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Practice Management--Medical Records
Purpose | Strategy
| Methods | Components | Principles and Pitfalls
Purpose
- Facilitate effective patient care by storing important information for future
recall--essential for continuity of care.
- Document clinical information for review by appropriate third parties (including
payors).
- Document clinical information for deterrence and defense of medical liability
litigation.
- Document clinical information for quality management and clinical research.
Strategy
Record and preserve, in a durable medium,
relevant, contemporary clinical information that is legible and readily retrievable.
Methods
- Paper systems
-manila folder with end-tab
-metal or plastic fasteners
-color-coded tab labels
-variety of standard forms available
- Computerized patient record (CPR)
-higher up-front costs
-unresolved concerns about confidentiality and security
-may be integrated with other computerized practice systems
-facilitates management tracking and clinical research
-rapidly developing software capabilities
Components (patient's name must appear
on every page of record)
1. Patient registration page (demographics, insurance, consent to
treat, record release)
2. Problem list
>acute versus chronic lists
>list each problem only once
>over time, becomes a comprehensive
"index" of the medical record
>problems should be dated>
3. Allergies--must be prominently displayed
4. Medication flowsheet (must be kept current to be useful)
5. Health promotion flowsheet or reminder system
6. Immunization record and consent documentation
7. Baseline history and physical
8. Progress notes (including record of all substantial phone
calls)
>S.O.A.P. format
>legible entries
>recorded contemporaneously
>accurate
>objective (avoid subjective or derogatory
comments about the patient)
9. Diagnostic reports
10. Hospital records (H&P, consultations, discharge
summaries, E.D. records, in reverse chronological order
11. Prior medical records
12. Correspondence records
Principles and Pitfalls
- NCQA standards are a commonly used guideline for medical records
review.
- Confidentiality
-required by medical ethics (divulge to no one except by patient's written permission)
-required by state and federal statute, with exceptions (public health, worker's
compensation)
-office staff education is critical in maintaining confidentiality
-breach of confidentiality is legally compensable
- Retention of medical records by the physician
-minimum duration: statute of limitations
-permanent retention required for disability, immunization records, occupational
exposures, malpractice suits, fraudulent concealment
- Alteration of medical records
-NEVER alter records to conceal an entry or substantially change it after
the fact
-corrections, when necessary, are done with a single line through incorrect entry, with
initials and date
-or correct by appending a dated statement and explaining the cause of the original error
Summary
A comprehensive, accurate, timely, organized medical record both
enhances and demonstrates the quality of patient care. By the physician's own choice
and habit, it can be our best friend, or worst enemy.
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