Source: http://slideplayer.com/slide/6205570/
Timestamp: 2020-02-18 08:29:49
Document Index: 379514688

Matched Legal Cases: ['art 1', 'art 2', 'art 1', 'art 2', 'art 1', 'art 1', 'art 1', 'art 2', 'art 2', 'art 2']

Published byRosemary Payne Modified over 4 years ago
2 Medical Records Where should medical records be kept?
3 Points to Remember Medical records must be kept confidential and in a secured, locked location. The record should never leave the medical facility in which it originated, except for legal reasons.
4 Medical Record What is placed into the patient’s medical record?
6 Ownership of the Medical Record
Patients own the content and have a right of access to the information in the record.
7 Authorization to Release Information
Patient must give written permission 1 year time limit if not otherwise stated Only requested information may be released Released information never includes insurance or financial information
8 Organization of the Medical Record
What are Source-Oriented Medical Records (SOMR)?
9 Source-Oriented Medical Records (SOMR)
Traditional method of keeping patient records. Information filed according to their sources Separate sections for laboratory reports, x-ray films, radiology reports, and so on. Forms and progress notes are filed in reverse chronologic order (newest on top).
10 Organization of the Medical Record
What are Problem-Oriented Medical Records (POMR)?
11 SOAP Notes What do these stand for? S O A P
12 SOAP Notes S – Subjective – what patient says
O – Objective – what you see/hear A – Assessment – diagnosis P – Plan - treatment
13 6 C’s of Charting Client’s own words Clarity (Clear) Completeness
Conciseness Chronological order Confidentiality
14 Charting Can you chart for someone else?
Why are we conscious of using correct medical terminology when charting? Why do we use correct grammar and punctuation?
15 Charting How do you correct an error that you made while charting?
16 Correcting a Medical Record
Draw a single line through error Make correction in chart above error Write “Corr” or “correction” in the margin Date and initial What is done for electronic records?
17 Correcting Electronic Records
If an error is made while typing, simply backspace and correct the error. If the error is discovered later, make an additional entry with corrected information. Do not delete or change previous entries on electronic records.
18 Equipment & Supplies
19 Equipment & Supplies Outguides
20 Basic Rules for Filing Which of these names is filled first in alphabetical order? Patricia A. McColm Patricia H. McColm Indexing Units a chosen according to the filing system to be used.
21 Basic Rules for Patient Filing
Rule 1: Last name, first name, middle name Example: Obama Barack Hussein
22 Basic Rules for Filing Rule 2: Initial used as a legal name is filed as a name Example: Eliot, T. S. Elliott T. S.
23 Basic Rules for Filing Rule 3: Foreign prefixes or abbreviations become one unit with the last name Example: Lisa M. Del Vecchio	Delvecchio Lisa M Jill A. St. John	Stjohn Jill A
24 Basic Rules for Filing Rule 4 – Hyphenated names are considered one unit George M. Andrews-Scott becomes Andrews-Scott George M
25 3 Major Filing Methods Alphabetic – What is it? Numeric – What is it?
Subject – What is it? Color Coding (used in all 3 major systems) Each letter is assigned a different color Each folder given a color-coded label Only full-cut folders are used
26 Tickler File What is it? How does a computer do this?
27 Project 3 Part 1 – Due in Unit 6 Part 2 – Due in Unit 7
There are two parts to this project. Part 1 – Due in Unit 6 Medical Records Essay – 40 points Filing – 15 points Part 2 – Due in Unit 7 HIPAA Essay – 40 points
28 Project 3 Download the following from the Unit 6 folder of Doc Sharing: Medical Records Filing Template Rubric for Project 3 Please be sure to view the instructions for Project 3 in the PowerPoint presentation located in the Unit 6 folder of Doc Sharing.
29 Project 3 – Part 1: Essay Use the template! Download the template and rubric from the Unit 6 folder in Doc Sharing. When you answer each question on the template, Use APA formatting (double space, size 12 Times New Roman font) Add a reference citation Write a minimum of 300 words total for all three questions. Do not use contractions (I’ve, can’t). Please use spell check and make corrections before you submit!
30 Project 3 – Part 1: Essay Answer the following questions in essay form (minimum 300 words total): 1. Why do medical records exist? (Explain four reasons. See Chapter 14, page 251 of your text.) 2. Discuss the advantages and disadvantages of establishing and maintaining electronic health records (EHRs). (See Chapter 14, page 252 of your text.) 3. Discuss and explain the five basic filing steps. Include why each is important (conditioning, releasing, indexing, etc.). These are in Chapter 14, pages 271 and 272 of your text.
31 Project 3 – Part 1: Filing Download and use the template!
List the names in alphabetical filing order last name, first name, middle name/initial Do not change the spelling of the names.
32 Project 3 – Part 2: HIPAA Essay
Answer the following question in essay form (minimum 300 words): Question: Explain how HIPAA Privacy Rules benefits the healthcare industry, patient, and physician. This essay is due by midnight Tuesday of Unit 7.
33 Project 3 – Part 2: HIPAA Essay
When you answer this question, Use APA formatting (double space, size 12 Times New Roman font). Add at least two reference citations. (Your text and the HIPAA website) Write a minimum of 300 words. Do not use contractions (I’ve, can’t). Include a title page. Add a reference page. Please use spell check and make corrections before you submit!
34 Project 3 – Part 2: HIPAA Essay
You will need to follow the link provided in the course: See Chapter 16 of your text for more information. Please be sure to state how HIPAA benefits all three of these: The health care industry The patient The physician
Jeff Steele, LDO, CPOT, ABOC Spokane Community College