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Medical Record Made Easy
Transcript of Medical Record Made Easy
The record was documented as part of the normal course of business
Record was created at or near the time of the delivery of healthcare
The person that is documenting in the record had actual knowledge of the events that are being recorded and has the legal ability to document in the chart
Electronic Medical Records are a Legal Document
Correction of Errors in the Medical Record Must be Made Correctly in Order for the Record to Continue to be Considered a Legal Document
Errors in the record should not be obliterated.
They need to be documented as an error, and the correct information needs to be entered. The information still has to be viewable.
One way of making an error correction is to create an addendum note that contains the corrected information.
Making error correction changes in the medical record without the proper documentation is illegal and unethical
An audit trail must show who made error correction changes in the medical record, the date and time of the error correction
If errors are not corrected properly, the legality of the medical record in a court of law can be called into question
Relationship between Medical Record and Billing
Only the individual who is legally allowed by state law to document in the medical record should document or make changes in the chart.
The provider is legally responsible for documentation contained in the patient’s medical and billing record, including ICD and CPT coding.
The provider is legally responsible for the bills that are submitted to payors, e.g. Medicaid and Medicare
Billers should not change codes without confirmation of the changes being made by the provider.
Provider makes an error in charting
Charts on the wrong patient
Lab results on the wrong patient
Process for “fixing” the patient record
When a patient record is corrupted
Patient Records: Legal Guidelines
Proof of event or procedure
Care is considered not done
Must document complete information about patient care
Document if patient is noncompliant
Patient Records: Standards for Records
Complete, accurate, and well-documented records are evidence of appropriate care
Incomplete, inaccurate, altered, or illegible records may imply poor standards
Everyone who documents in the patient record has a responsibility to the patient and employing physician
Health Insurance Portability and Accountability Act
Medical Record Made Easy
HIPAA - HITECH
Each patien's medical record contains
essentially the same categories of material.
Each patien's medical record should contain
information unique to the patient.
The format varies depending of physician's specialty.
Is a legal document
Purpose of the MR
Provides a medical picture and record
of the patient from birth to death.
It is a vital document for the continuous management of a patient's healthcare.
It can be use for statistics purpose
It can be use for research purpose
It can be use for legal purpose by both patient and healthcare provider
Joint Commission on Accreditation of Health Record Organizations (JCAHO)
1. Admitting Diagnosis
2. Evidence of a physician examination,
including a health history, not more
than seven days before admission or 48
hours after admission.
3. Documentation of any complications after
4. Signed consent forms for all treatments
5. Consultation reports from any other physician brought to the case.
6. All healthcare providers notes, treatment reports, labs, and all test reports.
Health Information Technology for Economic and Clinical Health Act