chapter 5 medical record Flashcards
What does the record say
Sign of the quality of care given
Reflects how well the physician is informed
Supports defensive medical practice
Justifies the billing
If well-kept, will help the office run smoothly
Who uses the mr?
Patient Clinical researchers Peer reviewers Reimbursement technicians Professional licensing and accreditation agencies
Released to
Courts
Courts
By subpoena
Copy the parts asked for or
Hand carry the record to the place requested
NEVER mail the chart, only copies of the chart
Usually there is a fee to copy the chart
Released to
Other physicians
Release of records should be obtained
Send by certified mail so you get a receipt
where else can you release mr to
insurance company
Advantages EHR
Advantages Can flag the patient for recall Files retrieved more quickly Takes up less space Analysis reporting is easier Charts are not misplaced Improves diagnosis coding and procedure coding Reduces labor – staff does not have to pull chart and re-file it Lowers malpractice premiums Storage space dramatically reduced Supplies reduced – charts, labels, etc.
Disadvantages EHR
Disadvantages
Cost
Downtime for training
Lost productivity during conversion
what is dicatation
Can be an in-office or outside service
Outside service might not even be in this country!
Both physician and transcriptionist should be trained about transciption
Ie format of the dictation
Need to spell patient names and include birth dates etc.
Arrangement of the Medical Record
Problem oriented method
Complaints or diagnosis are listed in front of the chart with a corresponding number
Then the chart is sectioned off according to the problem
Arrangement of the Medical Record
Source oriented method
Chart is sectioned according to type of information
So lab section, medications etc.
Most current goes on top
How long the chart is kept varies state to state
7 years in Michigan – Statute of Limitations
5 years after the patient dies
Usually the chart is moved to a “deceased” area
Charts can be thinned by
Take out parts that are not pertnent
