HEALTHSOURCE OF OHIO

POLICY:Medical Record

QI REVIEWED:June 17, 2008
January 17, 2006
August 16, 2005
April 7, 2004

January 2, 2003

EXECUTIVE REVIEWED:June 24, 2008
August 1, 2006

BOARD APPROVED:June 26, 2008
August 24, 2006

January 23, 2003

January 28, 1999

EFFECTIVE:January 28, 1999

The Manager at each center will be responsible for the maintenance, filing, accessibility, confidentiality, release and control of the medical records and medical record system. She/he will be responsible for the local enforcement of medical record policy and procedures. Individual duties in the maintenance and control of the records may be delegated but remains the responsibility of the Manager.

  1. Problem Oriented Medical Record
  2. A medical record (chart) utilizing standard forms and problem oriented SOAP format as outlined below will be maintained on each patient seen at HEALTHSOURCE centers.
  3. The standardized records system and Medical Records Policy will be reviewed and updated biannually by the Quality Improvement Committee.
  4. An updated copy of the Medical Record Policy will be filed in the Policy and Procedures Manual at each HEALTHSOURCE center.
  5. Each person whose signature or initials are in the medical record at that center must complete the signature sheet. See Appendix A.
  6. Variations to the standard medical format may be established on a center by center basis only after the approval of the Quality Improvement Committee or Medical Director in writing. The notice of this must also appear in the Medical Record Policies and Procedures filed at that center.
  7. Tab sets will be mandatory for all centers.
  8. A copy of the current Approved Abbreviation List will also be in this manual. See Appendix B.
  9. Records Management
  10. Confidentiality:
  11. There will be absolutely no staff discussion of patient problems or chart contents outside of the center or discussion of patient records within the center except for necessary business reasons. Breach of patient confidentiality on this basis is grounds for immediate dismissal of the involved staff member(s).
  12. Any paper with patient identification or medical information will be shredded before disposal.
  13. File Control:
  14. The chart file will be maintained in lateral files in a secured area inaccessible to cleaning personnel, maintenance, patients or visitors after working hours as possible.
  15. All charts will be returned to the active or inactive files at the close of the clinical day. No charts shall remain in physicians’, nurses’, managers’ offices, or other sites in the building. A “tickler” reminder system may be used for recall systems, lab follow-ups or patient follow up, but no charts should be left unsecured day to day for these purposes.
  16. All incoming lab and correspondence will be initialed by the provider then filed in the chart in a timely manner.
  17. The medical record of any patient may not be removed from the office for any reason other than court order, except for HEALTHSOURCE interoffice transfer.
  18. All centers will use a numeric filing system cross indexed by alphabetic Rolodex systems with one Rolodex for active charts and one Rolodex for inactive charts. (The exception is the Mt.Orab center which has an alpha system.) Printed or typed Rolodex cards will list the last name, first name, middle initial, birth date, and chart number of each patient. Rolodex system may be supplemented by computer system.
  19. Release of Information:
  20. Request received in the office.
  21. Authorization checked for validity. (If valid, proceed with the process. If not, retrieve valid request before going further.)
  22. Front office representative reviews chart for eligibility for processing fees and determine if the records are copied by the center, or if contracted service is utilized.
    NOTE: The Quality Improvement Committee states that two years of Progress Notes, Medication Lists, Problem List, and labs are to be copied for patients requesting records. If specifically requested any and all parts of the chart may be copied and released.
  23. Authorization is filed in the patient’s record with date of release, action taken and employee initials noted on the Authorization Form.
  24. If patient is transferring care to another provider then the patient’s chart is sent to storage and that information is entered in the Medical ManagerNextGen System noting the chart is in storage.
  25. If apatient is transferring care to another NetworkHSO office, copythe entire chart to be sent to that office, keep the original chart and a copy of the authorization in the chart with the transfer noted in the Medical ManagerNextGen System.

CHARGES: According to the State of Ohio rules and regulations

Patient transferring to another NetworkHSO office / No Charge
Patient transferring care to another physician/practice / $2.5984 per page for the first 10 pages, .539 per page for pages 11-50, .214 for each additional page
Patient requesting copies of records for themselves / $2.5984 per page for the first 10 pages, .539 per page for pages 11-50, .214 for each additional page
Continuity of Care / No Charge
Medicaid / No Charge
Attorneys requesting records (if applicable, per Smart Corp.HealthPort Fee Schedule)
Health Insurance / No Charge
Life/Auto Insurance (if applicable, per Smart Corp.HealthPort Fee Schedule)
  1. Chart Preparation:
  2. Pull medical record of established patient the day before the appointment. For new patients, begin new chart process.
  3. Stamp appointment date on the left side of the progress note. Add forms, stickers, and stamps as necessary. (a.) Year sticker on the jacket. (b.) Sex and age appropriate risk assessment sticker on the first appointment of the calendar year. (c.) Pediatric development assessment.
  4. When a patient signs in for an appointment, confirm the address on the sign-in label correlates with the patient demographic sheet and the computer screen. If necessary, update the patient insurance and/or demographic information and print updated information sheet to be placed on the left side of the medical record. Photocopy all information on the insurance card (front and back).
  5. Generate the patient docuscan form with the appropriate provider number and reason code and attach to the medical record.
  6. Charting on the Medical Record:
  7. The following persons will be permitted to make entries on the patient’s medical records: Physicians, State Licensed Professionals, professionals in training programs, and center personnel as permitted and as authorized to document on the patient’s permanent medical record according to State of Ohio law.
  8. To better identify the signatures of record, each person who is permitted to make entries on the patient’s medical record will be recorded on a signature list. It will contain the authorized individuals’ printed first name, middle initial or name, last name, professional designation, signature with approved professional abbreviations, initials, date of employment and date of termination. (Appendix A) It will be on file at the center. The Manager will be responsible for obtaining and updating all signatures.
  1. Record Configuration
  2. Exterior Chart:
    The outer chart jacket will be a lateral file, manila folder with a full cut tab on the right side and a cutaway on the top right corner with the following configuration:
  3. The patient’s name-last name, first name, middle initial, and the date of birth will be placed on the right hand corner of the cutaway on the back cover of the chart using a typed or printed label sticker. The patient’s legal name is used. Nicknames may be added if placed in quotation marks.
  4. A year sticker will be placed in the upper right lateral edge of the chart. The last year sticker will be covered with a new sticker when the chart is updated each year.
  5. For numeric systems, a color-coded patient chart number sticker will be placed on the lateral edge of the chart. For alpha systems, a name sticker, last name, first name, middle initial will be placed above a color coded first three letter of the last name sticker on the lateral edge of the chart.
  6. Interior Chart:
  7. A pediatric chart will be used for age’s birth through 11 years old. An adult chart will be used for ages 12 and older. (Exception: EastgatePediatricCenter uses pediatric chart birth through age 18.)
  8. The interior chart will consist of standardized forms, progress notes, laboratory reports and other patient information two hole punched at the top of each sheet and attached to the outside manila folder by machine bonded ACCO (or comparable) holders at the top right and left of the interior of the folder.
  9. Dividers must be used to separate Lab, X-ray, Correspondence and other sections.
  10. A separate divider will be used to identify a confidential section of the progress noted for material and information, which require specific Release of Information consent. (This includes Mental Health, drug addiction, sexually transmitted disease, and HIV treatment.)

The interior arrangement will be as follows (top to bottom): The only exception to this order is a Notice of Dismissal from practice, which must be placed above the Problem List on the left side.

LEFT SIDE
Adult and Adolescent
  1. Adolescent & Adult Problem ListOB Problem List ***OB ONLY***
    OB Guidelines/Appendix
    Laboratory and Education
    Genetic Screening/Physical Exam
    Smoking Cessation
    ACOG Menstrual/Medical History
    ACOG Plan/Education 1st,2nd,3rd Trimesters
    Ultrasound Report
    Individual Care Plan
    Social History
    Multi-Disciplinary Patient Teaching Record
    OB Education Checklist
    Oral Health History and Screening
    Proof of Pregnancy Letter
    Prenatal Risk Assessment
  2. Growth Chart (Adolescents to age 18)
  3. Chronic Medication List
  4. Depo-Provera Medication List
  5. Acute Medication List
  6. Abnormal Papanicolaou Test Results
    “Other” Tab
  7. Health Maintenance Sheet
  8. Database (appropriate for age)
  9. Physical forms for other agencies
  10. All Consent Forms (including Pain Management Contract)
  11. Privacy Notice
  12. Release of Information
  13. Request for Information
  14. Administrative Correspondence
  15. Advanced Directives
  16. MSP
  17. Work/School Excuse Forms
    “Referrals” Tab
  18. All Referrals
    “Insurance Information” Tab
  19. Patient Demographics
  20. Copy of insurance card
  21. Sliding Fee Application
  22. Authorization to Release Log
  23. Authorization/Revocation Form

Pediatric

  1. Pediatric Problem List
  2. Growth Chart
  3. Chronic Medication Sheet
  4. Acute Medication Sheet
    “Other” Tab
  5. Health Maintenance Sheet
  6. Database (appropriate for age)
  7. Developmental Assessments(Home & Safety Assessment optional)
  8. Format the same as Adult 8-18

RIGHT SIDE (dividers placed at named sections)

  1. Progress Notes *OB Records on top of GYN Progress Notes while pregnant, and after delivery filed under GYN tab in order of delivery.
    ACOG Antepartum Record
    ACOG Supplemental Visits
    ACOG Antepartum Progress Note
    Pain Management Forms
    Well Child Dental Examination sticker
    Menstrual Record
    “Confidential” Tab
  2. Confidential Notes and Reports, HIV Lab Reports, Behavioral Health referral form, PHQ form, BH Staffing Form, BH Insurance Verification/Pre-Certification Form, Montreal Cognitive Assessment, Mental Health, which require specific Release of Information Consent and Adult ADHD Checklist
    “OB/GYN” Tab
  3. Old Prenatal Forms: shingled GYN and Sports PE forms, Pregnancy Weight Records
    “Lab” Tab
  4. File labs in chronological order on shingled sheets on top of full sheet results
  5. Quantitative Beta-HCG Results
    “Radiology/EKG” Tab
  6. Radiology/EKG Reports, Pulmonary Function (both in and out of office)
    “Hospital Records” Tab
  7. Hospital records, including discharge summaries, ER reports, etc.
    “Correspondence/Letters” Tab
  8. Correspondence: including letters, outside physical exam forms, disability forms,peak flow record and prescription faxes
    ”Nursing Home” Tab
  9. All nursing home items filed in chronological order
  10. Completion Instruction for Individual Standardized Forms
  1. All forms shall have patient’s name-last name, first name, date of birth and chart number written at the top. A label system may accommodate this task.
  2. Problem List:
  3. After the initial assessment of the patient, any problem that the patient will have for an extended time (one year), in the judgment of the patient care provider will be entered on the Chronic Problem List. The physician or provider (Nurse Practitioner, Physician’s Assistant or Mental Health Professional) who identifies the health problem and prescribes medication will be responsible for maintaining and updating the problem list and medication list. This function may not be delegated to other staff members.
  4. Additional problems are added to the problem list, as they become apparent at subsequent visits.
  5. Allergies must be filled in. If there are no known drug allergies, write “NKDA”. If there are allergies, the type of reaction should be specified.
  6. Significant surgical procedures are included on the Problem List, but may be listed under one heading-eg. Major procedures of the head, neck, thorax or abdomen, especially involving neoplasm, any revascularization procedure, or any partial or complete resection of a major organ. Surgeries need not be listed as separate problems but may be grouped as above.
  7. Chronic problems are listed on the pre-numbered form along with the date of diagnosis.
  8. Educational handouts are documented in the right column by dating and initialing.
  9. Acute problems are listed on the pre-lettered form with the date of occurrence noted. If there is a recurrence of the problem, a new date of occurrence should be listed without rewriting the problem. If the right and left are involved, specify the problem to the left and put the side with the date, ie. not “ROM 3/12/93” but “OM R 3/12/93.”
  10. Acute problem list continues on the back of the form.
  1. Acute/Chronic and Depo-Provera Medication Sheets:
  2. The name of the chronic medication prescribed, dosage, and instructions are listed above the medication block at the top of each column.
  3. The date of refill, the amount of medication given and the number of refills are entered vertically in the column beneath the medication each time a prescription is written or a refill given by phone to the pharmacy. If not written by the ordering physician, this physician must initial refills.
  4. A vertical pen line is used to mark out a medication column to indicate that the medication has been discontinued.
  5. Acute medication prescribed is listed on the Acute Medication List with the amount given and number of refills clearly listed. Subsequent prescriptions of the same medication may be recorded in the boxes to the right, with the date, amount given and number of refills clearly listed.
  6. The Depo-Provera medication list will be renewed at one year intervals.
  7. Health Maintenance Sheet:
  8. The dates of administration of all immunizations are placed in the column horizontal to the listed immunization.
  9. Immunizations not pre-listed are entered in the left-hand column with the date of administration being placed next in the horizontal column to the right of the name of the immunization.
  10. The date of screening and the result of the screening test are listed horizontally to the right of the listed health screening exam or procedure. If further explanation is needed, an asterisk (*) is placed next to the result indicating that the progress note of that date should be consulted for further information.
  11. Pediatric Age Specific Developmental Assessment and Anticipatory Guidance Sheets
  12. The single sheet most appropriate for the age of the child will be selected. Only one sheet of each age is needed. The top portion of the sheet is completed by the parent/guardian.
  13. The lower portion of the sheet is given to the parent/guardian after completion of the top. The upper portion is filed on shingled sheets after the provider has initialed it. Documentation of the age specific anticipatory guidance will be assumed if the lower portion is not present in the chart and the upper portion is initialed. Alternatively, anticipatory guidance may be documented in the progress notes.
  14. (Patient Completed) Adolescent, Adult and Geriatric Data Base and (Parent Completed) Pediatric Data Base
  15. The front office will make certain the patient receives the age appropriate database for its completion.
  16. The patient, parent or guardian should complete the database sheet by the time of the initial visit. The forms are meant to be simple to read and self-explanatory so that the patient may complete the form. The physician may then review the form and write supplemental data or explanations on the sheet next to the entries. Nursing personnel will assure that both sides of the form are completed. The physician signs and dates the form after review.
  17. If a database is found unsigned, the patient is to be scheduled another visit to discuss the database. The physician will note in the medical record that the database was done, but not discussed. The database should then be filed in proper order according to policy.
  18. A database is completed on the initial visit, change of life cycle and to encourage annual well child visits age 3 and above and any annual health maintenance visit for adults.
  19. A major change in database should be documented in the Progress Notes and Problem List referring to the date of Progress Notes.
  20. Consents for Treatment and Special Procedures:
    See Consent for PHI Release and Use for Treatment, Payment or Healthcare Operations Policy. See Pain Management Policy.
  21. Progress Notes:
  22. The date of visit is stamped at the left of the sheet immediately below the last entry.
  23. The database update sticker appropriate for age is placed on the sheet at the first patient visit of each calendar year. (Note: Home & Safety Assessment stickers are optional)
  24. The standard intake is recorded.
  25. A brief note or chief complaint is recorded to the right of the date and signed by the recording nursing personnel. The provider will write or dictate progress notes to be transcribed in the following SOAP format.
  26. S Subjective portion will include the history or reported data concerning the problem(s).
  27. O Objective will include the physical and or laboratory findings relating to the problem(s).
  28. A Assessment will be the provider’s diagnosis, impression of the problem, differential diagnosis or discussion of the problem(s).
  29. P Plan will include the medications dispensed, instructions and/or education given, suggested follow up and test scheduled.
  30. Acute Medication and Chronic Medication must be clearly listed including the name of medication, dosage, frequency and amount prescribed.
  31. All oral, IM, IV or subcutaneous medications administered in the office must be recorded by the person giving the medication. The site of injection is also documented.
  32. Phone conversation with the patient, family members, or another health care provider is documented on the progress sheet or telephone message pad. If not made by a physician, the note needs a physician’s initials.
  33. All progress notes must be signed or initialed by the appropriate provider. If the name is typed in full with the professional designation, the signature may consist of the first and last initials.
  34. Account information is not part of the Medical Record and should not be recorded as part of the progress notes.
  35. All progress notes and entries must be legible and written in black ink or transcribed from dictation.
  36. Flow Sheet
  37. Parameters followed are listed in the left-hand column, eg. Hemoglobin AIC, blood sugar, Protime.
  38. The date of evaluation is entered horizontally in the top box with the results recorded in the box under the date.
  39. Laboratory Reports
  40. Laboratory results performed in the office are recorded on the In-Office lab slip and placed on the shingled lab sheet, after initialing by the provider.
  41. Small laboratory reports are shingled on the double adhesive sheets with the most recent report visible on the top.
  42. Full page labs are filed behind the shingled lab sheets and filed in chronological order.
Medical Records Policy

Addendum