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Chapter 1

Medical Record and Health History

QuestionAnswer
Good documentation: Works to legally protect the provider and medical staff
Incomplete records: Can be used as evidence to show that the patient did not receive quality care.
Information is strictly confidential: Must not be read or discussed by anyone not involved in the care of the patient.
HIPAA: Health Insurance Portability and Accountability Act.
HIPAA Privacy Rule: Federal law that protects patient's privacy. Went into effect April 14, 2003
Purpose of HIPAA: Provide patients wtih more control over use and disclosure of their health information - known as PHI - protected health information.
Who must comply? Anyone who uses, stores, maintains or transmits health information such as Health care providers, health plans or healthcare clearinghouses eg. billing services.
What is included in the HIPAA privacy rule?
Components of the Medical Record: Consists of numerous documents. Each document has a specific function.
Components of the Medical Record: Documents often consist of preprinted forms and computer templates.
Components of the Medical Record: Documents can be classified into categories.
Medical Office Administrative Documents: Contain information for efficient record keeping of office.
Patient Registration Record: Consists of demographic and billing information.
Patient Registration Record. Must be completed by all new patients.
Patient Registration Record: MA enters this information into the computer.
Patient Registration Record Information is used for numerous computerized functions (e.g. scheduling appointments, posting patient transactions, processing patient statements and insurance claims.
Original registration record PPR: Placed in front of patient's medical record.
Original registration record EMR: Usually shredded (after MA enters information into computer.
Patient Registration Record includes: Demographic information: Full name Address Phone (home and work)
Patient Registration Record includes: DOB Gender Marital status Employer
Patient Registration Record includes: Billing Information Name of responsible party SSN Address of responsible party Name of insured Policy and group number.
NPP Acknowledgement Form Written document.
NPP Acknowledgement Form Explains to patients how their health information will be used by the medical office, protected by the medical office.
NPP Acknowledgement Form Patient must sign the form - acknowledges that he or she has received the NPP.
NPP Acknowledgement Form NPP is filed in the patient's chart.
Correspondence: May be received from Insurance companies eg precertification authorization.
Correspondence Patient's attorney.
Correspondence Patient.
Correspondence May be sent from office: >Patient referral letter >Collection letter.
Medical Office Clinical documents" Medical Office clinical documents: >Records and reports that assist the provider in care and treatment of patient.
Health History Report: > Subjective data about the patient. > Health history obtained by having the patient complete a preprinted form. > Provider or MA during an interview.
Health History Report Health history, physical and laboratory and diagnostic tests are used to:
Health History Report Determine patient's state of health. >Arrive at a diagnosis - the scientific method of determining and identifying a patient's condition. > Prescribe treatment. >Document change in patient's illness after treatment.
Health History Report: >Thorough history obtained on each new patient.
Subsequent visits: Provides additional information regarding changes in patient's condition and treatment.
Physical Examination Report: Physical examination assessment of each part of the patient's body.
Physical Examination Report. Purpose: provides objective data about the patient and assists the provider in determining patient's state of health.
Physical Examination Report includes A summary of the provider's findings from each part of the body includes: General appearance Head and neck Eyes
Physical examination Report includes: Ears Nose Mouth and Pharynx Arms and hands
Physical Examination Report includes: Chest and lungs Heart Breasts Abdomen
Physical Examination Report includes: Genitals and rectum Legs and Feet
Progress Notes: Purpose is to update medical record with new information when patient visits or telephones the office.
Progress Notes: Must include date and time and signature and credentials of individual making the entry.
Progress Notes and Medical Record Detailed information on patient's medications includes: Prescription medications, OTC medications and medications administered at the medical office.
Purpose of Progress Notes is to: Update medical record with new information when patient visits or telephones the office.
Progress notes must include: Date and time Signature and credentials of individual making the entry.
Consultation Report is a: Narrative report of clinical opinion about a patient's condition by a practitioner other than the primary provider (consultant).
Consultation Report Usually is a specialist (eg cardiologist).
Consultant's opinion is based on: Review of patient's record and examination of patient.
Home Health Care Report The provision of medical and nonmedical care in a patient's home.
Home Health Care Report Purpose is to minimize the effect of disease or disability on the patient by promoting health, maintaining health and restoring health.
Home Health Care Report. Home Health care must be ordered by the provider.
Created by: bterrelonge