Coding Manager Handbook -- Chapter 2: The Medical Record

* Medical Record Docmentation (requirements)
* Standard Documentation Criteria
* Medical Record Audits and Audit review forms
* The Legal Medical Record (Legal Considerations)
* The Personal Health Record (PHR)



In this chapter I will discuss the documentation of what is necessary for the medical record. I will give you documentation guidelines for both outpatient and inpatient medical records, a long-term care record, and also filing systems for care of the records. I will also discuss the differences between the standard medical record, the legal medical record, and the personal health record. Last but not least I will try to give you the basics of the electronic health record system. I will try and cover the basics of choosing a system, implementation, necessary documentation criteria, storage and retrieval, and types of systems available.

Medical Record Documentation – The necessary basics.
Every healthcare facility has a medical record of some type. All documentation by any provider must be recorded timely and accurately, be complete legible and properly maintained. Medical record documentation is critical, for care of the patient for current, past, and future medical needs. Documentation is also critical for billing and payment of the provider, for legal protection of the provider and the patient. The medical record also helps paint the picture for the next provider of care that follows the patient. The information contained within that record should show all aspects of that patient’s heath care. That provider of care may be a dentist, chiropractor, physical therapist, social worker, health researcher or any of the ancillary health care providers, in addition to our “garden variety” of family practice, general medicine, pediatric and internal medicine practitionersAll of these need to have access to the patients previous medical record, in addition to their own documentation being added in. this record is truly vital to any health care practice as it helps provide a continuum of patient care, and also provide some financial and legal cushion to the practice.
The basics of any medical record include administrative data such as patient demographic information, insurance and billing information, release of information, assignment of benefits and consent to treat. Clinical documentation should have the patient’s relevant history, or a current History and physicial report, any referrals/consultation/correspondence documentation from outside providers, ancillary laboratory reports such as x-rays, pathology or blood work, and a current medication list.
Why maintain the record? The medical record is an invaluable source of information and record of the patient care. This includes a record of care for current and proposed treatment or procedures, this also provides a record to assess completeness, medical necessity and quality of patient care. Most outpatient records are not used for data mining, but inpatient records are abstracted for their data for research purposes, and legal justification of procedures if necessary.
Maintaining, or documenting in the record should be standardized for each practice, with an entry made for each time a patient is seen or evaluated. Be sure that you identify each entry with the date/time, and have a signature and title of the provider. All documentation should be legible. It doesn’t matter if the documentation is typewritten or handwritten, but if written, should be in black or blue ink. Do not “erase” or “white-out” any of the errors. If an error is noted, simply strike through the entry with a single line, and enter that this is an “error” initial and date with your initials above the error, then enter the correct information. Use abbreviations sparingly, and be sure to use only those that are approved well-known, or standardized for your healthcare specialty. If you do use unusual or “in-house” abbreviations, it is helpful to have an abbreviation key readily accessible to avoid any misinterpretation of the data contained within the record.
Records retention is always a concern, and there is not a “standard” timeframe for a medical record. State law determines how long those records are to be kept. However, you can transfer the data from hard copy, or electronic format to a storage facility (again hard copy or electronic) to save space. The ideal situation, is to have ready access to those records if the patient suddenly presents for care, or you need to release a copy of those records to an outside provider, or for a legal reason. It should be noted however, that the record itself is the physician or practice’s property, but the information contained within belongs to the patient. The patient is in control of the amount and type of information released, unless it is excepted by law. You cannot refuse patient access to their record, or the information contained within, but you can request that the patient be supervised if they would like to view their record, or you can choose to charge them for a copy of their record(s).
Documentation guidelines for dictation within the record normally follows a specific format. The most popular format amongst providers is the SOAP format or method. The other methodology for documentation is the POMR Method. This is the “problem oriented” medical recording method.

SOAP is the acronym that stands for :
S – Subjective findings
Patient’s Chief Complaint (CC)
History of present/presenting illness (HPI)
History’s, Patient’s Past Medical/Surgial, Family, Social, (PFMSS)
Review of Symptoms (ROS)
O – Objective Findings
Examination of the patient, and the results thereof
A – Assessment
The diagnosis, or impression of the compilation of complaint and findings together
P – Plan
This is the proposed or undertaken treatment for the above assessment
This includes prescribed medications, patient instructions, and or recommendations or referrals for other procedures or testing, or even admission for hospitalization

POMR is a bit different than the SOAP format, as POMR has essential components that are documented. These essential components are:
Database:
Complete patient history and information from complete examination and tests, also known as
t the clinical assessmsent
Initial Plan(s)
A complete detailed plan outlines the course of proposed treatment
Problem List(s)
A running list of the patient’s problems. current and historical
Documentation of completion of patient visit (SOAP notes)
Treatments or recommendations are documented within the record.

When putting together your basic medical record into a new office, standardization of the medical record should be put in place as a compliance policy of the office. In the table below, you will find a 25 point “checklist” of what should be included within your medical record(s) . Standardization of the medical record makes it very easy to train all staff in what does/does not belong in the record This checklist can also be used when performing routine internal compliance audits of your medical record. Some practices are subject to compliance audits for federal, state or legal reasons, which again, if you have a standardized medical record format being followed, it is much easier to retrieve and justify the medical documentation

25 Point Standard Documentation Criteria for use within an outpatient/office medical record.

Standard – Outpatient/Office Record
1. Elements in the Medical Record are organized in a consistent manner  The Medical Record is clearly and consistently organized

 Records are organized in chronological order

 Medical record does not contain information for other patients.
2. Medical Records are maintained and stored in a manner which protects the safety of the records and the confidentiality of the information  All medical records are to be stored out of reach and view of unauthorized persons

 All staff should be trained in record confidentiality and correct release of record information

 All electronic medical records will have access compatible hardware and software that will generate a legible copy of the record in order to comply with a patient, governmental, legal , or 3rd party payor request for record review, or ability to maintain a current electronic back-up of the electronic medical file.

 Ability to scan or insert hard-copy records into an electronic format into the electronic health record and be able to generate a copy and or backup as above.

 Record retention will be adhered to as per State, Federal or international or appropriate governing laws for Medical Record retention.

 Discarded or purged records shall be eliminated by the following methods:

1) Paper records: by incineration, shredding, pulping, redacting or other compatible process which renders the records permanently unreadable.

2) For electronic format such as computer disks, flash drives, tapes or microscan files, these must be completely purged and “wiped clean” or sanitized and re-formatted, not simply “erased or deleted”

3) For media such as film, photos or CD/DVD files, or any other type of recording media, the media should be destroyed with no possibility of recovery, to include crushing, incineration, and or “electronic purge” which can completely “wipe clean” or “sanitize and re-format” not simply erase or delete the information.


3. Patients name or identification number is on each page of the record  Each record should have either the patients name, or a unique identifier on every page of the record,to include both front and back pages of the record if documentation is on both sides of the page.

4. Entries are legible  Entries that are handwritten must be legible to a reader other than the author.

 Content of the record is presented in a standardized format that allows the reader to understand the content without the use of a separate legend and or key identifier

 Entries shall be made in Blue or Black ink.

 Errors shall be noted with one strike-through, with the notation of the word “error”, initialed and dated, corrected information to then be documented and initialed and dated.

5. Entries are dated  All entries must be dated at the time of entry documentation.

 Physician based visit documentation should be posted within the record within 72 hrs or three business days.

6. Entries are initialed and/or signed by the author  All entries need to be initial or signed by the author. However, this may be a handwritten signature or initial, a unique electronic identifier or initial, and this applies to all staff who document or contribute ANY information into the medical record.

 When initials are used, there should be a designated “key” on file within the office, as to who the initials belong to, and the same for each signature on file.

Standard – Base Line Data
7. Personal and biographical (demographic) data are included in the record  Demographic information is to be documented and include information necessary to identify the patient

 Patient’s current address and insurance billing information to include group number, policy number and current claim processing address/phone number

 Current Signature and Consent for treatment, in addition to consent for billing 3rd party payor insurance on file

 Copies of currently insurance cards – to be updated as necessary

 Demographic information may be maintained in a computer database as long as it is retrievable and can be printed as needed to transfer the hard copy record or to another practitioner or for monitoring and or clinical test/clinical trial purposes

8. An Initial H&P examination for new patients are recorded within 12 months of a patient first seeking care or within 3 visits whichever occurs first

Past Medical history is documented and includes serious accidents, operations or illnesses

Family history is documented

Birth history is documented for patients under the age of 6.  Within the initial visit (H&P) for new patients, there should be written evidence that the request for prior (or historical) medical records from the previous provider of care have been requested (if rec’d filed appropriately into the chart)

Documentation to be included:
 Initial H&P should be patient pertinent information such as age, height vital signs, past medical, mental heath, preventive health, screening health information, in addition to the currently chief complaint, Past Family, Medical, and Social history,

 Review of systems, patient questionnaires or data, Immunization history, prior surgical interventions, current and past medication lists.

 Pediatric history should contain birth history documentation and should be age appropriate
9. Allergies and adverse reactions are prominently listed or noted as “none” or NKA  All allergies (environmental, physical, and medication should be displayed in a prominent place on the record.

 A notation of when the allergy was first discovered should also be included if known.

10. Information regarding personal habits such as sexual behaviour, smoking, alcohol, use, substance use or abuse or lack thereof is recorded.
 Documentation of “social” history is to be treated with extreme confidentiality, especially in the cases of sexual behavior, drug use/abuse, alcohol use/abuse, tobacco use/abuse, sexual orientation, Gambling or addictive behaviors, exposure to sexually transmitted diseases or aberrant behavior of any type.
11. Updated problem list is maintained  A current and on-going “problem list” shall be maintained to summarize important patient medical information such as a patient’s major medical diagnosis, past medical/surgical history and recurrent complaints.

 Continuity of care between providers within the same practice should be demonstrated by each provider contributing to this documentation and by initialing, or signature if contributing or reviewing.

Standard: Visit Data

12. Chief Complaint or Purpose for visit is clearly documented  A chief complaint is the purpose for the visit as stated by the patient, and is recorded I the record.

 Documentation supports that the patient’s perceived need/expectation was/is addressed

 All telephone encounters (and or e-mail/internet encounters) relevant to medical issues are documented in the record and reflect the provider reviewed and/or acted upon the data.

13. Clinical assessment and/or physicial findings are recorded. Working diagnoses are consistent with the findings  Clinical assessments and physical examinations are documented and correspond to the patient’s chief complaint, purpose for seeking care and/or ongoing care for chronic or worsening illnesses.

 “working” diagnoses or medical impressions that logically follow the clinical assessment and physical examination(s) are recorded.

14. Plan of action and or treatment is consistent with diagnosis (es)  Treatment plans (proposed or enacted) therapies or other regimens are documented and logically follow previously documented diagnoses and medical impressions.

 Rationale for treatment decisions appear medically appropriate and substantiated by documentation in the record

 Laboratory tests are performed at appropriate intervals, and follow medically accepted guidelines for theordering of specific lab tests based upon “working diagnosis”, confirmed or chronic illness, or “rule out” dignosis confirmation.

15. There is no evidence the patient is at risk by a diagnostic or therapeutic procedure
 The medical record should always show clear justification for diagnostic, therapeutic and interventional procedures.
16. Unresolved problems from previous visits are addressed in subsequent visits
 Continuity of care from one visit to the next is demonstrated when follow-up of unresolved problem(s) from previous vists is/are documented in subsequent visit notes.
17. Follow up instructions and time frame for follow-up or the next visit(s) are recorded as appropriate  “Return to Clinic/Office/Provider” in a specified amount of time is recorded at the time of the visit, or as a follow-up to a consultation by a specialist, outside provider of service, such as laboratory, radiological or other diagnostic care provider.

 Follow-up is documented for patients who require specified periodic oversight for chronic, or episodic illnesses for reassessment, or medical clearance.

 Patient involvement in coordination of care is demonstrated through the use of patient education, follow up and return visits.

18. Current medications are documented in the record and notes reflect that long-term medication are reviewed at least annually by the provider and updated as needed  Current and past prescribed medications are easily found within the record.

 A current listing of over the counter medication that the patient is currently taking is also readily accessible.

 Changes to any medication regimen is noted when it occurs. If the regimen is to remain unchanged, the record needs to include documentation that the provider reviewed and decided to continue as initial prescribed, or denote that no changes will be made at this time.

 Medication review should be documented and initialed by the provider/prescriber.

 All medications (prescribed and OTC) should be reviewed on an annual or on-going basis.

 If the patient is being seen by numerous physicians, providers, specialists, document (if possible) those medications who’s oversight is being done by the initial prescriber.

Patient Education
19. Health care education provided to the patient/family members or caregiver(s) is documented in the record and updated as appropriate  Patient education may correspond directly to the reason for the visit, i.e. specific diagnosis-related issues such as dietary instructions, medication instruction/usage, DME care

 Non-compliance of said education/counseling is to be documented

 Patient education must be problem pertinent
Screening and preventive care

20. Screening and preventive care interventions are noted according to AMA guidelines  ,Counseling or education is given within the confines of a “wellness adult exam”, “well child check” or “preventive medicine/preventive illness” examination

 Preventive services from an outside provider should also be noted. (eg Pap test performed by OB/GYN)

21. Immunization records are completed and updated as given or due  Immunization from birth to present should be noted within the record.

 Current immunization given should also be noted even if provided by an outside provider of care.

Consultation/Specialty referrals
22. Requests for consultations are noted and filed within the record as appropriate  The provider of care should document clear decision rationale for a specialist referral or intervention(when needed) (eg when ortho requested for fracture, ENT requested for unresolved sinusitis etc..)

 Referrals or consultations are provided in a timely manner and the patient’s diagnostic severity is considered.
Ancillary, Diagnostic, Therapeutic services
23. Laboratory and diagnostic reports reflect that the provider has reviewed and provided interpretation as necessary
 A procedure or plan should be in place that as soon as the laboratory or radiology reports are received into the office, the medical record is retrieved and the reports are attached to the record.

 The ordering provider, or current provider of care should review, interpret and initial and date, or sign and date that they have reviewed the tests.

24. Patient notification of the laboratory and diagnostic test results and instructions, and follow up care are noted and documented when appropriate
 If any further testing or therapy is to be performed, that the request for this to be carried out is documented in the record

 The patient needs to be notified of their lab/radiology/pathology test outcomes, and any further testing or follow up noted.
.
 If notified via telephone call, documentation needs noted within the record

 If notified via hard copy, then a copy of that documentation needs filed within the record.

Continuity of Care
25. Continuity of care and coordination of care with other/outside providers such as primary and specialty providers is noted and documented within the record.  Communication and coordination of care regarding the patient care needs documented either via telephone call (with handwritten documentation in the record the call was made and the outcome)
 If notification and coordination of care is faxed or on hard-copy those documentations should also be filed within the record. (i.e. referrals to/from specialists etc)



Now that you’ve got your records documentation standardized, you will need to decide upon how you want to file these records within your office. There are numerous types of filing systems for office, but the most commonly used for hard-copy records within the office setting is the “color coding” alpha, year format. With this type of format, the color of the chart is chosen by the first letter of the patient’s first name, the charts are then filed by color, by patient last name (which is put on the colored file folder) , by current year (i.e. 08, 09) which is then also denoted on the chart. Some offices utilize a one color of chart or use a manilla chart, and file all charts alphabetically, by year. This is very common in long-term care facilities, or behavioral health facilities.
Inpatient records have basically the same standard format as an outpatient record, except these records are created and filed as 1 record “per admission” rather than each patient having 1 record with all the admissions contained within. The inpatient record closely resembles the outpatient record. Below, I’ve attached the table for the “standardized” format of the inpatient record. Inpatient records will vary depending on which area of the hospital and what is contained and required for each department.
Basic Inpatient Record Content
Content of the basic inpatient medical record  The medical record will contain sufficient information to identify the patient, and to support the diagnosis, justify treatment and document the course and results. These records must contain:
 Patient identification data to include the patients name, address, date of birth , next of kin, a unique identifying number and consent forms.
 History and Physical form to include Chief complaint, History of present illness, relevant Medical past/family/social history
 Review of body systems
 Physical Examination of patient
 Diagnostic and therapeutic orders
 Reports of procedures and interpretation and findings
 Any clinical observations related to patient care
 Discharge Summary
 Principal, and Secondary Diagnosis,
 Operative and/or diagnostic procedures performed
 Physician Signature/Attestation
Anesthesia Documentation
 Topical
 Local
 Regional  Preoperative Anesthesia Note
Must include an anesthesia history and risk of anesthesia by an anesthesiologist or CRNA
 Postoperative Anesthesia Note
Post Anesthesia recovery must document any allergic or abnormal reactions to anesthesia. Also document the patient’s medical condition prior to, during and afater the procedure. And Upon discharge must identify any significant problems, or need for follow up.

Operative Reports/Surgical Documentation
 Inpatient Operative Procedures
 Outpatient Operative Procedures
 Day Surgery/Ambulatory Proc.  Pre operative note including pre-op diagnosis
 Indications for surgery
 Contemplated procedures
 Reasons for proceeding in a high-risk case
 Post operative Findings and Diagnosis
 Submission of specimens to Laboratory or Pathology
 Name of the primary surgeon and assistant surgeon(s)
 Description of the procedures
 Description of the incision
 Technical procedures used
 Method of closure
 Drains or other medical devices utilized or implanted into patient
 Condition of the patient at conclusion of the operative procedure
 Any other pertinent data
Discharge Summary
 Should be completed with 30 days of discharge/death  Reason for admission
 Primary and Secondary diagnosis(es)
 Clinical course of admission or treatment
 Any significant findings
 Procedures performed
 Treatment rendered
 Discharge examination of patient
 Discharge planning notes reviewed and evaluated
 Patient condition at discharge
 Specific instructions for patient and family.
 If patient leaves AMA, it should be duly noted.
Progress Notes
 Progress notes must be written and signed within a 24 hour timeframe  Document any changes in patient’s condition
 Document any changes in treatment modality, or medication orders
 Progress from therapies (such as RT, OT, PT)
 Results from treatment
 Discharge planning and coordination of care with ancillary departments



Long Term Care (LTC) Facilites (acute care, skilled nursing facility) documentation is a combination of the Inpatient and Office type medical record. Documentation for these records needs to be “reasonable and necessary”, plus provide care appropriate to the patient who cannot be discharged to a home environment. Again, the basics of the record should be employed such as the basic inpatient record criteria and content for documenting within the record, and patient demographics, consents, and billing information criteria are the same.. The listing below outlines what documents are normally found within the LTC record.
 Pre-Admission screening and any additional appropriate updates
 Acute Care (Inpatient Hospital) H&P
 Acute Care (Inpatient Hospital) Discharge Summary
 Acute Care (Inpatient Hospital) transfer record (and orders0
 LTC H&P
 Current Physician Orders
 Current Physician Progress Notes
 Physician Consultation documentation
 LTC Discharge Summary
 Diagnostic Lab orders, indications and results
 Surgery or procedure intervention documentation
 Documentation to support and interrupted stay
 Documentation to support any and all procedures ordered and/or performed
 Nursing documentation is to include initial and daily assessments, treatment records, wound care documentation, medication administration records, fall risk assessments, and ADL’s (Activities of Daily Living)
 Respiratory care documentation of initial and daily assessments, ventilator management logs, respiratory plan of care, treatment goals, units of treatment provided
 PT, OT and Speech-Language Pathology documentation of initial and daily assessments, plan of care, treatment goals and units of treatment provided.
 Nutritional Therapy documentation of initial and daily assessments, plan of care, and patient goals.
 Case Management, Medical Social Work documentation to include admission screening tools, discharge planning, coordination of team goals and plan of care.
 Team conference documents for the entire LTC facility stay to include all discharge plans, coordinated plans of care, conference attendees and titles (to include physicians, NP’s or PA’s)
 Documentation to support the need for complex LTC i.e. “reasonable and necessary” for appropriate patient care based upon the patients current medical status.

Each facility, whether an office, outpatient, or inpatient can and will have different formats for how the documentation record is to be organized within the chart. All need to adhere to the basics of what should be entered into each and every chart.

Medical Record Audits and Audit Review Forms
Coding managers are normally charged with completing or having to have completed pre and post medical record and coding audits. These audits can serve many different purposes. Once you determine the focus of your audit, you will need to have specific audit tools to obtain the information you require from the medical record. Most audits that will be performed will be looking for data such as:
 Facility or Office policy regarding compliance
o All Signatures and initials are documented with specified timeframes
o Record is complete, and legible
o Patient identifiers are on every page
o Billing information such as CMS 1500 and UB82’s have been filed
o Patient demographic information is current, and consents are signed.

 ICD9 Diagnosis, ICD9 Procedures, CPT Procedures are validated by comparison to the operative/procedure notes, admitting and attending diagnosis(es) and discharge diagnosis(es)

 Complications and adverse events are properly recorded and documented

 All billing records that are filed with insurance carriers via the CMS 1500 or UB82 are validated by comparison to the operative/procedure notes, admitting and attending diagnosis(es) and discharge diagnosis(es), to include any modifiers

 RVU, DRG, APC, assigned values are validated against the billing that was filed with the 3rd party payors.

 Medical Record Audits much also clearly demonstrate that the care was medically “reasonable and necessary” (as defined by CMS) and appropriate for the diagnosis and condition of the patient during the visit, admission, or procedure.

The audit of the billing record(s) will ensure that the diagnosis and procedure codes billed and reported to the 3rd party payors match what has been documented in the H&P, Operative/Procedure records, Progress Notes and discharge summary

THE LEGAL MEDICAL RECORD – Legal Considerations

Currently, the term “legal medical record” is interchangeable with the term“medical record”, however there are some subtle differences. For legal purposes, most written (or handwritten) records are condidered “heresay” and not admissible in a court of law. However, medical records or “legal medical records” are considered a “business-type” record, similar to business records such as sales receipts, accounts payable, accounts receiveable records. If the basic medical record documentation is recorded accurately and timely as per policy (or law if applicable) and kept as a representation of your “medical business” and considered as an “official recording” of what happened between the patient and provider of care, then the record can be considered a “legal medical record” and is admissible with court systems.
It should be noted that no matter how “good” the documentation is, it may or may not represent good or bad medical care provided by the physician. A patient has the right under HIPAA law to dispute any and all recorded documentation by a provider in regard to the patient’s care, and documentation of service. A well documented record is also an asset in legal cases of malpractice. If your record is poorly written or has many areas that are “blank”, “disorganized”, incomplete, or missing large areas of documentation, this can appear to a court of law, that the practice, or provider of care, may have areas of incompetence, or be negligent in regard to patient care .
In some cases, the billing record is a separately identifiable record. The billing record stands alone, and the medical record stands alone based upon what is documented within each record. However, under HIPAA, both billing records and health (clinical) records are considered protected health information (PHI). There are cases in which the medical record needs to be kept in a “lock box” of such. Those are normally records that are being reviewed or needed in an on-going legal process. Some of these legal processes include treatment of a victim in a crime, the offender of the crime, or even the birth records of a baby being adopted out. These records require additional security. The protocol for releasing copies of these types of records have specific State and Federal laws that must be abided by. In the case of normal day-to-day medical records, it is protected from unauthorized disclosure by law, and use of consents to release records need to be utilized in all areas of medical practice. HIPAA law also covers confidentiality, and release of medical information. HIPAA law allows for disclosure of the medical without a signed patient consent for healthcare providers who are directly involved in the clinical care of the patient, for medical offices who need to access the record for the purpose of obtaining payment from a payor for care or treatment of the patient, and the record may be released for routine healthcare activities such as documentation review, quality management review, safety issues/risk management issues, and if requested by a government entity for legal or criminal proceedings.(i.e by court order, subpoena or other legal directive)
Within the legal medical record there should be some internal mechanisim for documentation/release of record accountability. This documentation needs to record and authenticate all releases of records. Within that documentation, it needs to show who performed the release, what records were released, and where the records were released to.
It is advisable for any coding manager to have a good grasp of the law regarding release of medical records within their organization, and state. If you are unsure whether or not to release a record, choose to delay the release until you can legally verify that those documents can be copied and released. Always err on the side of caution. If you are employed in a large facility, your Risk Management department can usually give you the most current information.

THE ELECTRONIC MEDICAL RECORD/ ELECTRONIC HEALTH RECORD (aka EMR/EHR)
The verbage of “electronic medical record” and “electronic health record” are interchangeable. A good definition of what an electronic medical record is a medical record in a digital format. Deciding upon an EMR is a huge task. They come in many different types and variations for single provider offices with simple record keeping and documenting, to an “all inclusive” EMR with transcription capabilities, Medical billing interfaces, with all the “bells and whistles”. No EMR is “perfect” even though the software is getting better and better all the time, there are still flaws inherent in all systems.
HIPPA , privacy and security laws also play a part, as your EMR must be able to document who has accessed the records, recorded, authenticated, into the record. In addition, the electronic software must also have the capability to store and retrieve records when needed . `-There are many resources for practices to look at prior to implementing an EMR.. Some practices have implemented what is known as a “hybrid” record, which utilizes both a “paper chart” and an “electronic chart”. Some practices have even begun scanning old paper chart records into the digital record for convenience rather than using both a paper and digital format for their documentation purpose.
In addition to the electronic medical record, many practices want to bundle their patient management/billing systems with their EMR. Some of the benefits of an EMR/HER is a reduction of medical errors, increase physician efficiency, improve documentation, reduce costs, and have a standardized documentation methodology for all of your records, and the ability to fax physician orders and prescriptions directly to other providers. Some of the barriers to an EMR/EHR is physician reluctance to use a data system, poor project management and implementation strategies, technical challenges (i.e. not enough IT support, or hardware/software issues, clinic financial impact to the up-front expense of converting to an electronic record, and frustrations of slow or poor performance of the record systems. Once you have decided upon converting to an EMR, here are a few ideas to get the project started:
 Identify the staffing needed/required for the EMR/HER projct
 Define the project management requirements and goals
 Understand the EMR hardware, software and/or network configuration tasks
 Introduce the EMR “workflow” concept for all areas affected (office and clinical)
 Review training strategies for the physicians, clinical and office staff

Change will happen! Be sure to include the staff and keep them apprised of all the changes that can and will be happening with an EMR/HER conversion or implementation. These changes WILL affect how the provider and clinical staff interact with patients and the office staff. These changes can and will affect the coding processes, the billing processes, how patients transition through the office. New taks and assignments will be happening. Your staff will have to realize that their “job functions” will change. If those changes are going to be long term, you should change their “job descriptions” to match these changes.
Currently there are 2 forms of implementation process for an EMR/HER.
 “The Big Bang” which is a full-blown switch from paper charts/record documentation to a full fledge EMR/EHR system deployed all at one time on a prescribed date.
 “Modular – Phase-in” method. This method allows for secquential implementation of the EMR at timed intervals and assessing success/failures as they are implemented.

There are pro’s and con’s to each of these methodologies. The “big bang” is initially more work, and more “pain” so to speak, but with the rapid deployment, also comes quicker acceptance of the changes by staff, and hopefully a quicker return on your investment. With the “modular – phase in” approach, there is less disruption to your practice, but employee and physician acceptance may be also slower, and have more criticism to the “faults” or “failures” that may be real or perceived by the implementation. Also, with the phase in – it may be more long-term out of pocket expense for project management, hardware and software IT support, and most of all – physician support!
You will want your EMR to document some of these basics… I have outlined these basics in the table below:
Documented into the EMR/HER by: Who What/Where
Receptionist/Billing Front Office Staff  Patient Demographic Information
 Patient Insurance Information
 Release of Records
 Consent to Bill, Consent to Treat
Nurse  Vitals
 Chief Complaint
 Subjective Information
 Past, Family, Medical, Social, History’s

Physician/Provider  Review of Systems
 Examination
 Medical Decision Making
 Orders such as Lab/X-ray/Pathology Requests
 Referrals to outside providers
 Documentation of Prescriptions (faxed or handwritten)
 Electronic Signature or attestation of provider/physician
Coding/Check out staff  All procedures and diagnoses correctly assigned to correspond with the provider/physician documentation
 All modifiers correct appended
 CMS 1500 filled out
 Appropriate co-pays collected
 Billing of the claim to 3rd party payor(s)

Planning the implementation of the EMR will be critical to the success or failure of the EMR/EHR for your practice. I love the saying “fail to plan, plan to fail” as that really sums up what happens with an EMR. Other critical implementation factors are the ability to flexible with the timelines, and know that those timelines may need to be adjusted, expecially if you are doing a “phase in” type conversion. If you are doing a “big-bang” conversion, you may have to evaluate if there are any “showstoppers” or critical issues that are identified prior to the “go-live” date.
Careful planning and training of the staff will also aid to the success (or failure) of the EMR conversion. Communication with the staff is vital, but within that communication, involve your staff in the processes of planning and training. Get their input and ideas. Many times, those who are working directly with the systems are the ones with the best ideas of how to make is successful. In addition, if the staff has bought into these processes, they will be more productive and effective when the final go-live, or full implementation takes place. Don’t place unrealistic expectations upon the staff or physicians. The learning curve of EMR implementations is usually underestimated. Even if productivity is still “the same” in the front office, it may be taking the physician or providers more time for documentation, therefore the the amount of patients seen per day by the providers are less.
Training, Training, and more Training! A good tool for training is to designate “super-users” who can help all staff learn and become proficient in all areas of the EMR/HER. Be sure to perform lots of “mock scenarios” to simulate all types of situations that could possibly happen. Once the staff is comfortable with the processes, reinforce the knowledge with mini-test scenarios, using verbal, written, and real-time “tests”. Do the same thing for the physicians, providers, and clinical staff. In addition to their training, once you “go live” reduce your practice schedule for a “reasonable” amount of time. This amount of time, should be determined by how comfortable the front and back office feels about the implementation, and you as the manager see how things are progressing. As things begin running more smoothly after the implementation, gear up the schedules back to the “normal amount”. In summary, PLANNING, PLANNING, PLANNING, TRAINING, TRAINING, TRAINING, will lead to EMR implementation SUCCESS!!!

THE PERSONAL HEALTH RECORD (PHR)
What is a personal health record? This is a record that is created and maintained by the individual upon which it pertains. The “ideal” is that the PHR contains a complete summary of the entire health and medical history of the patient. An electronic PHR would ideally be able to be contained in a computerized data format that could be accessed by medical personnel. The idea of a PHR is a relatively new concept, but is gaining momentum based upon the fact that more and more of the population has access to electronic data via personal computers, hand-held data tools such as cel phone’s, laptop and mini-laptops and PDA’s. At this time, there is not a “formal” or “mandated” information set to be held within a PHR. The most common data that is held within the PRH is
 Personal demographic information
 Emergency contact information
 Date of your last physicial
 Name of your current Medical and Dental Providers of care
 Your blood type
 Allergies and adverse allergic reactions (such as to specific drugs, or medicines)
 What current medications are being taken (both over the counter and prescribed)
 Chronic and Acute illnesses and hospitalizations
 Surgeries
 Vaccinations (such as flu, pneumonia, or tetanus)
 Current lab tests and results
 Personal and Family health history
 Living Will or End of Life plans
No matter which type of data storage you choose, Paper, Personal Computer, Portable Computer, or Internet based, be sure to update the information on a regular basis, and let your family and providers of medical care know that you have a personal health record, and how they can be part of the accessibility, or interchange of the data.