What are the basic purposes of the medical record?
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Revised 8/20/21 Show
Properly documenting patient’s medical records has always been important, but never more than now, given today’s healthcare landscape where the government ties reimbursement to the quality of the medical record. “Medical reimbursement is reflective of what you document, not just what you do,” says Dr. David Schillinger, SCP Health’s Chief Medical Officer. “We can take care of a patient with a wrist fracture, pneumonia, or a myocardial infarction, but if there is no documentation, there is no reimbursement.” For that reason and more, Dr. Schillinger encourages providers to “put thoughts to paper” and put good documentation practices into place. Four Reasons to Document Medical Records ProperlyFollow along with four reasons why it’s vital to properly document patients’ medical records. 1. Communicates with other health care personnelDocumentation communicates the what, why, and how of clinical care delivered to patients. These records allow other clinicians to understand the patient’s history so they can continue to provide the best possible treatment for each individual. Proper documentation also serves as a means to facilitate patient navigation and coordination along the continuum of care, from EM to HM and transitioning into the post-acute care setting. 2. Reduces risk management exposureThorough and accurate documentation mitigates risks and reduces the chance of a successful malpractice claim. A well-documented record serves as evidence of treatment and care, helping to alleviate liability concerns in the event of a claim. It is unlikely you will remember details of a particular case several years later when you are in the middle of a professional liability claim. Your documentation will be the tool you rely on in this situation. 3. Records CMS Hospital Quality Indicators and PQRS MeasuresDocumentation captures value-based care metrics that, increasingly, the government is asking hospitals to provide. These include Hospital Quality Indicators and MIPS measures. 4. Ensures appropriate reimbursementA well-documented medical record can facilitate effective revenue cycle processes, expedite payment, reduce any “hassles” associated with claims processing, and ensure appropriate reimbursement. “Ninety-five percent of ensuring appropriate reimbursement is just good documentation practices that most our clinicians know,” Dr. Schillinger says. “The other five percent consists of learning the rules provided by the federal government and other organizations that we need to know from a documentation compliance standpoint so that we are reimbursed correctly.” Other reasons why proper medical record documentation is important include:
How to Improve Your Documentation SkillsIt’s one thing to know the reasons documentation is important, and it’s another to ensure that it’s done correctly. There are several ways to help clinicians improve their documentation skills. 1. StandardizationUse industry standards to create note-taking guidelines that work for your practice. Make sure that clinicians are focusing on clear and concise communications that will benefit other readers of the medical records. 2. Regular ReviewReview prior records and encounters; with current EMR’s, this is often a simple process. Some health records even allow you to view records from other facilities on the same system. 3. Peer SupportNo one understands the ins and outs of documentation quite like other clinicians. Pinpoint excellent documenters as go-to experts for questions and concerns. Peer-to-peer support of documentation will increase standardization and productivity. 4. Continued EducationClinicians never stop learning as they practice and that should be true when it comes to documentation as well. Regular emails with tips and ideas for improvement help keep clinicians up to date on best practices and increase documentation compliance. ConclusionClear and concise medical record documentation is critical to providing patients with quality care, ensuring accurate and timely payment for the services furnished, mitigating malpractice risks, and helping healthcare providers evaluate and plan the patient’s treatment and maintain the continuum of care. Take Dr. Schillinger’s advice and “put thoughts to paper.” Make your clinical documentation complete, accurate, and precise. The only difference between entries into a patient record made by students and those made by practicing professionals concerns the obvious need for supervision of students’ clinical practice while they are learning the skills and knowledge necessary to become proficient in the profession. Teaching institutions have rules for the conduct of the person assigned to supervise a student's clinical experience. These rules usually require the supervising individual's signature, in addition to the student's signature, on each entry in a patient record. This process, called countersigning, indicates that the supervisor is aware of what that student is thinking about the patient. Furthermore, the use of residents at teaching institutions has been addressed by Medicare in the Teaching Physician Guidelines. This document provides guidelines relative to the supervision and documentation that are required when services are provided by residents. Generally speaking, physician services furnished in teaching settings are reimbursed when the services are predominantly furnished by the physician who is not a resident, or the services are performed jointly by a teaching physician and a resident, or by a resident in the presence of a teaching physician. It is important that anyone in a teaching institution become familiar with these requirements to ensure that appropriate care is provided and documented. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9781416044857500184 Emergency Medical Treatment and Active Labor Act and Medicolegal IssuesRon M. Walls MD, in Rosen's Emergency Medicine: Concepts and Clinical Practice, 2018 Medical RecordAll areas of the hospital used to conduct the MSE must create a medical record for the patient and keep a log of those presenting for examination and treatment.33 If members of the hospital medical staff see their patients in the ED, on either a scheduled or an unscheduled basis, the hospital must create a medical record and require the physician to document the care provided in that record. The physician's private office records documenting care provided at the hospital are insufficient. Most important, the emergency clinician should document whether an EMC was determined to exist forevery patient seen in the ED, even if the initial chief complaint is seemingly trivial. The legal purpose of the required MSE is to determine if an EMC is present. To facilitate documentation, ED charts should include two checkboxes: one labeled “EMTALA EMC present” and the other “EMTALA EMC absent.” The person performing the MSE should check the appropriate box for each patient, and completion of this documentation should be a prime part of the ED's quality improvement monitoring program. View chapter on ClinicalKey Emergency Medical Treatment and Labor Act (EMTALA)Todd B. Taylor MD, in Pediatric Emergency Medicine, 2008 Maintenance of Information [42CFR§489.20(r)(1)]Medical records related to individuals transferred to or from the hospital must be maintained for a period of 5 years from the date of the transfer. Also, a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC must be maintained, as well as a central log on each individual who comes to the ED seeking assistance and whether he or she refused treatment, was refused treatment, or was transferred, admitted and treated, stabilized and transferred, or discharged. Although perhaps not intuitively obvious, the “list of physicians on-call” must identify specific physicians' names (i.e., not the group name and not a mid-level provider taking “first call”). Although most hospitals keep medical records indefinitely, the statute of limitations for an EMTALA violation is 2 years [42USC§1395dd(d)(2)(C)], although penalties may be assessed up to 6 years [42USC§1320a-7(a)(c)(l)] after the incident. What are 3 things in a medical record?List The 9 Contents Of The Patient's Medical Record. Identification Information.. Medical History.. Medication Information.. Family History.. Treatment History.. Medical Directives.. Lab results.. Consent Forms.. How many purposes does a health record have?According to the American Institute for Health Management, there are five purposes a Medical Record for several key reasons: Patient Care. A patient's records provide the documented basis for planning patient care and treatment. Communication.
What is the purpose of a medical record and why is it important that it is accurate?The records form a permanent account of a patient's illness. Their clarity and accuracy is paramount for effective communication between healthcare professionals and patients. The maintenance of good medical records ensures that a patient's assessed needs are met comprehensively.
What is the purpose of a medical record quizlet?to identify the patient, support and justify the patient's diagnosis, care, treatment and services provided; document the course of treatment and results; and facilitate continuity of care among health care providers.
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