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Medical records have a long history in medicine. However, standardization of those records doesnâ€™t. Early on, physicians kept sporadic notes on a patientâ€™s health care. It wasnâ€™t until 1928 that the American College of Surgeons, or ACOS, decided to implement standards for improving health care, including the standardization of medical records. The ACOS realized that physicians could provide better care for patients when there was documentation of their medical history and treatment.
To oversee these improvements in medical records, the ACOS implemented the American Association of Record Librarians. This organization is still in existence today, but itâ€™s now known as the American Health Information Association, or AHIMA.
You may be wondering how weâ€™ve moved from no records, to standardized paper records, to todayâ€™s electronic medical records. The healthcare industry became interested in using computers as early as the 1960s, when computers were becoming more popular. However, not many computers existed, with only around 2,000 computers being used in the United States in 1960! Computers were also very different from what we know today. They were very expensive, and the processors were huge. You may have even seen some early photographs of computer systems that took up entire rooms!
It wasnâ€™t until the 1980s that healthcare organizations started using computers.
Many started with transitioning their master patient index, or MPI, which lists all of the patients and the dates they were seen in the hospital, into an electronic format that could be stored on a computer. Computer systems back then werenâ€™t like we know them today. The different computer systems werenâ€™t able to â€œtalkâ€ to each other and share information. For example, a billing office system might not have been able to share information with the system in the medical records department or the pharmacy. However, computer manufacturers and software companies continued to work on improving technologies throughout the 1990s.
In 2000, a real emphasis was placed on creating a true electronic medical record that could share information across departments and, in some cases, across different healthcare facilities within the same network. The Centers for Medicare and Medicaid (CMS) headed this push as a way to reduce documentation errors that were resulting in patient harm and even death. The CMS also wanted decision-support systems that would help physicians and other healthcare providers make better choices.
Today, most healthcare facilities have hybrid medical record systems, meaning that they use both paper-based and electronic medical records. Converting paper medical records can be time consuming and costly, so many facilities still have some medical records on paper. However, the Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law on February 17, 2009, to help promote the adoption and use of health information technology.
To encourage healthcare providers to implement electronic medical records, the CMS created the Medicare and Medicaid EHR Incentive Programs to â€œprovide incentive payments to eligible professionals, eligible hospitals, and critical access hospitals (CAHs) as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology.â€ Incentive payments can range from $44,000 to just over $63,000.
Weâ€™ve taken you through a brief history of the medical record, all the way up to where we are today. Now, letâ€™s take a closer look at the traditional paper-based record and then the electronic medical record to give you a better understanding.
Medical records are legal documents that contain all of the medical history and treatment information on a patient being seen by a healthcare provider. In a paper-based record system, each healthcare provider maintains his or her own medical record on the patient. This can create issues when a patient has been seen at one hospital and then later is treated at another. In some cases, one healthcare provider may need to request a copy of the patientâ€™s record from another healthcare provider to completely understand the patientâ€™s medical history and previous treatment.
Medical records can include the following:
- Patient demographic information
- History and physical reports
- Laboratory reports
- Progress notes
- Therapy notes
- Surgical reports
- Nursing notes
Medical Record Formats
Although information and reports may be similar, not all medical records are formatted the same way. The layout and format of a medical record depends on the type of healthcare facility and its particular information needs.
Chronological medical records are one of the most common medical record types used in health care. In chronological records, each patient visit is sectioned by date. For example, all of the December 3, 2016, information is filed together in the record. Then, the patientâ€™s March 14, 2017, visit information is filed together on top of the December 2016 visit.
Problem-oriented medical records, or POMRs, list a patientâ€™s â€œproblemâ€ or diagnosis, at the front of the record. Whenever new issues are identified with the patient, theyâ€™re noted on the problem list. This helps healthcare providers quickly identify patient issues and also identify trends.
The POMR is divided into four parts:
- Problem list
- Progress notes
SOAP charting is a common approach used by physicians thatâ€™s often also taught to medical students and other healthcare professionals. Itâ€™s referred to as â€œSOAPâ€ based on the first letter of each section:
SOAP charting can actually be part of another medical record format. For example, physician notes may use the SOAP format, but all the other reports in the record may be in the POMR format.
The source-oriented medical record, or SOMR, is a commonly used format in environments such as clinics. The patient information is in reverse chronological order, with each report or note type filed together. For example, if a patient was in the hospital for surgery on March 31, 2017, and then again for surgery on November 2, 2017, the November 2 information would be filed on top of the March 31 information. Each section, such as progress notes, surgical reports, X-rays, nursesâ€™ notes, etc., are each sectioned within the record. So, all the progress notes are together, all the surgical reports are together, etc., with the most recent date filed on top.
One of the biggest complaints with this format type is that itâ€™s difficult to identify patterns or see all of the information about one hospital stay or office visit because itâ€™s filed in different sections.
Doâ€™s and Donâ€™ts of Medical Records
As we mentioned earlier, medical records are also legal records. Not only do they help the healthcare provider to understand a patientâ€™s treatment, but theyâ€™re also used to communicate with others about what happened with the patient during the physician encounter or hospital stay. That means that many people may see and use the information. Because of this, there are important guidelines to follow when documenting information in the patientâ€™s medical record.
When documenting in the patientâ€™s record:
- Document only facts.
- Include everything thatâ€™s done and discussed with the patient.
- Write legibly in black ink.
When working with medical records:
- Donâ€™t record opinions.
- Donâ€™t document issues with the office or between employees.
As a legal document, itâ€™s important that documentation errors are treated in the correct way in the patientâ€™s medical record. If a patientâ€™s record is subpoenaed for a court case but has a bunch of information scribbled out, it might look like the healthcare provider is trying to hide information.
When dealing with medical record documentation errors:
- Donâ€™t erase the information.
- Donâ€™t scribble through the information so that it canâ€™t be read.
- Donâ€™t correct the information using correction fluid (e.g., Wite-Out).
To correct medical record documentation errors, strike through the statement with a single line, note above it â€œerror,â€ and then supply the date and your initials. If additional information needs to be added, title it â€œaddendumâ€ and then document the correct information.
When using an electronic medical record, information can be deleted and reentered if it hasnâ€™t been saved yet. If an error is discovered after the file has been saved, an addendum should be added as a separate note with the title â€œCorrection.â€
Medical Record Storage
As you can imagine, itâ€™s important to store medical records in a safe and secure place. Itâ€™s the healthcare providerâ€™s responsibility to ensure that the patientâ€™s privacy and confidentiality are protected at all times. Itâ€™s also the healthcare providerâ€™s responsibility to provide the patient treatment information, as needed.
There are three types of records that a healthcare provider will primarily deal with: active, inactive, and closed. Active records are records for patients who have been treated within the past three years. Inactive records are records for patients who havenâ€™t been treated at the facility within the past three years. Closed records are records of patients who are no longer being seenâ€”they may have moved away, started seeing another physician, or died.
Federal and state regulations specify where records should be stored and how long a patientâ€™s medical record should be kept, depending on the type of record.
Because of space limitations, it often isnâ€™t practical to keep every single patient record for the entire time a provider is in practice. Healthcare providers should be aware of the state and federal regulations that govern the retention of records for the types of patients they serve. For example, an average time to keep an inactive or closed record is 10 years. However, for minors the records must be kept until theyâ€™re at least 18 years old.
Filing Medical Records
Medical records must be filed in such a way that they can be retrieved quickly and easily whenever theyâ€™re needed. There are actually different methods of filing medical records depending upon the facility and providerâ€™s needs.
The following are common types of filing systems:
- Subject matter
- Color coding
There are a number of variations with the numeric filing method that the medical assistant should be familiar with:
- Straight numeric: Records are filed based on the sequential number.
- Terminal digit: Records are filed with the last two numbers filed first (the â€œprimaryâ€ numbers). For example, with 12-24-00, the 00 is looked at first, and then back to the beginning to file under 12, then 24.
- Middle digit: Records are filed with the two middle digits first. For example, with 12-24-00, the 24 is looked at first, and then the 12, then 00.
- Unit: Assigns one number to a patient thatâ€™s used for every visit.
- Serial: Assigns a different medical record number each time the patient is seen.
Releasing Medical Records
A normal part of healthcare office work is releasing patient information. Due to the confidential and private nature of patient information, strict laws, rules, and regulations must be followed when releasing a patientâ€™s information.
Naturally, a patient (or the patientâ€™s legal guardian) can release his or her own information. However, when can healthcare facilities release patient information without the patientâ€™s authorization? Medical records can be released without patient authorization to
- Healthcare workers treating the patient
- Business associates of the healthcare provider who provide services necessary for the information (transcription companies, insurance agencies, etc.)
- Qualified research and educational institutes
- Government agencies, as permitted by law
- Legal authorities for lawsuits
Quality assurance, or QA, in health care ensures that standards of care are being met within a facility. Designated staff members within the healthcare organization monitor and evaluate the services provided to make sure that patients are receiving quality care.
By standardizing care, healthcare providers understand whatâ€™s needed to treat certain diagnoses no matter where theyâ€™re treated. Some organizations that help ensure that quality standards are met include
- The Joint Commission (TJC)
- Occupational Safety and Health Administration (OSHA)
Electronic Medical Records
Electronic medical records (EMRs) are often called electronic health records (EHRs). Although the terms are often used interchangeably, EMRs and EHRs arenâ€™t the same thing. EMRs contain all of the data used to treat patients at a particular office. However, EHRs are broader; they not only contain patient data, but they also go beyond that to network with ancillary providers and other facilitiesâ€™ systems to provide the entire history of a patientâ€™s treatment. Today, the term â€œEHRâ€ is becoming more widely used, probably because CMS uses that term when discussing upcoming technology implementation requirements.
EHRs have the following advantages over paper-based medical records:
- Easier and faster access to information
- Ability to access information from any computer
- Easy to update patient information
- Quick sharing of patient information between providers
Converting from a paper-based record to an electronic record can be time consuming and extremely costly. Thatâ€™s why many healthcare providers are reluctant to make the change. In many cases, providers hire an outside company that specializes in the conversion and schedules it to happen over a period of time.
The U.S. government has played a key role in the development of healthcare programs. Today, weâ€™re watching history unfold with the implementation of the Patient Protection and Affordable Care Act of 2010, which was created to help Americans afford better-quality health insurance, to reform the health insurance industry, to expand Americansâ€™ healthcare rights, and to reduce wasteful healthcare spending.
Most people associate universal healthcare coverage with President Barack Obama. However, President Harry Truman was actually the first American president to introduce a plan for universal health coverage. In 1945, President Truman wanted private insurance for those who could afford it and public services for people who couldnâ€™t afford it. At the time, President Truman proposed a comprehensive, prepaid medical plan through the Social Security System that would pay for doctor, hospital, nursing, laboratory, and dental costs. At that time, Congress didnâ€™t pass the plan. It wasnâ€™t until 1965 that President Lyndon Johnson signed the Medicare bill that created federal health insurance coverage for the elderly and poor. The new law detailed a program of hospital insurance for the elderly and health care for needy children under Social Security. This meant that healthcare services to the elderly and poor would be reimbursed by federal and state sources.
Today, the terms health insurance and medical insurance are often used interchangeably; however, they arenâ€™t technically the same. To the insurance industry, health insurancemeans protection against income losses for illnesses or injury, disability income, and accidental death or dismemberment. Medical insurance covers specific medical expenses. However, weâ€™ll use both terms to mean medical insurance.
Insurance is something that helps protect against loss or risk. Today, there are many different types of insurance that offer protection to people. In health care, thereâ€™s major medical insurance. This type of health insurance provides benefits for most types of medical expenses incurred, but is subject to a large deductible. These policies usually pay covered expenses whether an individual is in or out of the hospital.
Thereâ€™s also group health insurance, which generally provides coverage to a group of employees. This type of insurance can be in the form of lump sum payment or periodic payments to compensate for income losses due to bodily injury, sickness, or disease and medical expenses. Private health insurance is also called individual insurance or nongroup insurance.
Private health insurance is an insurance plan used most often by self-employed people and others who arenâ€™t eligible for group plans. Private insurance holders pay premiums, or pre-established amounts. The insurance company then puts that money into a designated account and pays claims out of that account.
Managed Care Organizations
A managed care plan is a plan that finances and manages the delivery of healthcare services. Typically, managed care involves a group of providers who share the financial risk of the plan or who have an incentive to deliver cost-effective, quality healthcare services.
The purpose of managed care is to deliver quality, cost-effective health care through monitoring and managing how services are utilized. When managed care first came into existence, many providers had a hard time with it. Prior to managed care, providers were reimbursed for what they billed insurance companies. However, it wasnâ€™t long before insurance companies noticed that this method of reimbursement didnâ€™t give providers any incentive to save money. Providers were ordering whatever tests they wanted for patients and using a great deal of supplies. With the implementation of managed care, services and supplies are closely monitored.
In general, managed care health plans are different health care systems that office services to a specific population. Managed care health plans work by
- Creating arrangements with selected providers to provide healthcare services to their members
- Mandating credentialing standards for the selection of healthcare providers
- Creating quality assurance and utilization review programs
- Providing financial incentives for members to use providers and facilities associated with the health plan
A health maintenance organization, or HMO, is a prepaid plan that provides services to plan members. The HMO system was developed to funnel as much care as possible through one provider to control the high costs associated with specialty care.
HMOs work by having medical providers contract with the HMO to provide medical services to plan members. Members are then required to use only those providers to receive the full benefits of the HMO plan. As you can imagine, some beneficiaries find the HMO concept to be very limiting because they donâ€™t have the freedom to choose whatever provider they want to see at any time.
HMOs emphasize preventive care to keep patients healthy, with the goal of reducing healthcare costs. All care is directed through the primary care physician or other primary healthcare worker. Reimbursement is made on a fixed payment per patient per month. If the patient must see a specialist, that specialist must also be in the HMO network. The patient is responsible for any charges for services performed outside of the HMO network.
Just like any healthcare plan, HMOs have both advantages and disadvantages.
The advantages of HMOs include
- Predictable costs
- Routine coverage
- Less paperwork because claim forms donâ€™t need to be completed for each service or visit
HMO disadvantages include
- The patient having to use one primary care physician for all services
- Approval being required prior to hospitalization or specialty care
HMOs are generally the most restrictive type of managed care plan. This â€œgatekeeperâ€ type of plan means that the primary care physician (PCP) or other healthcare professional is the case manager for the patient who is responsible for overseeing all aspects of the patientâ€™s care. This means that the patient must receive preauthorization by the PCP for a specialty care referral or hospital admission. The only time a preauthorization isnâ€™t necessary is in an emergency situation.
There are also a number of different types of HMOs:
- Group model: The HMO contracts with a multispecialty group to provide services.
- Independent (or individual) practice association (IPA): The HMO contracts with an organized group of individual physicians to provide services.
- Network model: The HMO contracts with two or more multispecialty groups to provide services.
- Staff model: HMO employs physicians and healthcare workers directly to provide services.
Preferred Provider Organizations
Preferred provider organizations (PPOs) are made up of a group of hospitals and physicians who provide services to insurance company clients for a set fee. These providers are then listed as preferred providers for the patients who have this type of insurance. The PPOsâ€™ ability to recruit a large network of hospitals and physicians affect the success of the plan.
The PPO plan is sometimes considered less restrictive than the HMO plan because itâ€™s a way to contain costs while still retaining the patientâ€™s choice of physician. The patient has the ability to choose a physician or hospital from the designated provider list. However, the PPO requires the beneficiary to obtain a referral from the primary care physician if the patient wants to see another physician within the PPO network.
The advantages of PPOs to patients include
- Freedom to choose from a large list of providers
- Fixed costs
- Generally no or low deductibles
The disadvantages of PPOs include
- Larger copayments because of the vast network provided
- The patient being responsible for costs and paperwork when care is provided outside of the network
Point-of-service (POS) plans are often seen as one of the most flexible managed care plans. POS plans are similar to HMOs but include some of the features of the PPO model.
POS plans are sometimes called â€œopen-ended HMOsâ€ because the patient must choose a primary care physician (just as in HMO plans), but thereâ€™s an option available for receiving care from hospitals or physicians not in the POS network.
In this case, the patient doesnâ€™t need a referral, but the deductible and out-of-pocket expenses are higher. The premiums for POS plans are higher, but some patients are okay with this because it allows more freedom in choosing providers.
Exclusive Provider Organizations
Exclusive provider organizations, or EPOs, are part of employer groups that are trying to control costs. The EPO consists of medical providers, mainly physicians and a hospital, who have joined together to offer their services to specific clients. This means that employees or their beneficiaries can obtain services only from the medical providers who are part of the EPO. However, patients using an EPO generally donâ€™t have to name a primary care physician or have referrals to see other providers in the network. A downside of these plans is that there are no out-of-network benefits.
As we discussed earlier, government has played a key role in healthcare programs for years through Medicare and Medicaid. Itâ€™s now taking a larger role with the implementation of the Affordable Care Act.
The federal government provides the following types of insurance:
- Military health plans
Medicare and Medicaid
The Health Care Financing Administration, or HCFA (pronounced â€œhic-fuhâ€), was created under the Department of Health and Human Services in 1977 as a way to coordinate and administer the Medicare and Medicaid programs. On July 1, 2001, the HCFA was renamed, and is now called the Centers for Medicare and Medicaid Services, or CMS, to reinforce the agencyâ€™s mission to serve Medicare and Medicaid beneficiaries. Since the name change, the CMS has placed increased emphasis on responding to the needs of Medicare and Medicaid beneficiaries and providers.
Medicare was formally known as Title XVIII of the Social Security Act and was initially commonly referred to as Health Insurance for the Aged and Disabled. It was part of the bill that President Johnson signed into law in 1965. Medicare is a federal government program for persons age 65 and older as well as those who fall into disability categories outlined by Medicare.
Medicaid is part of Title XIX of the Social Security Act. Medicaid reimbursement comes from both federal and state sources to help people in need.
TRICARE is a healthcare program available for all seven branches of the uniformed services, their families and survivors, and retired members and their families.
In the 1990s, the program was reorganized and the name was changed to reflect the new three-part program that includes TRICARE Prime, Extra, and Standard. TRICARE covers healthcare services for active military personnel and their dependents. Those persons covered by TRICARE are able to receive treatment from any military healthcare facility.
The Civilian Health and Medical Program of the Department of Veterans Affairs, or CHAMPVA, covers most healthcare services for
- Dependents and survivors of permanently and totally disabled veterans
- Survivors of veterans who died from service-related conditions
- Survivors of those who died in the line of duty
TRICARE and CHAMPVA are often confused. If youâ€™re eligible for TRICARE, you canâ€™t be eligible for CHAMPVA. A military retiree or the spouse of a veteran who was killed in action is a TRICARE beneficiary. CHAMPVA is a Department of Veterans Affairs program and is for eligible veterans and their families.
Medical Insurance Claims
An insurance claim is simply the form that the physician or hospital submits to the insurance company for payment. An important part of the medical assistantâ€™s job may be to assist in processing insurance claims for the provider. Because insurance claims are whatâ€™s provided to the insurance company and are how providers get paid, itâ€™s important to have a thorough understanding of them.
The CMS-1500 is the CMSâ€™s universal healthcare claim form for professionals. The CMS-1500 is the claim form used by providers of outpatient health services to bill insurers for their fees.
The claim for payment is generated from information found in the patientâ€™s medical record. Specific information is then transferred to the CMS-1500 claim form and sent to the third-party payer for reimbursement. The claim can be submitted manually or electronically.
The CMS-1450 is also known as the UB-04, or the Uniform Bill. Itâ€™s the institutional claim form used by hospitals to receive payment from third-party payers. As with the CMS-1500, the information entered on the CMS-1450 also comes from the patientâ€™s medical record.
CMS-1450 versus CMS-1500
There are distinct differences between the CMS-1500 and the CMS-1450 claim forms. The CMS-1500 claim form is the professional claim form used by the physician office for services and procedures. The CMS-1450 is the institutional claim form used for any services performed in the hospital.
You may be thinking, â€œWouldnâ€™t it be easier to use one claim form for all services?â€ This would be easier, but the hospitals and physician offices use different coding, billing, and reimbursement methods. The CMS-1500 and CMS-1450 each have the specific information needed for each type of facility.
Unfortunately, a normal part of health care is dealing with claim denials, or rejections. This means that