Discuss how a chart is to be organized, include data elements, source oriented v

Question

Discuss how a chart is to be organized, include data elements, source oriented versus problem oriented, active, inactive or closed status. Describe protocols for retrieving, routing, purging, storing, transferring, retaining and destruction of medical records. What filing systems are available, i.e. numbering, alphabetical and alphanumeric and which one would you choose? Include what order would you organize medical encounters into one chronological file. What type of information (labs, x-rays, progress notes, etc.) would you gather? What supplies do you need to build that record? Answer in detail if the record belongs to the patient since he/she pays for the services?

Explanation / Answer

Organizing chart based on source oriented and problem oriented

Source oriented

Problem oriented

Organizing pattern

Organizing pattern

(subjective, objective, assessment, plan, intervention, evaluation and response)

Retention

Storage

Destruction

Transferring

Retrieving

It is outlined by public records administrator office

It must be retained for the entire retention period as outlined in the schedule

There should be right to maintain records longer than what is stipulated on the hospital policy

During retention period the records will be protected from alteration, tampering, loss and physical damage

For records maintained by health information management and other clinical areas, retention will follow hospital guidelines and each department will review and assess record needs based on space constraints and will determine if they are suitable for archiving based on specific departmental policy

Storage areas for inactive records can include either an area inside the facility that has been approved for records storage use, or an off-site

Certain things are not approved for storage areas like storage ware houses, mini storage facilities, garages, basements, homes etc

Storage areas approved for records storage must be physically secure and environmentally controlled to protect records from unauthorized access and damage or loss due to temperature fluctuations, fire, water damage,pests and other hazards

Inactive records moved to off- site storage are boxed, labeled and logged out of our medical record tracking system to allow for efficient access and retrieval

No entire medical record shall be destroyed on an individual basis

Records should be destroyed if they are currently involved in open litigation, lawsuit, subject of any government investigation or similar activities

Paper records that are scanned into any electronic medical record system and it will be destroyed after scanning, indexing and 100% quality checking has taken place.

Medical records will be destroyed in a manner that does not allow for the information to be retrievable, recognizable, reconstructed or practically read.

Transferring allows the user in the system from one file room toanother.

This option might be used when a number of decentralized file rooms

The process of transferring data is almost a mirror image of the creation of retirement index.

The instructions to remove and add records to the index are identical

Inquiry and record ordering access to the medical registry system through website

We need basic requirements

Accessing the file index through the web interface

Security alert

Login processes

Online record retrieving screen

Question 3:

Best method in filing is numeric system:

Question no:4 & 5

Question 6:

Question 7

The records are owned by and the property of the health care provider.

Physician to provide a current copy of the record to the patient under most circumstances.

So it allows a patient or his/ her designee to receive a copy of the requested record. So payment is very important for the storage , retrieving the data.

Source oriented

Problem oriented

1. It is traditional type of medical records
2. Information is arranged according to who supplied the data
3. Problems and treatments are described on the same form
4. Presents some difficulty with tracking progress of specific events

1. Problem oriented medical record makes it easier to track specific illnesses
2. It consists of following data:

1. Data base
2. Problem list
3. Educational, diagnostic and treatment plan
4. Progress notes

1. Each person or department makes notatios in a separate sections of the patient’s chart
2. Different disciplines chart on separate forms
3. Each reader must consult various parts of the record to get a complete picture
4. Records become bulky

Organizing pattern

1. Each health care has its own section of the chart
2. Sections for MD’s
3. Nursing notes
4. Laboratory
5. Social services
6. Physical therapy
7. Procedure reports
8. Use progress and narrative notes

1. Easy way of filling the record.

Organizing pattern

1. All health care disciplines use the same forms referencing patient problems
2. SOAP or SOAPIE or SOAPIER

(subjective, objective, assessment, plan, intervention, evaluation and response)

1. The problems are arranged on basis of active problems and inactive problems.

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