MEDICAL INFORMATION

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References & Links

2000-2001 Standards for Ambulatory Care, Joint Commission on Accreditation of Healthcare Organizations.

Scope of Occupational and Environmental Health Programs and Practice, American College of Occupational and Environmental Medicine Statement, 1991.

AAOHN and ACOEM Consensus Statement for Confidentiality of Employee Health Information, American Association of Occupational Health Nurses and American College of Occupational and Environmental Medicine, May 1997.

Management of medical information is vital to the successful treatment of the patient and required to meet compliance standards of the profession. Communication of patient information, particularly over time, to those providing services must be conducted in an organized, consistent and confidential manner.

Clinics should have medical record policies in place that spell out how the medical information is to be managed, as well as a demonstrated practice of consistently following those policies. In part, medical records’ policies must address:

• how information is gathered

• how confidentiality is preserved

• how and to whom that information may be released

• who is authorized to make an entry and which entries are legally required to be co-signed

• the retention of medical records according to organizational policy and government regulations, specifically addressing patients with toxic exposures and

• the specific requirements of electronic and paper medical records.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) spells out clearly in its Ambulatory Guidelines how medical information should be managed. First the information management policies must address both internal and external needs as well as the complexity of the services delivered. It realizes that delivering care in today’s healthcare environment is complex and requires communication not only to the patient but also to the other providers and payers. It stresses the confidentiality, security and integrity of the information. The medical record must:

• contain sufficient information to identify the patient, the reason for the visit, the diagnosis, any treatment rendered and medications ordered or dispensed

• document the course of the treatment

• include any diagnostic test results

• note communication with external sources regarding care

• be dated and signed by an authorized individual

• use standardized terminology and abbreviations

• document discharge and medication instructions, signed by the patient

• document patient education

• if urgent or emergeny care is rendered, document the time of arrival and discharge as well as the condition on discharge.

The process begins with the initial intake of the patient and accurate recording of the information obtained at registration. The manner in which this information is obtained must be confidential and yet accurate. Many clinics have the patient complete forms on a clipboard in the waiting room. If the registration clerk has questions regarding this information, the questions must be asked in a confidential manner away from the other patients in the waiting room. If the patient has been in the clinic before, and a chart has been prepared, the accuracy of the demographic information from the last visit must be confirmed. The purpose of the visit should also be confirmed at this time, as well as the time the patient enters the clinic. For occupational health patients, it is imperative that the current employer be noted accurately on the record. It is a breach of confidentiality if the information is sent to a former employer because a record was not updated at the time of registration.

The record must contain consent for treatment and a release of information to employers or payers as required by law. The registrar must assess the ability of the patient to read and understand the information being presented. If there is doubt, a private place should be provided to explain further. If a hearing deficit is detected, the registration clerk must accommodate the patient with a private room and written instructions. If there is a language barrier, and an interpreter did not accompany the patient, the clinic should have access to interpreters who will assist the patient in understanding. If more than one patient has the same name, as in a junior and senior, the chart should be identified with a stamp or label to note caution when handling this medical record.

The medical record next accompanies the patient to a confidential treatment area, where medical personnel collect sufficient information to identify the patient, support the purpose of the visit and secure the additional information necessary to proceed. This area should allow for both visual and auditory privacy. Patient rights and the reason for the examination should be reviewed at this time. Review paperwork to ensure that proper consents have been signed.

This is a good time to again assess the employees’ understanding of their right to release the information and to inform them of special protections, such as disclosure of HIV and drug and alcohol treatment information. Patients should not be giving consent under duress but services should not be provided unless all consents have been signed and obtained. All practitioners should be identified with an ID badge and introduced to the patient. In many cases the patient may undergo ancillary testing prior to seeing a provider. In other cases it may be a nursing assessment to evaluate an injury. Regardless of the purpose of the visit, allergy information should be obtained at this time. If any are reported, they need to be noted on the record and an alert note or stamp placed on the outside cover of the medical record. In addition, information should be obtained regarding current medication and dosage.

If this patient is receiving continuous occupational health service and has had at least three visits, the medical record must include a summary list of all significant diagnoses, conditions, procedures, drug allergies and medications. The list must be maintained and updated at all visits thereafter. If a medication is added during treatment, it is also added to the list, as well as documented in the physician notes. This JCAHO requirement is often overlooked by occupational practices.

The information must be in a list and must be stored in the same location on all medical records to assist the practitioner in accessing needed information quickly. If the patient is seen in more than one clinic or location in the same organization and each clinic maintains a separate medical record, the list in each record indicates there is information in another record. Use a standardized form so that all the required data and documents are in the same order on each chart. An exception to the list is when the diagnosis and treatment plan, including measurable goals, are determined prior to a series of treatments. This exception applies to physical and occupational therapy departments.

Continuing care must be appropriately recorded and should include progress toward established goals. Record the response to the treatment plan including decreased pain, changes in range of motion, and progressive healing or lack thereof for an injury such as a wound. New to the 2000 JCAHO standards is this focus on pain: patients must be educated, assessed and monitored for their response to pain treatment/pain management. While the JCAHO will not be scoring clinics on this revision of the standards in 2000, they will begin scoring at a future date. Any procedure or patient education delivered or medication dispensed during the visit must be documented by the clinician delivering the care. When the patient is discharged from an episode of care, the record must include the clinical findings that led to that decision. Should a patient choose to terminate care before being released (or has repeated no-shows), the medical record must reflect this information.

Medical Records must be secured in a locked area and protected against loss, destruction, tampering or unauthorized access. Electronic medical records must be secured with a sign-on system. The policy should indicate the levels of security and access rights for various positions, taking into consideration each person’s "need to know."

Medical data transmissions, whether external or internal, must be timely and accurate. Verbal orders of authorized individuals, if accepted by policy, are transcribed by qualified personnel. When required by state law or federal regulation, the orders are authenticated within the specified time. There should also be a policy covering access to professional publications, external databases and Internet connectivity. If the clinic contributes to an external data base the security and confidentiality of the information is maintained.

Caution is necessary in release of medical records. Basic to the release is the receipt of a signed statement from the patient requesting the release. Care should be taken to review signatures that come in the mail after discharge. In addition, only the medical records of the clinic or the organization and not any correspondence from other practitioners should be included in the release. Copies of the request for release of information and the date, number of pages and person releasing the records are documented and maintained in the record.

In addition to policies and procedures, clinic management should provide education during orientation and competency review for all staff members who will handle or manage medical information. The education is appropriate to the level of responsibility and must be documented in the employee’s educational file.

Medical Records are periodically reviewed for completeness, accuracy and timeliness. The findings of these reviews, as well as a periodic internal audit of a clinic’s practice regarding the management of medical information, will demonstrate areas for improvement, which can then be used as indicators for measuring Performance Improvement. Action taken to improve the necessary functions will be reported as appropriate for the organization. .

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