Organization of the health record
Source-oriented medical records
The traditional patient record is a source-oriented medical record (SOMR); that is, observations and data are cataloged according to their source - provider (progress notes), laboratory, radiology, hospital, or consultant. Forms and progress notes are filed in reverse chronologic order (i.e., most recent on top) and in separate sections of the record according to the type of form or service rendered (e.g., all laboratory reports together, all x-ray reports together, and so on). Reverse chronologic order is used so that the provider and staff members do not have to search to the bottom of the record to find a recent laboratory report or a test.
Problem-oriented medical records
The problem-oriented medical record (POMR) is a departure from the traditional system of keeping patient records. The POMR is a record of clinical practice that divides medical action into four categories:
- The database, which includes the chief complaint, present illness, patient profile, review of systems, physical examination, and laboratory reports.
- The problem list, a numbered, titled list of every problem the patient has that requires management or workup. This may include social and demographic troubles in addition to strictly medical or surgical ones.
- The treatment plan includes management, additional workups needed, and therapy. Each plan is titled and numbered with respect to the problem.
- The progress notes include structured notes that are numbered to correspond with each problem number.
Several companies have developed file folders for organizing patient data according to the POMR. The problem list is placed at the front of the record. Special sections are provided for current major and chronic diagnoses/health problems and for inactive major or chronic diagnosis/health problems.
SOAP progress notes
Progress notes usually follow the SOAP approach. SOAP is an acronym for the following:
- Subjective impressions or patient reports
- Objective clinical evidence or observations
- Assessment or diagnosis
- Plans for further studies, treatment, or management
Authorization to release health records
All requests for health records should be made in writing, and the request should be kept in the patient’s record.
If a provider is involved in a liability suit, both parties enter the discovery process and must disclose the pertinent facts that may influence the outcome of the case; each time the provider needs to release information, a separate signed request form must be sent, and that signed form itself serves as the release.
Most offices charge a fee to print or copy health records, whether it is a per-page charge or a per-record fee. Fees for copies, including electronic copies, must be reasonable and cost-based; follow the facility’s policy and procedures manual and applicable law for the release of records. Some providers designate the office manager to handle requests for records releases.
Pay particular attention to records release requests involving a minor. In most cases, the parent or legal guardian is entitled to read through the patient’s health records; however, according to the HHS, there are three situations in which the parent may not be legally entitled to review the records of his or her minor child:
- When the minor is the one who consents to care and the parent is not required to also consent to care under state law
- When the minor obtains medical care at the direction of a court or a person authorized by the court
- When the minor, parent, and provider all agree that the doctor and minor patient can have a private, confidential relationship
If the provider believes that the minor might be in an abuse situation or that the parent or legal guardian may be harming the patient, the provider is required, both legally and ethically, to report the abuse. This duty is part of the mandatory-reporter framework, which requires healthcare professionals to report suspected child abuse or neglect to the appropriate authorities.
Sometimes patients want to look at their own records. They certainly have a right to see this information, but some patients may not understand the terminology used in the record. A staff member should always remain with a patient who is looking at his or her health record. Remember, the original health record should never leave the medical facility. Always follow office policy when releasing health records.
When a release is presented to the office, copy only the records requested in the release. Do not provide additional information that is not requested. The patient must specify that substance abuse, mental health, and/or human immunodeficiency virus (HIV) records are to be released. Remember that the patient ultimately decides whether a record can be released. If any question arises about what is to be released, consult the office manager or the provider.
Documenting in a paper health record
When documenting in a paper health record the entry will always start with the date in the MM/DD/YYYY format. The date will be followed by the time. This may be written in standard or military time. If standard time is used it must be followed by AM or PM (e.g., 2:00 PM). If military time is used it is in a four-digit format without a colon (e.g., 1400). All entries must be written in black or blue ink following the format designated by the healthcare facility. Documentation should be in the order in which the steps were completed. Vital signs are charted in their standard sequence: temperature, pulse, and respiration (TPR) measurements are documented in the “O” or Objective section of the SOAP note starting with temperature, then pulse, then respirations, followed by blood pressure.
Making corrections and alterations to health records
Corrections sometimes must be made to health records. The first step is to verify the proper procedure for making corrections in the facility’s policy and procedures manual. Some providers prefer a specific method for correcting errors in the health record. Erasing, using correction fluid, or any other type of obliteration is never acceptable.
To correct a handwritten entry:
- Draw a line through the error.
- Insert the correction above or immediately after the error in a spot where it can be read clearly.
- If indicated by the policy and procedures manual, write “Error” or “Err.” in the margin.
- The person making the correction should write his or her initials or signature below the correction and the date. Follow the format indicated in the policy and procedures manual.
Corrections to health records must be done in a legible manner and must be clearly understood. Always initial and date corrections to health records.
Errors made while using the computer are corrected in the usual way. However, an error discovered in an entry at a later date is corrected in the same manner as for a handwritten entry. This is sometimes called an addendum. Never attempt to alter health records without using this specific correction procedure, because this alteration of records may indicate a fraudulent attempt to cover up a mistake made by a staff member or the provider. Do not hide errors. If the error could in any way affect the patient’s health and well-being, it must be brought to the provider’s attention immediately. An EHR system will track the changes made within the record.
Transfer, destruction, and retention of paper health records
As with EHRs, paper health records are also classified as active, inactive, and closed. A paper record system must have a system established for regular transfer of files from active to inactive status or possibly destruction. The expansion of records and the file space available can influence the transfer period. Records for patients currently hospitalized may be kept in a special section for quick reference and then placed in the regular active file when the patient is discharged from the hospital. In a surgical practice, the record frequently includes the specific date on which the patient is discharged from the provider’s care, and the notation is made on the record, “Return prn” (from the Latin pro re nata, “as the occasion arises” or “when needed”). This record may safely be placed in the inactive file.
Most medical facilities use a year sticker on the file folder that indicates the last year the patient visited the clinic. If the file has a sticker showing that the patient’s last visit was in 2014, and he or she presents to the clinic on January 5, 2016, a 2016 sticker should be placed over the one that indicates 2014. These stickers often are included with color-coded filing systems. The medical assistant can easily look at a group of files and see which ones need to be changed to inactive or closed status.
Retention and destruction
Retention and destruction guidelines are the same for paper health records as for EHRs.
Long-term storage
Large healthcare facilities without a full EHR may convert paper records to microfilm or optical disk for long-term storage, though both technologies are expensive and most practices are better served by moving toward electronic storage, which can keep records indefinitely.
Patient education
Patients worry about the security of their information, particularly about who can access it and their lack of control over who views their records. Lawsuits often are filed when patients discover that an unauthorized person has accessed their PHI. The medical assistant should expect hesitation and even reluctance from these patients, listen to their concerns, and explain the safety procedures that apply to the EHR in language the patient can understand. To reassure patients that their records are protected at all times, the medical assistant must know how the EHR is protected and what security measures are in place. Some facilities prepare a brochure to explain the conversion process to the patient and the advantages of the EHR system.