How do you ensure accuracy of medical records?

Maintain Accurate Medical Records

1. Legible – If your handwriting is not legible, consider dictating your notes.
2. Timely – Most electronic medical record systems document the date and time of all entries.
3. Accurate – Ensure your documentation accurately reflects what occurred during a patient encounter.

What is the best way to correct an incorrect entry in a medical record?

Proper Error Correction Procedure

1. Draw line through entry (thin pen line). Make sure that the inaccurate information is still legible.
2. Initial and date the entry.
3. State the reason for the error (i.e. in the margin or above the note if room).
4. Document the correct information.

What are the four purposes of medical records?

It tells the patient’s “story”: the presenting problem and the treatment received; Helps to plan and evaluate a patient’s treatment; Creates a permanent record for the patient’s future care; Builds a database to evaluate the effectiveness of treatment that may be useful for research and education.

Why is patient documentation so important to the medical record?

Proper documentation, both in patients’ medical records and in claims, is important for three main reasons: to protect the programs, to protect your patients, and to protect you the provider. Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time.

What to do if a doctor lies to you?

You can sue your doctor for lying, provided certain breaches of duty of care occur. A doctor’s duty of care is to be truthful about your diagnosis, treatment options, and prognosis. If a doctor has lied about any of this information, it could be proof of a medical malpractice claim.

How to review and summarize medical records in personal?

Work with your attorney and the client to discover the different issues to look for in the medical records so you know what to ask for from the providers. 1. Once you obtain the medical records your first task is to sort through the records and look at the ER, History and Physical, Discharge, Consults and Admissions records.

How to conduct a medical record review-NCHA?

How to Conduct a Medical Record Review Appropriate reimbursement comes from the review’s capture of severity, clinical validation, coding accuracy, medical necessity, and quality outcomes. The record review should also track communication among CDI and coding professionals, if applicable, for efficiency, clarity, and understanding of the review

Can you ignore lab data in medical records?

Ordinarily, you can just ignore the reams of laboratory data that will inevitably accompany a patient’s records. However, if for some reason a particular lab value, such as blood sugar (glucose), is important to the case, there will usually be a guideline as to what “normal” values should be.

What kind of medical records are specially protected?

Specially protected records include mental health records; drug/alcohol treatment records; psychotherapy notes; testing for or treatment of HIV, AIDS and STDs; and mental health, behavioral health or treatment records of substance abuse programs. If you are unsure if a part of the record is specially protected, ask a supervisor.

When does a medical record review take place?

When should a record review begin? Typically, reviews begin 24–48 hours after admission and/or initial assessments are completed. A good rule of thumb is to review a record when there is enough information on which to base a query (e.g., after the history and physical is completed, and initial diagnostic testing is performed).

What is the Privacy Rule for medical records?

Your Medical Records. The Privacy Rule gives you, with few exceptions, the right to inspect, review, and receive a copy of your medical records and billing records that are held by health plans and health care providers covered by the Privacy Rule.

How to Conduct a Medical Record Review Appropriate reimbursement comes from the review’s capture of severity, clinical validation, coding accuracy, medical necessity, and quality outcomes. The record review should also track communication among CDI and coding professionals, if applicable, for efficiency, clarity, and understanding of the review

What to do if you think your medical record is incorrect?

If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request.