SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes.

SHOPS is funded by the U.S. Agency for International Development.Abt Associates leads the project in collaboration withBanyan GlobalJhpiegoMarie Stopes InternationalMonitor GroupO’Hanlon Health Consulting

Business for Health Business Skills for Private Medical Practices

Module 8: Manage Medical Records

A A Quick StartQuick Start Welcome! Welcome!

While you are While you are waiting waiting for the class for the class to begin, to begin, please take please take the Pre-the Pre-Test and Test and make sure make sure your your name is on it name is on it before before you hand it to you hand it to the the facilitator. facilitator. Thank you!.Thank you!.

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AgendaAgenda

WelcomeWelcomeOutpatient Medical RecordsOutpatient Medical Records

Medical Records Policies and ProceduresMedical Records Policies and ProceduresMedical Records AuditsMedical Records Audits

Medical Records ManagementMedical Records ManagementManage Medical RecordsManage Medical RecordsSummary and EvaluationSummary and Evaluation

CloseClose

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Learning ObjectivesLearning Objectives

During this session, you will:During this session, you will:1.1. propose the patient information and forms propose the patient information and forms

that should be included in outpatient that should be included in outpatient medical records;medical records;

2.2. recommend how an outpatient medical recommend how an outpatient medical record can be organized;record can be organized;

3.3. assess the content of your current medical assess the content of your current medical records;records;

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Learning ObjectivesLearning Objectives

4.4. discuss your current medical records discuss your current medical records policies and procedures;policies and procedures;

5.5. assess your current medical records assess your current medical records policies and procedures;policies and procedures;

6.6. design a checklist for auditing the design a checklist for auditing the completeness of medical records;completeness of medical records;

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Learning ObjectivesLearning Objectives

7.7. design a peer review checklist for auditing the design a peer review checklist for auditing the quality of medical records;quality of medical records;

8.8. assess your current medical records management;assess your current medical records management;9.9. decide how to handle issues related to medical decide how to handle issues related to medical

records management;records management;10.10.discuss the next step; anddiscuss the next step; and11.11.state your key take-away from this session.state your key take-away from this session.

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IntroductionIntroduction

You will have 1 minute to introduce yourself:You will have 1 minute to introduce yourself:

1.1. Your nameYour name2.2. Your positionYour position3.3. Your businessYour business4. How long you have been in business4. How long you have been in business

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Outpatient Medical RecordsOutpatient Medical Records

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Outpatient Medical FormsOutpatient Medical Forms

Design a well organized and complete Design a well organized and complete outpatient medical record. outpatient medical record. Please identify:Please identify:1.1.The forms you need in the medical recordThe forms you need in the medical record2.2.The information that should be collected The information that should be collected on each formon each form3.3.The order in which the forms should be The order in which the forms should be placed in the medical record, placed in the medical record, with # 1 being with # 1 being the first form you would see the first form you would see

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Medical Records Content AssessmentMedical Records Content Assessment

Medical Records Should Contain:Medical Records Should Contain:

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1. Problem list 7. Personal data2. Medications 8. Pertinent history3. Adverse drug reactions 9. Physical exams4. Allergies 10. Documentation for each visit5. Smoking status 11. Lab/other studies6. Alcohol/drug abuse 12. Working diagnoses

Etc.

Example of Primary Care Medical Example of Primary Care Medical Record Documentation StandardsRecord Documentation Standards

Criteria Description PointsBiographical/Personal Data 8General Chart Organization 5Personal History 38Social Habits 12Office Visit/Follow Up 29Preventive Services 20

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Medical Records Policies and Medical Records Policies and ProceduresProcedures

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Medical Records Policies and ProceduresMedical Records Policies and Procedures

Who prepares a new patient medical Who prepares a new patient medical record?record?

What system is used for filing and What system is used for filing and retrieving medical records?retrieving medical records?

Who is allowed to make entries into Who is allowed to make entries into the record?the record?

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Medical Records Policies and ProceduresMedical Records Policies and Procedures

What procedure do you use to What procedure do you use to indicate the need to follow up on indicate the need to follow up on patient referrals or external patient referrals or external diagnostic test results?diagnostic test results?

What are your security procedures What are your security procedures regarding medical records?regarding medical records?

How do you maintain patient How do you maintain patient confidentiality?confidentiality?

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Medical Records Policies and Procedure Medical Records Policies and Procedure AssessmentAssessment

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Patient MedicalRecord

Information Management

ReferencesReferences

Simple Ambulatory Medical Record Simple Ambulatory Medical Record Documentation StandardDocumentation Standard

Sample Clinical Records Management Sample Clinical Records Management PolicyPolicy

Policy and Procedures Writing Guide Policy and Procedures Writing Guide and Templateand Template

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Medical Record AuditsMedical Record Audits

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How to Conduct Medical Record AuditsHow to Conduct Medical Record Audits

What are the best What are the best ways to conduct audits ways to conduct audits of medical records for of medical records for completeness of data completeness of data and documentation of and documentation of quality of care?quality of care?

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Auditing for Auditing for Completeness Completeness of Medical of Medical RecordsRecords

Create a peer review audit checklist. Create a peer review audit checklist. For For example:example:1.1.Are all of the necessary forms in the Are all of the necessary forms in the record?record?2.2.Are all clinical notes signed, dated and Are all clinical notes signed, dated and timed?timed?3.3.Are patient vital signs recorded for Are patient vital signs recorded for each visit?each visit?

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ReferenceReference

Sample Peer Review Policy and Sample Peer Review Policy and Procedure: Quality Audit Procedure: Quality Audit

Sample Peer Review WorksheetSample Peer Review Worksheet

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Quality Issues in Medical RecordsQuality Issues in Medical Records

Identify five issues that need a medical Identify five issues that need a medical record peer review. record peer review. For example:For example:1.1.Did the provider prescribe the correct Did the provider prescribe the correct drug?drug?2.2.Were the blood tests that were Were the blood tests that were ordered the correct tests?ordered the correct tests?3.3.Was the chest x-ray consistent with the Was the chest x-ray consistent with the differential diagnosis?differential diagnosis?

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Auditing for Auditing for Quality Quality of Medical Recordsof Medical Records

Create a peer review audit checklist Create a peer review audit checklist based on the issues listed based on the issues listed in the previous activity.in the previous activity.

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ReferenceReference

Sample Peer Review Policy and Sample Peer Review Policy and Procedure: Quality AuditProcedure: Quality Audit

Sample Peer Review WorksheetSample Peer Review Worksheet

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Medical Record ManagementMedical Record Management

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Medical Record Management Medical Record Management AssessmentAssessment

✔✔ 1. The practice maintains complete and 1. The practice maintains complete and accurate medical records accurate medical records

✔✔ 2. Medical records are stored in a secure 2. Medical records are stored in a secure location location

✔✔ 3. There is a unique medical record for each 3. There is a unique medical record for each patient patient

✔✔ 4. Records are organized for easy retrieval4. Records are organized for easy retrieval

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Manage Medical RecordsManage Medical Records

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Case Study: Filing FollyCase Study: Filing Folly

Working with your table, please identify:Working with your table, please identify:1.1. the issuesthe issues2. the causes2. the causes3. how to avoid them in the future; and3. how to avoid them in the future; and4. what the hospital should do to manage 4. what the hospital should do to manage

the current situation.the current situation.

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Case Study: Filing FollyCase Study: Filing Folly

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1. Issues 2. Causes 3. How to Avoid

4. How to Handle the Current Situation

Summary and EvaluationSummary and Evaluation

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Evaluation SheetEvaluation Sheet

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The Next StepThe Next Step

1.1. Develop a Medical Record Data Quality Develop a Medical Record Data Quality ChecklistChecklist

2.2. Ensure your Medical Record Policies and Ensure your Medical Record Policies and Procedures include file management, Procedures include file management, confidentiality, and record retentionconfidentiality, and record retention

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The Next StepThe Next Step

3.3. Design a monthly Patient Medical Record Design a monthly Patient Medical Record Peer Review process for quality and Peer Review process for quality and appropriate use of servicesappropriate use of services

4.4. Randomly pull five patient medical records Randomly pull five patient medical records and conduct a review for data and conduct a review for data completeness and quality of service. completeness and quality of service. Document results and take action when Document results and take action when needed.needed.

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Let’s See How Much You’ve LearnedLet’s See How Much You’ve Learned

Please take the Post-Test.Please take the Post-Test.

We will compare it to your Pre-Test We will compare it to your Pre-Test to see how much you’ve learned in to see how much you’ve learned in this session.this session.

Thank you.Thank you.

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My Key Take-AwayMy Key Take-Away

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