A medical record is one of, if not NOT, most important documents in the provision of medical services. This is what tracks patient treatment. This allows medical professionals to analyze the patient's medical history and also plan a course of treatment for the future.
It is a communication tool that not only provides clinical data on the patient’s current and past medical history, but is also used to review and recover insurance claims, as well as to analyze the use and quality of medical care.
Content of medical record
* Face sheets, meetings for each visit
* Vital signs
* Doctor's orders
* History and physical forms
* List of medical problems
* Drug lists
* Progress notes
* Summary
* Authorization Forms
* Diagnostic Testing
* Laboratory testing
* Operational reports
* Pathology reports
Documentation
Documentation is the most important function for storing accurate medical records, as it records all the important details and facts regarding patient care.
Documentation:
legal documentation
includes patient history
chronologically documents patient care
allows doctors to plan and evaluate patient care
ensures continuity of care
allows all physicians involved in patient care to communicate with each other
provides evidence of care provided in court cases
assists with claims handling and reimbursement
helps in meeting accreditation requirements
Medicare and Medicaid Services (CMS) Policy Centers for Documentation
Documentation MUST include:
evidence of physical examination was performed no more than seven days prior to admission or within 48
business hours
results of patient consultations and the results of such assessments
all orders, progress notes, drug records, procedures and radiology results, laboratory results,
and vital signs
valid diagnosis
patient medical complications
any relevant risk factors
information that reflects the CPT / ICD-9 codes that have been submitted to patient insurance
patient-signed consent forms
summary summarizing the results of reception, care and care
plans for follow-up care
Soap. Model
subjective
Subjective information includes information provided directly by the patient, for example, how they feel, their opinion about their care and why they made an appointment. It represents the patient's point of view on their condition.
A task
Objective information is a doctor's point of view. It includes information that was discovered and measured by a doctor during an exam or test.
assessment
The assessment determines the basic diagnosis characteristic of the visit and includes the interpretation of this condition by the doctor. When a patient has several diagnoses, the doctor will dictate his assessment based on the patient's complaint on the same day.
Plan
The “Plan” segment is when the doctor makes a plan of action for the diagnosis, usually this condition characteristic of visiting this day.
Documentation issues
Each organization must ensure that each page in the medical record contains the first name or patient identification number (first and last name of patients, first and last names, social security number or personal identifier).
It is also necessary that all entries in the medical record include the identification of the author.
Any known drug allergy should be noticeable in the record, preferably on the front of the chart.
If any issues have not been resolved from a previous visit, they should be resolved on subsequent visits.
intelligibility
The most common problem in medical records is legibility. It is vital that the content of the medical card is legible for someone other than the author, because 1) the documentation has a significant impact on the settlement of legal claims and 2) poor readability can lead to misunderstandings (i.e., if the pharmacist incorrectly prescribed the prescription and wrong drug for the patient).
It is recommended that organizations and doctors use transcription services. It is also recommended that organizations and doctors use computers to print orders and recipes.
verbiage
Medical record entries must NOT include spaces or unacceptable language. This will damage the integrity of the rest of the medical record.
Entries should NOT reflect the view that something unexpected happened. Words like "unintentionally", "unintentionally" and "unexpectedly" should NOT be used in dictations.
Records should also NOT use words that are non-specific and cause doubts, especially in the case of a lawsuit. Words like "appeared" and "apparently" should NOT be used.
Entries should NOT contain ambiguous words or phrases such as “do well” or “eat better”.
Claims reimbursement
Documentation is the best support for proving “medical necessity”. Bad or minimal documentation can lead to a denial of claim.
Documentation Rules
Error correction
To correct a mistake inside the post, the author must pass one line through it so that the original content is still visible. If the error is completely closed or darkened, it will cause anxiety, and the worst can be assumed that it could be. Then the correct documentation should be written over the error and should be signed, dated, and the reason for the correction should be noted.
rumor
Any statement made by anyone other than the author of the entry should NOT be documented as if it were a fact. You must specify the source of the statement, and the operator must be in quotes.
Phone calls
Under no circumstances should medical consultation be provided by telephone unless it is established who is at the other end of the call. There must be politicians who dictate who can give advice by phone (i.e. Nurses, doctors ... NOT adopters), and what are the limits of the type of advice that someone other than a doctor can provide.
ALL telephone conversations must be documented and placed in chronological order in the medical record.
Countersignatures
Signature - The signature of the doctor who reviews the record after the primary doctor signs it. Signature means that the doctor understands and agrees with the care described by the dictating doctor.
It is important to recognize that when a provider signs an entry in the medical record, they are responsible for everything contained in the entry.
Abbreviations
Although the reductions shorten the time, many of them are ambiguous and may be misinterpreted by other doctors. To avoid any misinterpretation, use only standard abbreviations.
Documenting the discontinuation of the doctor / patient relationship
All problems associated with patient non-compliance should be objectively documented in a medical record. Any action taken, reinforcement, or education should also be noted.
When the doctor intends to notify the patient of the termination, they must be indicated orally. Then, a certified letter must be sent to the patient, stating the reasons for termination and the time frame in which the relationship will end. A copy of the certified letter should also be kept in the record.
Record hold
The length of time that medical records are to be maintained varies between statutes of restriction rules and individual state charters.
However, each organization MUST apply clear policies and procedures regarding the preservation and storage of medical records.
Release records
Entries may be published only in accordance with individual state and federal laws.
Organizations should also have a clear policy on the issuance of medical records, which should define:
* who can request and receive a copy of the patient's medical record
* who has the right to issue medical records and which parties
* How does the practice protect protected medical information?
* how records will be monitored and documented
A strong policy in relation to the foregoing greatly helps to avoid responsibility.
Record Ownership
Ownership of medical records is a unique situation, since both the patient and the medical object have ownership rights. The object owns a physical record, but the patient has the information in the record.
Therefore, the entry MUST remain in a medical facility, and the facility must ensure the protection of patient information.
Patients have the right to any information in their report, but such rights vary between states.
legal
When legal claims arise, medical records rely on the definition of the standard of care that has been provided. Little or no documentation regarding the course of treatment strongly supports the requirement of negligence.
Medical records may disclose:
- a series of events that led to the trauma of the patient and the subsequent requirement
- inefficient use of information in the medical record
- poor communication from the doctor or department to another
- illegible entries or orders
