Curriculum to Accompany

Medical Assisting:

Administrative and Clinical Competencies,

6th Edition

Course:

Facility and Records Management

Curriculum to Accompany Medical Assisting: Administrative and Clinical Competencies, 6th Edition

Course: Facility and Records Management

Contents

Part A: Preparing for the Day

Part B: The Patient’s Medical Record

Part C: Filing

Curriculum to Accompany Medical Assisting: Administrative and Clinical Competencies, 6th Edition

Course: Facility and Records Management

Course Overview

This module deals with concepts and duties assigned to a medical assistant in the administrative realm. Having patients’ charts ready for the day, preparing the office area for the scheduled patients, and opening/closing the office are all part of being an efficient medical assistant. When working with patients’ charts, one needs to pay close attention to the legal documents that compose the medical record such as patient information forms, chart notes, lab and x-ray reports, and any correspondence from other providers. It is imperative that each patient’s medical record be current, available, and organized properly. Again, confidentiality of the medical record as mandated by HIPAA must be observed.

Resource List

Textbook: Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Thomson Delmar Learning, ISBN 1-4180-6633-8. Chapter7.

Student CD-ROM: CD-ROM that accompanies Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition. This CD-ROM contains StudyWARE, The Critical Thinking Challenge, and an Audio Library.

Workbook: Workbook to accompany Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Thomson Delmar Learning, ISBN 1-4180-3267-0. Chapter 7.

Instructor’s Materials: Instructor’s Resource Manual to accompany Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition,by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Thomson Delmar Learning, ISBN 1-4180-3268-9.

Instructor’s CD-ROM: Electronic Classroom Manager to accompany Thomson Delmar Learning’s Medical Assistant: Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Thomson Delmar Learning, ISBN 1-4180-3269-2.

DVD:Thomson Delmar Learning’s Skills and Procedures for Medical Assistants DVD Series. Program 1, Administrative Skills. Series ISBN 1-4018-3868-5.

The Internet: It is strongly recommended that faculty and learners alike have a working knowledge of the Internet.

Equipment List

  1. Multimedia projector
  2. Computer with Internet access
  3. Multimedia equipment
  4. AAMA credentialing information
  5. AMT credentialing information
  6. DVD player

CAAHEP content

III.C.1.f(1) Basic medical assisting clerical functions

III.C.1.f(4)Operational functions

ABHES content

VI.B.1.b(7)(a)Manual and computerized records management

VI.B.1.b(7)(e)Reception, public and interpersonal relations

VI.B.1.b(7)(f)Office safety and security

CAAHEP competencies

III.C.3.a(1)(c)Organize a patient’s medical record

III.C.3.a(1)(d)File medical records

ABHES competencies

VI.B.1.a(3)(b)Prepare and maintain medical records

VI.B.1.a(5)(c)Use appropriate guidelines when releasing records or information

VI.B.1.a(5)(h)Perform risk management procedures

VI.B.1.a(6)(a)Maintain the physical plant

VI.B.1.a(6)(f)Exercise efficient time management

Learning Activities

(HW)Terminology Notebook. Assign chapter for reading and have students define key terms and retain in a key term notebook for future reference.

(ICD)Discuss why it is important to prepare the waiting room and examination areas

(ICA)Complete Procedure 7-1.

(ICA)Complete Procedure 7-2; attach the patient information form as the work product to the performance evaluation checklist.

(ICA)Complete Procedure 7-3.

(HW)Chapter 7, Unit 1 Workbook Assignment Sheet.

(ICD)Talk about the impact of HIPAA for small offices as contrasted to larger medical settings.

(ICA)Show a DVD clip—“Administrative and clinical sections of the medical record” from Program 1: Administrative Skills (Skills and Procedures series).

(ICA)Obtain blank patient charts and inserts and have the students to organize them for medical records.

(ICA)Provide the student at least one scenario to chart in the SOAP format.

(HW)Activity. Complete Activity 1 on page 213 of the text.

(HW)Chapter 7, Unit 2 Workbook Assignment Sheet.

(ICA)Prior to completing Procedure 7-4, give the student at least ten words to place in alphabetical order as practice.

(ICA)Complete Procedure 7-4.

(ICA)Complete Procedure 7-5.

(ICA)Complete Procedure 7-6.

(ICA)Complete Procedure 7-7.

(HW)Have the student to research the state law for the length of time medical records must be retained for your state.

(HW)Chapter 7, Unit 3 Workbook Assignment Sheet.

(HW)The Critical Thinking Challenge, page 212.

(HW)The StudyWare Challenge, Chapter 7. Have students take the Quiz in “Quiz Mode” and either email their scores to the instructor, or print the scores to turn in.

(ICA)Following review of the chapter and homework assignments, give a quiz on this chapter that includes the content and competencies listed for CAAHEP and ABHES.

Part A: Preparing for the Day

Learning Objectives

Cognitive

  1. Define the key terms presented in the unit.
  2. List five things to check in the reception room environment.
  3. List four tasks to perform prior to opening the office besides checking the reception area.
  4. Explain why having a receptionist is important.
  5. Live at least five responsibilities for a receptionist.
  6. Identify five pieces of information found on a completed charge slip.
  7. List four things you will find inside a new patient’s chart.
  8. List two reasons to use a checklist.

Psychomotor

  1. Open the office.
  2. Obtain new patient information.
  3. Close the office.

Initial Questions and Activities

Discuss why it is important to prepare the waiting room and examination areas.

Key Concepts / References & Activities / Slides
Preparing for patients in the office / Pages 183-184
Procedure 7-1 / 3-4
Receptionist’s duties / Pages 184-185
Procedure 7-2 / 5-8
Closing the office / Procedure 7-3 / 9

(ICA) In-Class Activities

  1. Complete Procedure 7-1.
  2. Complete Procedure 7-2; attach the patient information form as the work product to the performance evaluation checklist.
  3. Complete Procedure 7-3.

(ICD) In-Class Discussion

  1. What are six recommendations to follow when opening the office?

(1) unlock the door (2) check the physical environment of the reception area (3) retrieve phone messages (4) pull the day’s charts (5) check the examination rooms (6) check common work areas

  1. What steps should be taken to close the office at the end of the day?

(1) restock and clean the examination rooms (2) collect the charts unless the physician needs them for dictations (3) turn off all appliances (4) prepare the bank deposit to take to the bank (5) activate the answering system (6) turn off the lights (7) lock the door and activate the alarm system (if there is one).

(HW) Homework Assignments

  1. Terminology Notebook. Assign unit for reading and have students define key terms and retain in a key term notebook for future reference.
  2. Chapter 7, Unit 1 Workbook Assignment Sheet.

Presentation Tools

Note to Instructors: If you change Objectives or Assignments, don’t forget to change the slides accordingly.

Chapter 7, Slides 1-2 / Introduce the course and unit.
Slide3-4 / Opening the office—tasks and things to check.
Slide 5 / The importance of the receptionist.
Slide 6 / The role of the receptionist.
It may not always be the responsibility of the receptionist to open and close the office; the office manager may have that duty. This will be according to each office’s policy and assigned responsibilities.
Slide 7 / Charge slips.
Slide 8 / New patient charts.
Include what demographics are and why they are important.
Slide 9 / Closing the office.
Slide 10 / Have students answer the checkpoint questions on the slide to review the content in the unit.

Part B: The Patient’s Medical Record

Learning Objectives

Cognitive

  1. Define the key terms presented in the unit.
  2. Describe the importance of the medical record as a legal document.
  3. List examples of subjective information.
  4. List examples of objective information.
  5. Describe methods of recording progress notes.
  6. Describe the correct procedure for making corrections to progress notes.
  7. List the differences between a conventional record and the problem-oriented medical record.
  8. Explain the History Physical Impression Plan (HPIP) method of recording patients’ medical information.
  9. Describe the major sections of a medical record.
  10. Explain the reason for a tickler file.
  11. Explain the purpose of chart audits and their importance.

Initial Questions and Activities

Talk about the impact of HIPAA for small offices as contrasted to larger medical settings.

Key Concepts / References & Activities / Slides
HIPAA / Page 190 / 14-15
Purpose of medical records and what constitutes a complete medical record / Page 191 / 12-13, 16-21
Records management / Figure 7-8
Page 195 / 28-30
POMR / Page 195 / 22-27
Electronic Health Records / Page 198

(ICA) In-Class Activities

  1. Show a DVD clip—“Administrative and clinical sections of the medical record” from Program 1: Administrative Skills (Skills and Procedures series).
  2. Obtain blank patient charts and inserts and have the students to organize them for medical records.
  3. Provide the student at least one scenario to chart in the SOAP format.

(ICD) In-Class Discussion

  1. What is the role of the Privacy Officer that is mandated by HIPAA?

The Privacy Officer tracks who has access to Protected Health Information (PHI) within each office to ensure patient privacy and confidentiality of the records.

  1. What are the rationales behind having a complete medical record?

A complete medical record serves to (1) plan patient care and continuity in the evaluation of treatment (2) provide documentary evidence of the course of a patient’s evaluation, treatment, and change in condition (3) furnish evidence of communication between the physician and any other provider associated with the patient’s care (4) afford protection of legal interests of the patient and the physician (5) establish a database for continuing education and research (6) maintain relationship between the medical office and the insurance company for reimbursement.

(HW) Homework Assignments

  1. Terminology Notebook. Assign unit for reading and have students define key terms and retain in a key term notebook for future reference.
  2. Activity. Complete Activity 1 on page 213 of the text.
  3. Chapter 7, Unit 2 Workbook Assignment Sheet.

Presentation Tools

Note to Instructors: If you change Objectives or Assignments, don’t forget to change the slides accordingly.

Chapter 7, Slide 11 / Introduce the unit.
Slides 12-13 / The medical record as a legal document.
Slides 14-15 / HIPAA security safeguards.
Slides 16-17 / Subjective and objective information found in the medical record.
Slides 18-20 / Methods of recording progress notes.
Slide 21 / Correcting a medical record.
Include in your discussion that errors made in a medical record should never be scribbled out, obliterated with a marker, or “whited-out.” Emphasize that documentation in medical records should only be done in blue or black ink (except for allergies that should be in red ink).
Slide 22 / Conventional records versus source-oriented medical records (SOMR)
Slides 23-24 / The problem-oriented medical record (POMR).
Slides 25-26 / The SOAP method of charting (subjective, objective, assessment, plan).
Subjective information in addition to the chief complaint includes a history of the present illness (HPI).
Slide 27 / The HPIP method of charting (history, physical, impression, plan).
Slide 28 / Sections of the medical record.
Remind the learner that financial information should not be inserted into the patient medical record.
Slide 29 / Tickler files for managing medical records.
Slide 30 / Chart audits.
Identify who is responsible for performing chart audits.
Slide 31 / Have students answer the checkpoint questions on the slide to review the content in the unit.

Part C: Filing

Learning Objectives

Cognitive

  1. Define the key terms presented in the unit.
  2. Explain basic filing methods.
  3. List the steps used in filing.
  4. Describe methods of removing and replacing patient files.
  5. List the storage media used for “paperless” filing systems.
  6. List and discuss the sections of a medical chart.
  7. Describe purging files.
  8. Explain ways to locate a missing chart.
  9. Explain the pros and cons of alphabetical and numeric filing systems.

Psychomotor

  1. File items alphabetically.
  2. Pull a file folder from alphabetic files.
  3. File items numerically.
  4. Pull a file folder from numeric files.

Key Concepts / References & Activities / Slides
Filing steps / Figure 7-12
Pages 200-201 / 33-35
File management: finding a missing chart, storage, and supplies / Pages 201-205 / 36, 37, 40
Rules of alphabetical filing / Pages 206-208
Procedure 7-4
Procedure 7-5 / 41
Rules of numeric filing / Pages 208-209
Procedure 7-6
Procedure 7-7 / 42
When and how to purge files / Pages 211-212 / 39

(ICA) In-Class Activities

  1. Prior to completing Procedure 7-4, give the student at least ten words to place in alphabetical order as practice.
  2. Complete Procedure 7-4.
  3. Complete Procedure 7-5.
  4. Complete Procedure 7-6.
  5. Complete Procedure 7-7.
  6. Following review of the chapter and homework assignments, give a quiz on this chapter that includes the content and competencies listed for CAAHEP and ABHES.

(ICD) In-Class Discussion

  1. Name the five steps for proper filing technique.

(1) inspect (2) index (3) code (4) sort (5) store

  1. Which filing system is the most effective in protecting patient privacy?

The numerical filing system serves to protect the patient’s privacy as the chart (medical record) does not reference the patient name on its exterior.

  1. True or False?If a patient has not seen the physician for two or more years, it is acceptable practice to dispose of the record.

False; the patient may return. If the patient is deceased, forms may be requested for completion.

(HW) Homework Assignments

  1. Terminology Notebook. Assign unit for reading and have students define key terms and retain in a key term notebook for future reference.
  2. Have the student to research the state law for the length of time medical records must be retained for your state.
  3. Chapter 7, Unit 3 Workbook Assignment Sheet.
  4. The Critical Thinking Challenge, page 212.
  5. The StudyWare Challenge, Chapter 6. Have students take the Quiz in “Quiz Mode” and either email their scores to the instructor, or print the scores to turn in.

Presentation Tools

Note to Instructors: If you change Objectives or Assignments, don’t forget to change the slides accordingly.

Chapter 7, Slide 32 / Introduce the unit.
Slide 33 / Basic filing methods.
Click on the icon to play a brief video clip.
Slides 34-35 / Steps in filing.
Slide 36 / Removing and replacing medical records—using OUTguides.
Slide 37 / Paperless filing systems.
Slide 38 / Sections of a medical chart.
Slide 39 / Purging files.
Slide 40 / Locating missing charts.
Slide 41 / Alphabetic filing system.
Slide 42 / Numeric filing system.
Slide 43 / Have students answer the checkpoint questions on the slide to review the content in the unit.
Slides 44-45 / The Keys to Career Success slides emphasize the relationship of the material learned in the classroom to on-the-job success.

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