Quality Assurance in Health Care - Lecture Notes PDF

Quality Assurance in Health Care Dr. Ayat Gamal El-Din Saied Dr. Saied Lecturer at Department of Neuromuscular disorders and its surgery. Objectives: Different between documentation, records & reports. Importance of patient medical record...

Quality Assurance in Health Care Dr. Ayat Gamal El-Din Saied Dr. Saied Lecturer at Department of Neuromuscular disorders and its surgery. Objectives: Different between documentation, records & reports. Importance of patient medical records. Compare SOMR, POMR, SOAP, and CHEDDAR medical record formats. Identify the six Cs. Describe the need for neatness, timeliness, accuracy, and professional tone in patient records. Illustrate the correct procedure for correcting and updating a medical record.  Documentation is  the process of communicating in written form about essential facts for the maintenance of continuous history of events over a period of time. Records is  the permanent written communication that documents information relevant to a client’s health care management. Reports  Summarizes the services of the person or personal and of the agency “Or are oral or written exchange of information”. Importance of records &reports Documentation 1- Communication 2- Planning Client Care 3- Auditing Health agencies 4- Research 5-Education 6- Reimbursement 7- Legal Documentation 8- Health Care Analysis Additional Uses of Patient Records Patient Quality of Education Treatment Test results Research Peer review Health issues TJC review Source of data Treatment Health-care instructions analysis and policy decisions  Standards for Records Evidence of appropriate care Complete Accurate Everyone who documents in the patient record has a responsibility to the patient and physician Who Write Records?? 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. 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 Records includes: 1. Admission and discharge records 2. History of physical examination 3. Progress notes 4. Physician's orders 5. Vital signs record 6. Graphic record 7. Nurses' notes Medical records Medical assistants role regarding patient health records Documentation Maintenance Medical records – critical to patient care Evaluation Management Treatment Contents of Patient Medical Records Patient Registration Form  Date  Patient demographic information  Age, DOB  Address, phone number  Insurance/financial information  Emergency contact 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) 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 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 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 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 Patient confidentiality Patient confidentiality is essential for successful doctor-patient relationships, improved health outcomes and personalized care. Healthcare providers must be familiar with legal frameworks and guidelines to ensure patient confidentiality. Securely handling and storing electronic health records, paper documents regarding patients, as well as disposing of such information appropriately Maintaining Confidentiality The right to notice of privacy practices. The right to limit or request restriction on health information and its use and disclosure. The right to confidential communications. Maintaining Confidentiality (cont.)  The right to inspect and obtain a copy of their PHI.  The right to request an amendment to their PHI.  The right to know if their PHI has been disclosed and why.  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. Types of Medical Records Source-Oriented Medical Records (SOMR) Information is arranged according to who supplied the data Problems and treatments are on the same form Difficult to track progress of specific events Types of Medical Records (cont.) Problem-Oriented Medical Records (POMR) Data Base Problem List Each problem numbered Sign vs. symptom An Educational, Diagnostic, and Treatment Plan per each problem Progress Notes 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 SOAP Documentation Information the patient tells you ubjective data What the physician observes during bjective data the examination The impression of the patient’s ssessment problem that leads to diagnosis The treatment plan to correct the illness or problem lan CHEDDAR Format Expands on SOAP format Chief complaint, presenting problems, subjective C statements H History – social and physical history D Examination CHEDDAR Format Expands on SOAP format D Drugs and dosage A Assessment of diagnostic process and diagnosis R Return visit information or referral Apply Your Knowledge Label the following items as either (S) “subjective” or (O) “objective.” S headache ____ O pulse 72 ____ O vomited x 3 ____ S nausea ____ O skin color ____ O respirations 16, labored ____ ____ S chest pain ____ S poor appetite Excellent! The Six Cs of medical Records Client’s words Clarity Completeness C onciseness Chronological order confidentiality Apply Your Knowledge 1. What are the six Cs of charting? ANSWER: The six C’s of charting are Client’s words Conciseness Clarity Chronological order Completeness Confidentiality Appearance, Timeliness, and Accuracy of Records Neatness and legibility Medical transcription Handwritten notes Blue ink Highlight specific items such as allergies Make corrections properly  Accuracy  Check information carefully  Never guess or assume  Double-check accuracy findings and instructions  Make sure most recent information is recorded Professional Attitude and Tone Note patient comments Do not record personal or subjective comments, judgments, opinions, or speculations You may call attention to problems or observations by attaching a note to the report, but do not make such comments part of medical record. Apply Your Knowledge What is important to remember when you are documenting in the medical records? ANSWER: It is important that medical records be neat and legible, timely, accurate, and maintain a professional tone. Correcting and Updating Medical Records Medical records are created in “due course” Information is entered at the time of occurrence Untimely submissions may be regarded as “convenient” Additions should not appear deceptive Document why late entry is made Date and initial added items Using Care with Corrections Correct mistakes immediately Draw a line through the original information Insert correct information Document why correction was made Date, time, and initial correction Have a witness, if possible m/d/yyyy 00:00pm misspelled JHC /chj Apply Your Knowledge What is the appropriate way to correct an error in a patient’s medical record? ANSWER: To correct an error in a patient’s medical record: Draw a line through the original information It must remain legible Insert correct information above or below original line or in margin Document why correction was made Date, time, and initial correction Responding to Release of Records Request Records are property of the practice Release of Contain confidential personal health Information to HMO Insurance information )PHI( which belongs to Company the patient Must have patient’s written consent I authorize Dr. “your name”release my health- to release care information to the above-named insurance company. Christopher Hansen mm/dd/yyyy Patient Signature Date Procedures for Releasing Records New authorization to transfer records Verbal consent is not valid File in medical record Copy original materials – only information requested Call to confirm receipt of materials Legal and ethical Special cases principle: Protect the Not always clear who can authorize release patient’s right to privacy If unsure, ask your supervisor at all times.  Auditing Medical Records Medical auditing is a systematic performance assessment within a healthcare organization. Most healthcare elements can be audited. By identifying errors and devising remedial actions to eliminate them, the medical audit serves a vital role in a healthcare organization’s compliance plan. Examination and review Completeness Accuracy Types Internal External Apply Your Knowledge The medical assistant receives phone call authorizing transfer of medical record information for a client to another physician’s office. What would you do in this situation? ANSWER: Never release information based on telephone authorization. You cannot be sure who the caller is. Tell them you need a written and signed release of information. Types of Reports Written reports 1- Day, evening and night report 2- Incident report. 3- Report of complain. 4- Report including negligence. 5- Transfer report 6- Reports for requisition. 7-Birth and death report 8- Anecdotal report >> based on descriptions and reports of individual, personal experiences, or observations Reports used in hospital: Birth and death report Transfer report Change of shift report Accident (incident) report Anecdotal report Report of complaint Reports for requisitions Purposes of writing reports  In Summary 1 >> Medical records are legal documents that give a complete, concise, chronological history of a patient’s past medical history, current medical issues, treatment plan, and treatment outcome. Additionally, they act as a communication tool between care providers. The patient medical record provides physicians and other healthcare providers with all the important information, observations, and opinions that have been recorded about a patient. 2 >> The records that comprise the patient medical record include, but are not limited to the following: patient registration form operative reports medical history form hospital discharge summaries physical exam form follow-up notes laboratory and other test results records of telephone calls records from physicians or hospitals, signed informed consents physician diagnosis and treatment correspondence with or about the plan patient  In Summary (cont.) 3>> SOMR files documents in the medical record in strict chronological order POMR files the same documents according to numbered problems found on the patient problem list. SOAP notes organize medical record documentation according to subjective, objective, assessment and plan. The CHEDDAR format breaks down this information even further into chief complaint, history, exam, details, drugs, assessment, and return visit plan.  In Summary (cont.) 4 >>The six Cs are client’s words, clarity, completeness, conciseness, chronological order, and confidentiality. 5 >> Neatness, legibility, accuracy, and professional tone are musts in maintaining medical records. >>Remember that patient medical records are legal documents. >>Personal thoughts and observations should never be a permanent part of the patient medical record.  In Summary (cont.) 6 -The proper way to make corrections in a medical record is to draw a single line through the error so that the original entry is still legible. Any additions to a medical record should also be made as soon as the need for the addition is noted, and the reason for the addition or change should also be clearly documented. 7 In order to release any confidential medical information, express written permission from the patient must be received. Only release records that are expressly requested and authorized by the patient. Thank You 