birth, place of birth, and permanent address
• Includes the medical record number

Legal Data

• It has a signed consent for treatment by appointed doctors
• Authorization for the release of information

Financial Data

• Has information relating to the payment of fees for medical services.
• Includes payment for hospital services

Clinical Data

• Confirms if a person's medical record is whether they were admitted to the hospital.
• Notes if they were treated as outpatients
• Asserts if they were an emergency patient

Patient Identification

• Accurate identification of a patient is the backbone of an effective and efficient medical record system.
• Correct identification is needed to positively identify patients.
• Every single patient has one medical record number and one medical record.
• Identifying patients means being able to find a patient's medical record whenever they come to the health care facility
• It also means that a patient's previous admission can be linked to the current admission using the medical record number.
• Clerks interview patients in the outpatient department or admission office, and thus are responsible for correctly identifying patients.
• Clerks ask accompanying patients questions and are responsible for giving the necessary information if the patient is unable to

Unique Patient Characteristics

• It is something about a patient that does not change, such as the patient's national number, health insurance number, or, in the case of a newborn, a biological characteristic like a fingerprint or footprint.
• The medical record umber can be a unique patient characteristic
• A patient's age is not unique, as it does change
• Where a person lives is not unique because it can change.
• A patient's place of birth is not unique, as most people live in a different part of the country to where they were born

Medical Record Number

• Effective patient identification is the beginning of an efficient medical record system
• Once a patient has been identified, the next step is to identify their medical record.
• Collecting patient identification data, assigning a medical-record number, or verifying an existing medical record number should be the first step in every admission procedure.
• The patient is given the number when they first attend the hospital
• The number is used during current admissions to identify patients.
• The number is a permanent identification number assigned in straight numerical sequence by the admission staff.
• The MRN is recorded on all medical record forms relating to that particular patient.is record number

Medical Record Number Procedure

• The MRN should start at number one (1)
• The MRN should progress in order
• The MRN is only for one patient
• The record should only apply once for a patient in their life.
• 342 is the most recent number issued, the following issued number should be 343 and 344
• The number is issued for life
• The number should not be pre-assigned, and not be issued again, not even if the patient is dead
• One patient should have ONE medical record

Content of Medical Record

• Components are common to most patient records
• Contents can be electronic or paper-based, depending on the facility type
• Patient records contain a variety of clinical data and information involved in the care of the patient.
• The identification sheet is generally the first report or screen a user will encounter when accessing a patient record, and is both a clinical and administrative document.
• Diagnoses are recorded by physicians and coded by administrative personnel. The codes and other demographic information are used for reimbursement and planning purposes.
• Problem lists list significant illnesses and operations patients have experienced, and are maintained over time. They are not specific to a single episode of care: they are maintained by attending or primary care physicians, or collectively by all the health care providers involved in the patient's care.

Specific Records

• Medications prescribed and subsequently administered to a patient, with any medication allergies the patient may have.
• Nursing staff are responsible for documentation and maintenance of patient records. Nurses are responsible for administering medications, according to physician's orders.

History and Physical

• History is provided by the patient and is documented by an attending physician.
• Describes any major illnesses and surgeries the patient has had.
• Asses for any significant family history of disease, patient health habits, and current medications
• States what the physician found when a hands-on examination was performed

Progress Notes

• Reflect the patient's response to treatment.
• Includes the provider's observations and plans for continued treatment.
• The notes are made by physicians, nurses, therapists, social workers and other clinical staff.
• Each provider is responsible for the information in their notes.

Consultation

• Notes or reports record opinions about patient's condition made by a health care provider, other than the attending physician.
• Reports come from physicians and others working inside or outside a particular health care organization.

Attending Physicians

• They have medicine residences and specialties in hospitals

Physcian's Orders

• Physician's orders are a physician's directions, instructions, or prescriptions given to other members of the health care team

Health Care

• It is a system where procedures and treatments must be ordered by the correct practitioner

Radiological Reports and Imaging

• A radiologist is responsible for interpreting mammograms, ultrasounds, and scans
• They document their findings
• The findings are in timely manner for physicians to treat patients

Actual Images

• They are maintained in departments for hard copies, not maintained like medical records
• They are important documents

Lab Results

• There are specific tests like Urinalysis, cholesterol level, or complete blood count
• There are tests where personnel document results
• Also the results are permanent for patients

Healthcare Provider Reliabilty

• Needs timely and responsible care during the time system is undergoing
• All results are in with treatment

Consent Form

• Practitioner Provides Treatment for authorization records