MEDICAL RECORDS
Name one purpose of a medical record.
To document the course of patient care, including the provider’s evaluation, prescribed treatment, and changes in the patient’s condition.
What does HIPAA help protect in a medical office?
The privacy and confidentiality of patients’ health information.
A patient says, “My stomach hurts.” Is this subjective or objective information?
Subjective.
What does EMR stand for?
Electronic Medical Record.
Name one filing system used in a medical office.
Alphabetic, numeric, geographic, subject, or chronological.
Name one type of information found in a patient’s medical record.
Examples include demographics, medical history, medications, allergies, progress notes, lab results, insurance information, or referrals.
A medical assistant tells a friend details about a patient’s diagnosis. What is the concern?
This is an unauthorized disclosure of private patient information and may violate HIPAA.
A temperature of 101.2°F is what type of information: subjective or objective?
Objective.
What is one major difference between an EMR and an EHR in this chapter?
An EMR is maintained within a single organization; an EHR emphasizes sharing/interoperability across healthcare facilities.
What are the five steps in filing paper medical records?
Inspecting, indexing, coding, sorting, and storing.
How do medical records help provide continuity of care?
They let authorized members of the healthcare team review previous care, findings, and treatment.
A medical assistant opens a celebrity’s chart just out of curiosity. Is this appropriate?
No. Accessing a record without a work-related, authorized reason is inappropriate.
What do the letters in SOAP stand for?
Subjective, Objective, Assessment, Plan.
Name one advantage of electronic health records.
Examples: searchable information, quick transmission of results, legible electronic prescriptions, reminders, coordination of care, or trending.
In a chronological arrangement, what determines the order of records?
Date or time
Name one way medical records can help reduce unnecessary healthcare costs or work.
They can help avoid duplicate tests, incompatible therapies, or repeated efforts.
A computer screen displays a patient chart where unauthorized people can see it. What should the medical assistant do?
Follow office security procedures to protect the screen and prevent unauthorized viewing, such as locking the screen when away.
Progress notes should be dated, timed, and what else?
Signed by the person making the entry, according to office policy and applicable requirements.
Name two components that may be found in the medical record.
Any two: demographics, administrative data, insurance/financial information, correspondence, orders/referrals, past medical history, clinical data, progress notes, diagnostic/lab information, medications/allergies.
A medical office uses terminal-digit filing. How are patient records organized in this system?
Records are filed using the last digits of the assigned numbers as the primary filing unit, rather than starting with the first digit.
A patient sees a new provider. What information in the record could help the new provider understand the patient’s care so far?
The medical history, medications and allergies, progress notes, diagnostic information, lab results, and prior records.
A caller asks for a patient’s medical information. What should staff do before releasing information?
Verify the caller’s identity and authority, follow office policy and applicable privacy rules, and ensure the disclosure is permitted.
A handwritten chart entry contains an error. What is the proper general correction method described in the chapter?
Draw a single line through the error so it remains readable, write the correction, enter the time and date, and begin the note with “correction” or “late entry” as appropriate. Never erase it or use correction fluid.
What is the purpose of the problem-oriented medical record (POMR) approach?
To organize the record around the patient’s problems; the chapter also identifies formats such as SOAP, HPIP, and CHEDDAR.
A medical office needs to locate a paper chart quickly. Name two types of supplies or equipment that can help organize and store records.
Examples: folders, OUTguides/OUTfolders, vertical pockets, index tabs, self-stick numbers and labels, and standard office equipment.