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Medical Records and Health Information Technician
Medical Records Technician Training
Last Updated: September 8, 2015
What should a Medical Records and Health Information Technician in the state know?
Annotation or definition of Medical Records and Health Information Technician in the state.
Biochemistry lab errors verification
Duties of Medical Records and Health Information Technician in a hospital and at primary health center.
Documentation Requirements for the Acute Care Inpatient Record
Format of medical records.
Individual or individuals who can see medical records.
Medical Record Keeping Standards
Pattern in which medical records need to be maintained.
Primary Care Medical Record Documentation Standards
Request for medical records.
Type of posting

Annotation or definition of Medical Records and Health Information Technician in the state.
What is a Medical Records and Health Information Technician in the state?
A person with duties to compile, process, and maintain medical records of hospital and primary health center patients. This is accomplished in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements and standards of the health care system in the state and outside the state.

Biochemistry lab errors verification
What are the most common reasons lab values of biochemistry result are low or high?
Improperly collected blood samples.
Improper tube in which human blood was collected.
Improper storage of blood samples.
Wrong machine analysis or sample.
Transient low or high values caused by lifestyle, like diet, exercise, medication, other reasons.
At the end, you should consider other medical reasons.

How do you collect samples for human blood chemistry analysis?

How many tubes and types of tubes do you utilize in collecting samples for biochemistry analysis?

How do you verify that the biochemistry lab is not giving any errors?

Where do you forward the blood samples for biochemistry analysis?

What types of machines in biochemistry do analysis of human blood samples?

Documentation Requirements for the Acute Care Inpatient Record
Medical Record Keeping Standards
A medical record documents a Memberís medical treatment, past and current health status, and treatment plans for future health care and is an integral component in the delivery of quality health care.

The standards are as follows:

Medical Record Content

A separate problem list in each medical record documents significant illnesses and medical conditions.
A current medication list.
Medication allergies and adverse reactions are prominently displayed in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.
Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations, and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses.
For patients 12 years and over, there are appropriate notations concerning use of cigarettes, alcohol, and substance abuse (for patients seen three or more times).
The history and physical documents appropriate subjective and objective information for presenting complaints. Working diagnoses are consistent with findings.
Treatment plans are consistent with diagnoses.
Clinical evaluation and findings are documented for each visit.
Unresolved problems from previous office visits are addressed in subsequent visits.
Review for appropriate utilization of consultants.
There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure. An immunization record for children is up to date or an appropriate history is made in the medical record for adults.
An immunization record for children is up to date or an appropriate history is made in the medical record for adults.
There is evidence that preventive screening and services are offered in accordance with AmeriHealthís practice guidelines.

Medical Record Organization

Each page in the record contains the patientís name or ID number.
Personal/biographical data includes address, employer, home and work telephone numbers, and marital status.
All entries in the medical record contain the authorís identification. Author identification may be a handwritten signature, a unique electronic identifier, or initials.
All entries are dated.
The record is legible to someone other than the writer.

Information Filed in Medical Records

Laboratory and other studies are ordered, as appropriate.
Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls, or visits. The specific time of return is noted in weeks, months, or PRN (as needed).
If a consultation is requested, there is a note from the consultant in the record.
Specialty physician, other consultation, lab, and imaging reports filed in the chart are initialed by the practitioner who ordered them to signify review. Review and signature by professionals other than the ordering practitioner do not meet this requirement. If the reports are presented electronically, or by some other method, there is also representation of review by the ordering practitioner. Consultation and abnormal lab and imaging study results have an explicit notation in the record of follow-up plans.
The existence of an advance directive is prominently documented in each adult (>18) Memberís medical record. Information as to whether the advanced directive has been executed is also noted.
Records of hospital discharge summaries, emergency department visits, home health nursing reports, and physical therapy reports are maintained in the Memberís record.

Ease of Retrieving Medical Records

Medical records are organized and stored in a manner that allows easy retrieval and are to be made available to AmeriHealth as defined in the Professional Provider Agreement.

Confidentiality of Information

Medical records are stored in a secure manner that allows access to authorized personnel only. Protected Health Information (PHI) is protected against unauthorized or inadvertent disclosure and staff receive periodic training in confidentiality of Member information. Medical records are safeguarded against loss or destruction and are maintained according to state requirements. At a minimum, medical records must be maintained for at least 11 years or until the Member reaches the age of majority plus six years, whichever is longer.

Maintenance of Records and Audits Medical and Other Records


Request for medical records.
What are other heading under which the request can be asked?
Authorization of release of medical record information

What is the date this request was submitted?

What is the name of the individual whose medical records have been requested?

What is the date of birth of the individual whose medical records have been requested?

What is the address of the individual whose medical records have been requested?

What is the hospital mailing address in the state from where medical records need to be released?

Have you enclosed photo identity card with the request?

What facts have been requested relevant to medical records in the state?

Medical/legal abstracts
Discharge summary
History and physical
Lab results
Outpatient reports
Psychiatric details
Other records (please specify)

Is the photo identity card the person whose medical records are required?
This is possible.
If someone else requests medical records, authorization is required from the person whose medical records are sought.

Here are facts about specific required details.

What is in my medical records at this hospital?
What is in the records of lab results?
When were the lab tests last done?
When was I first seen at this hospital?
When was I last seen at this hospital?



What do lab results reveal relevant to these lab results?

Glucose
Cholesterol
Urea
Creatinine
Other available lab tests.

Type of posting
What type of job posting is this?
Medical Records Technician is a nonexempt job posting.
Individual who imparts Medical Records Technician Training from a distance via computer and Internet is an exempt posting.


Primary Care Medical Record Documentation Standards
Medical Records
Personal Information
Care Team
Advance Directives
Allergies
Immunizations
Insurance
Lab Results
Medications
Plan of Care
Problems
Procedures
Social History
Vital Signs
Chart Summary
Chart Access History
Criteria Description Points Biographical/Personal Data 8
  1. Patient identification Patientís name or an ID number on all pages 1

  2. Date of Birth In chart 0.5

  3. Current address In chart or computer database 0.5

  4. Work/home telephone numbers In chart or computer database 0.5

  5. In chart or computer database 0.5

  6. Marital status, as applicable Marital status for patients = age 18 0.5

  7. OB/GYN name, as applicable In chart 0.5

  8. Advance directives Discussion re: Health Care Proxy, Living Will, DNR or Advance Directive 4 General Chart Organization 5

  9. Signed entries Sign or initial each entry, electronic signature is acceptable. Credentials (MD, DO, PA, NP, RN) must appear after the practitionerís name. 2

  10. Dated entries All entries dated 1

  11. Organized medical record Entries are in sequential order 2

  12. Legible medical record Illegible notes are an automatic failure and considered a quality issue. 0 Personal History 38

  13. Problem list Up-to-date list of significant medical and / or psychological illnesses / diagnoses 5

  14. Medication list List current medications 5

  15. Allergies and/or adverse reactions List allergies and adverse reactions to medications, or NKA noted 5

  16. Past medical history List illnesses, surgeries / operations, and mental history 5

  17. Family medical history List health history of parents and / or siblings. 4

  18. Social living environment Patient occupation, education and / or living situation 2 Social Habits For patients 11 years and older: 12

  19. Tobacco use Assessment of use, packs per day, counseling for any use / abuse of inhaled or chewed tobacco use 3

  20. Alcohol use Assessment current use / abuse and / or counseling cessation 3

  21. Substance use Assessment current use / abuse and / or counseling cessation 3

  22. HIV/STD risk Sexual activity or abstinent, number of partners, sexual orientation, and if protection is used consistently 3 Office Visit/Follow up 29

  23. Pertinent subjective and objective information History and objective finding [PE or lab] for presenting problems 6

  24. Labs, studies, treatment plan ordered Assessment for presenting problems [complaints, history, results of the physical / psychological assessment] 6

  25. Diagnosis/impression consistent with findings Plan for presenting problems [benefits and risks discussed] 3

  26. Time frame for return visit Next steps documented [specific number of days, weeks, months or years, or PRN] 2

  27. Referrals/consultants Use of referral / consultants documented 2

  28. Chronic medical conditions monitored as applicable Care related to i.e. Diabetes, Behavioral Health, ADHD, CAD, Ischemic Vascular Disease, HTN, Asthma, and Obesity. 2

  29. No shows documented Document missed appointments 1

  30. Evidence of specialist visit / emergency room / inpatient stay as applicable Discharge summary or appropriate consultation report indicating care and services with evidence of PCP review 5

  31. Tests, labs, consultations, followup Test, lab results, consultant summaries with evidence of PCP review 2

  32. Care rendered must be medically indicated No apparent risk to the patient is identified. Fail = Quality Issue Preventive Services 20

  33. Diet/Nutrition discussion and/or counseling Assessment & Counseling as needed i.e. Low calorie, low fat, low sodium, low cholesterol, food allergies intolerances, or counseling 5

  34. Patient safety Injury prevention measures: accident / poisoning prevention, car seats, bicycle safety, stranger danger, seat belt use, bike / motorcycle helmets 5

  35. Age/gender preventive health Per Planís Preventive Care Guidelines 5

  36. Immunization record Up-to-date and complete [adult tetanus, influenza, pneumonia vaccine Ė if applicable]