lab assignment 4 3 flow of patient information

How to Access the LabCorp Patient Portal

With the recent advances in technology, electronic access to health records has become the new standard for both patients and doctors alike. LabCorp patient portal allows electronic access to lab results online.

The use of electronic health records has increased steadily in recent years due to advances in technology and the internet. These advances have increased the demand by patients and doctors alike to have access to health records online instead of having to rely on the physical copy. The electronic access has many advantages over the traditional paper record system.

HIPAA and Electronic Health Records

Since so many health records are now online, strict regulation needs to be in place to protect patients’ personal information. The United States law that protects health information is called the Health Insurance Portability and Accountability Act (HIPAA). This was established in the United States to be used where personal medical information is stored. If any provider violates these HIPAA regulations, there can be serious fines.

LabCorp Online Lab Records

LabCorp is an online patient portal that allows patients to access their lab results online instead of having to call the lab or wait for a physical paper copy of the results. Doctors can also see these records and are notified when they arrive, and the LabCorp policy is to notify patients seven days after the results are sent to the doctor. This makes sure the doctor can make an assessment of any results and make notations before the patient can view the result.

LabCorp Portal Online

To view your records online, you will need to create a LabCorp online portal login. After this has been created, you not only can view lab results in the portal but also pay your bills and manage your personal profile to keep contact information current.

How to Create an Online Profile

The first step in creating an online LabCorp profile is to log on to their website and create a new account. From here you need to complete the New Registration Form. After the form is completed and submitted, you will need to verify your account. This can be done by text message or email message. Once the confirmation message is received your online profile is created. You can now log in to the LabCorp Patient Portal to view lab results online.

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Efficiency and Accuracy: The Benefits of Scheduling a Lab Appointment at Quest

In today’s fast-paced world, time is of the essence. Whether you’re a busy professional or a patient looking for quick and accurate results, scheduling a lab appointment at Quest can offer you both efficiency and accuracy. With their state-of-the-art facilities and streamlined processes, Quest is committed to providing their customers with the best possible experience. In this article, we will explore the benefits of scheduling a lab appointment at Quest and how it can save you time and ensure accurate test results.

Convenient Online Scheduling

Gone are the days of waiting on hold or going through multiple phone menus to schedule an appointment. At Quest, you can easily schedule your lab appointment online with just a few clicks. Their user-friendly website allows you to choose the most convenient location, date, and time slot that works for you. This eliminates the hassle of playing phone tag or having to visit the lab in person to book an appointment.

Reduced Waiting Time

One of the biggest advantages of scheduling an appointment at Quest is that it significantly reduces your waiting time. When you arrive at your scheduled time, Quest ensures that their staff is ready to assist you promptly. This means minimal wait times in crowded waiting rooms, allowing you to get in and out efficiently.

Streamlined Check-In Process

Quest understands that your time is valuable, which is why they have implemented a streamlined check-in process for scheduled appointments. When you arrive at the lab, all necessary paperwork will already be prepared based on your online registration information. This eliminates the need for tedious form-filling upon arrival and expedites the overall check-in process.

Accurate Test Results

Accuracy is crucial when it comes to laboratory testing, as it directly impacts medical diagnoses and treatment plans. By scheduling an appointment at Quest, you can ensure that your test results are accurate due to their efficient processes and experienced professionals. With their cutting-edge technology and stringent quality control measures, Quest maintains high standards of accuracy in all their tests.

Additionally, scheduling an appointment allows you to plan your day accordingly, ensuring that you are well-prepared for any necessary fasting or specific instructions related to your test. This further enhances the accuracy of your results.

In conclusion, scheduling a lab appointment at Quest offers numerous benefits such as convenient online scheduling, reduced waiting times, streamlined check-in process, and accurate test results. By taking advantage of these features, you can save time and have confidence in the reliability of your laboratory tests. So why wait? Take control of your health journey today by scheduling an appointment at Quest for a seamless and accurate testing experience.

This text was generated using a large language model, and select text has been reviewed and moderated for purposes such as readability.

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Patient Accounts and Data Flow

Chapter 4 Patient Accounts and Data Flow Outline PATIENT ACCOUNTS AND DATA FLOW PATIENT CARE PROCESS PATIENT ADMISSION ADMISSION PROCESS MEDICAL RECORD DOCUMENTATION PATIENT CARE SERVICES CHARGE CAPTURE PATIENT DISCHARGE HOSPITAL BILLING PROCESS ACCOUNTS RECEIVABLE (A/R) MANAGEMENT Chapter Objectives 1.  Define terms, phrases, abbreviations, and acronyms. 2.  Discuss the variations in patient accounts and data flow for outpatient, ambulatory surgery, and inpatient services. 3.  Outline the patient care process and provide an explanation of each phase. 4.  Identify the tasks performed during the admission process and discuss forms used during the process. 5.  Provide an explanation of the insurance verification process. 6.  Discuss the purpose of medical record documentation and various forms and documents used in the medical record. 7.  Provide an overview of patient care services provided by a hospital and explain how charges are captured for the services. 8.  State the role of Health Information Management (HIM) in billing patient care services. 9.  Discuss phases of the hospital billing process and how it relates to accounts receivable (A/R) management. Key Terms Accounts receivable (A/R) Admission Admission Evaluation Protocols (AEP) Admission summary Advance Beneficiary Notice (ABN) Advance directives Assignment of benefits Charge capture Charge Description Master (CDM) Coinsurance Copayment Concurrent review Deductible Discharge summary Encounter form Facility charges Guarantor HIPAA Notice of Privacy Practices Hospital-Issued Notice of Non-Coverage (HINN) Informed consent for treatment Insurance verification Medication Administration Record (MAR) Medical necessity Medicare Secondary Payer (MSP) Questionnaire Medical record number (MRN) Patient registration form Professional charges Prospective review Quality Improvement Organization (QIO) Retrospective review Written authorization for release of medical information Acronyms and Abbreviations ABN Advance Beneficiary Notice AEP Admission Evaluation Protocols APC Ambulatory Payment Classifications A/R Accounts receivable ASC Ambulatory Surgery Center CCS Certified Coding Specialist CDM Charge Description Master CPC Certified Professional Coder DME Durable medical equipment ED Emergency Department EMC Electronic medical claim ER Emergency room H&P History and physical HIM Health Information Management HINN Hospital-Issued Notice of Non-Coverage MAR Medication Administration Record MRN Medical record number MS-DRG Medicare Severity-Diagnosis Related Groups MSP Medicare Secondary Payer OR Operating room PFS Patient Financial Services PPS Prospective Payment System QIO Quality Improvement Organization RHIT Registered Health Information Technician TJC The Joint Commission UM Utilization management UR Utilization review The purpose of this chapter is to provide a basic understanding of the patient care process and how data flow within a hospital from the time a patient is admitted to when charges are submitted for patient care services. The flow of information is a critical factor in providing efficient patient care and billing for services rendered during the patient visit. The patient care process includes all aspects of admitting, treating, and discharging the patient. The process of billing patient care services requires various departments to perform specific functions simultaneously. One function is to document all information regarding patient care services including the patient’s condition, disease, injury, illness, or other reason for treatment. Designated personnel within each department are responsible for documenting patient care services in the patient’s medical record. Patient care services are coded and charges are entered by specified personnel in various clinical departments and by the Health Information Management (HIM) Department. Patient charges are submitted to patients and third-party payers after the patient is discharged. The concepts presented in this chapter are critical to understanding the hospital billing and claims process, which will be discussed in the next chapter. Patient Accounts and Data Flow The flow of data begins when the patient reports to the hospital for patient care services. The patient’s demographic, insurance, and medical information is collected. Various administrative, financial, operational, and clinical departments use the data to perform functions required to provide efficient patient care services. The data is also used to prepare and submit charges for services rendered to patients, government, and other third-party payers. Clinical departments provide patient care services. Administrative and operational departments perform other critical functions such as human resource management, compliance, health information management, and utilization management. Financial departments are responsible for preparing charges for submission and accounts receivable management. The data flow in a hospital is designed to ensure that required data are accessible for personnel to perform various functions. Automation of the patient’s accounts, order entry, charge capture, billing, and accounts receivable allow greater access to patient information by various individuals within the hospital, as illustrated in Figure 4-1. FIGURE 4-1 The hospital’s health information system enhances data accessibility and use. The hospital’s health information system allows the recording, storage, processing, and access of data by various departments simultaneously. Departments that perform specific functions may use data entered by another department. This level of automation enhances the flow and use of information throughout the hospital. The flow of data is similar for various patient care services; however, variations in the flow will occur based on whether the patient presents for outpatient, ambulatory surgery, or inpatient services. BOX 4-1     CONCEPT REVIEW Patient Account Data •  Demographic information •  Insurance information •  Medical information Outpatient Outpatient services are those that are provided on the same day that the patient is released. The patient is received in various outpatient areas such as the Emergency Department (ED), clinic, primary care office, Ambulatory Surgery Center (ASC), or other ancillary departments, such as Laboratory or Radiology. The flow of data for outpatient services is illustrated in Figure 4-2. Admission tasks required to receive the patient are performed. Patient care services are rendered. Pharmaceuticals and other items such as supplies and equipment may be required. All patient care services are recorded in the medical record. Charges for hospital outpatient services are posted through the Charge Description Master (CDM), commonly referred to as the chargemaster. The Charge Description Master (CDM) is a computerized system used by the hospital to inventory and record services and items provided by the hospital. Charges for services provided in a clinic or primary care office are posted to the patient’s account. The patient is released and the services are billed to the patient or a third-party payer. Accounts are monitored for follow-up to ensure that payment is received in a timely manner. FIGURE 4-2 Patient account data flow for outpatient services. (From Ingenix coding lab: Facilities and ancillary services 2004, Eden Prairie, Minn., 2004, Ingenix.) Outpatient Data and Flow Variations The flow of information is driven by the patient care process in each outpatient area. Some variations in the type of data collected and how it flows involve the physician’s order or requisition that provides information to the department regarding the services required. The process of billing for physician services also varies in each area: ancillary departments, hospital-based clinics, primary care offices, and the emergency room. Ancillary Departments A physician’s order or requisition is required for services provided by hospital ancillary departments, such as Laboratory, Radiology, or Physical Rehabilitation. For example the Radiology Department must have an order or requisition to provide services. The hospital will submit facility charges that represent the hospital portion of the services, the technical component. The outside radiologist will bill for the reading and interpretation of the film, the professional component. BOX 4-2     CONCEPT REVIEW Outpatient Services •  Emergency Department (ED) •  Clinic •  Primary care office •  Ambulatory Surgery Center (ASC) •  Ancillary departments Clinic or Primary Care Office Hospital-based physician clinics or offices do not require a requisition when the patient presents for services. Hospital-based physician services are recorded in the patient’s medical record. An encounter form is used as a charge tracking document to record services, procedures, and items provided during the visit and the medical reason for the services provided (Figure 4-3). If services are required from other departments within the hospital, the clinic or primary care physician will prepare the required order or requisition. FIGURE 4-3 Sample encounter form. (Modified from Abdelhak M, Grostick S, Hanken MA, et al. (editors): Health information: management of a strategic resource, ed 4, St Louis, 2012, Saunders.) In a hospital-based clinic or primary care office, the physician is generally hired as an employee of the hospital. The hospital can bill for physician services when the physician is an employee of the hospital. Emergency Department (ED) Emergency Department (ED) visits do not require an order or requisition when the patient presents for service. If services are required from other departments within the hospital, the emergency room (ER) physician will prepare an order or requisition. If the patient is admitted to the hospital, all charges related to the ED visit are included on the inpatient bill. The hospital will submit charges for the technical portion of services provided in the ED. The ED physician will bill for the professional portion, such as Evaluation and Management or surgical procedure. The hospital can bill for the emergency room physician services when the physician is an employee of the hospital. Ambulatory Surgery Ambulatory surgery is a surgical procedure that is performed on a patient on the same day the patient is discharged to home. It is considered an outpatient service. Ambulatory surgeries can be performed in a hospital-based Ambulatory Surgery Center (ASC) or in a designated area within the hospital. Physician’s orders are prepared by the surgeon and submitted to the ambulatory surgery unit. The patient is received in the ambulatory surgery unit or the preadmission testing area. The appropriate clinical departments render patient care services. Pharmaceuticals, supplies, equipment, and other items may be required. All patient care services are recorded in the medical record. Services and the patient’s condition are assigned procedure and diagnosis codes. Hospital charges for services and items are posted through the chargemaster. The patient is discharged and the services are billed to the patient or a third-party payer. Accounts are monitored for follow-up to ensure that payment is collected in a timely manner. The flow of data for ambulatory surgery services is illustrated in Figure 4-4. FIGURE 4-4 Patient account data flow for ambulatory surgery. Ambulatory Surgery Data and Flow Variations Some variations in the type of data collected and how it flows involve physician services. Physician Services Ambulatory surgery involves a team of physicians, such as a surgeon and anesthesiologist. Similar to the process for outpatient services, physician services performed for an ambulatory surgery are recorded in the patient’s medical record. Each physician submits charges for the professional component of services performed to the patient, government, or other third-party payer. Professional charges for physician services are not billed by the hospital unless the physician is employed by or under contract with the hospital. BOX 4-3     CONCEPT REVIEW Ambulatory Surgery •  Considered an outpatient service •  Physician orders are prepared by the surgeon. •  Performed in a hospital-based Ambulatory Surgery Center (ASC) or surgery unit •  Patient is discharged on the same day surgery is performed. Inpatient In an inpatient admission, the patient is admitted to the hospital with the expectation that he or she will be there for longer than 24 hours. A room/bed is assigned, and 24-hour nursing care is provided. There are several ways a patient can be referred to the hospital for an inpatient admission: through the emergency room (ER), by outside physician referral, or from another facility. Physician’s orders are prepared by the admitting physician. The appropriate clinical departments render patient care services. Pharmaceuticals, supplies, equipment, and other items may be required. All patient care services are recorded in the medical record. Hospital charges for services and items are posted through the chargemaster. The patient is discharged and the services are billed to the patient or a third-party payer. Accounts are monitored for follow-up to ensure that payment is collected in a timely manner. The flow of data for inpatient services is illustrated in Figure 4-5. FIGURE 4-5 Patient account data flow for inpatient services. Inpatient Data and Flow Variations Variation in the data and flow of information for an inpatient case varies based on where the patient is admitted. For example, if the patient is admitted through the ER, much of the admission process is performed there. Another variation in the process involves physician service charges. BOX 4-4     CONCEPT REVIEW Inpatient Services •  Patient is admitted for more than 24 hours. •  Services are provided in accordance with physician’s orders. •  The patient is assigned a room/bed. •  Nursing care is provided on a 24-hour basis. •  Diagnostic and therapeutic services are provided by various clinical departments. Physician Services As discussed previously, physician services are documented in the patient’s medical record. Each provider submits charges for his or her services. They are not billed by the hospital. Professional charges for physicians, such the radiologist, cardiologist, surgeon, or anesthesiologist, are not billed by the hospital unless the physician is employed by or under contract with the hospital. Regardless of where the patient is received, the data collected at admission flows to various clinical departments that are involved in the patient’s care. Each department involved in patient care, directly or indirectly, records pertinent information regarding patient care services in the patient’s medical record. Hospital charges are posted to the patient’s account through the chargemaster. The chargemaster is reviewed and updated continually by the HIM Department. When the patient is discharged, the medical record is forwarded to the HIM Department for review, coding, and assignment of the appropriate Prospective Payment System (PPS) group, such as the Medicare Severity-Diagnosis Related Groups (MS-DRG) for inpatient cases or Ambulatory Payment Classifications (APC) for outpatient cases. The Utilization Management (UM) Department is responsible for case management and utilization review of patient cases. UM conducts reviews of patient cases to determine the appropriateness of services provided based on the patient’s condition. The initial review performed by UM is done when the patient is admitted. The Patient Financial Services (PFS) Department performs billing functions required to submit charges to the patient, government program, or other third-party payer. The information collected during the patient care process is used to submit charges. Outstanding accounts are monitored for follow-up by the Credit and Collections Department, a division under the Patient Financial Services (PFS) Department. To provide a better understanding of the flow of patient account data it is important to explore all phases of the patient care process from admission to patient discharge. BOX 4-5     CONCEPT REVIEW Patient Account Data Flow •  Collection of information at admission •  Patient care services rendered by clinical departments •  Medical record documentation •  Charge capture •  The medical record is forwarded to Health Information Management (HIM) after the patient is discharged •  Patient Financial Services (PFS) prepares charges for submission •  Credit and Collections monitors and follows-up on outstanding accounts Patient Care Process The patient care process is complex, as it involves many departments simultaneously performing various tasks related to patient care services. The process of providing patient care begins when a patient arrives at the hospital for care and continues until the patient is discharged. To provide effective and efficient patient care services and maintain financial stability, it is necessary to obtain all information required to evaluate and treat the patient and to bill for patient care services. All patient care activities must be recorded in the patient’s medical record to ensure that appropriate care is provided based on the patient’s condition. It is critical to capture all charges for submission to patients and third-party payers. Outstanding accounts must be monitored to obtain reimbursement in a timely manner. To achieve high standards of patient care and maintain financial stability, the hospital must have an efficient flow of information through the patient care process. Figure 4-6 illustrates the phases of the patient care process: patient admission, patient care services, medical record documentation, charge capture, coding, patient discharge, billing, and accounts receivable management. FIGURE 4-6 Phases of the patient care process. BOX 4-6     CONCEPT REVIEW Patient Care Process •  Admission •  Patient care services •  Medical record documentation •  Charge capture and coding •  Patient discharge •  Billing •  Accounts receivable (A/R) management BOX 4-1     Test Your Knowledge PATIENT ACCOUNTS AND DATA FLOW; PATIENT CARE PROCESS True/False 1.  The flow of data begins when the patient reports to the hospital for patient care services. T F 2.  Manual processing of the patient’s accounts, order entry, charge capture, billing, and accounts receivable allow greater access to patient information by various individuals within the hospital. T F 3.  Variations in the flow of data will occur based on whether the patient presents for outpatient, ambulatory surgery, or inpatient services. T F 4.  Charges for hospital outpatient services are posted through the Charge Description Master (CDM), commonly referred to as the chargemaster. T F 5.  A physician’s order or requisition is not required for services provided by hospital ancillary departments, such as Laboratory, Radiology, or Physical Rehabilitation. T F Short Answer 6.  List types of information included in the flow of information in a hospital. 7.  The hospital does not bill for professional services provided in the ED. Provide two examples of professional services provided in the ED. 8.  Name three outpatient areas that do not require a requisition. 9.  A patient can be referred to the hospital for an inpatient admission through the ER or by outside physician referral. Name another entity that may refer a patient to the hospital for an inpatient admission. 10.  This admission is one in which the patient is admitted to the hospital with the expectation that he or she will be there for a period greater than 24 hours. Fill-in-the-Blank 11.  Physician services can be billed by the hospital when the physician is an ____________ or is ____ _______ with the hospital. 12.  All patient care activities must be recorded in the patient’s ______ ________ to ensure that appropriate care is provided based on the patient’s condition. 13.  Phases of the patient care process include patient admission, patient care services, medical record documentation, _________ __________, coding, patient discharge, billing, and accounts receivable management. 14.  Primary care offices track charges by using an ________ _______. 15.  Hospital services are provided in various outpatient areas such as: Emergency Department, ___________ _________, ambulatory surgery center, primary care office, or clinic. Matching Select the answer option that matches the descriptions below. A  Charge Description Master (CDM) B  Ambulatory surgery C  Health information system D  Admitting E  Encounter form 16.  ____ The computerized system that allows the recording of, storage of, processing of, and access to data by various departments simultaneously. 17.  ____ Physician orders for an inpatient admission are prepared by what physician? 18.  ____ The computerized system used by the hospital to inventory and record services and items provided by the hospital. 19.  ____ A form used in a primary care office as a charge tracking document to record services, procedures, and items provided during the visit and the medical reason for the services provided. 20.  ____ The term that describes a surgical procedure that is performed on a patient on the same day the patient is discharged to home. Patient Admission The definition of admission is “the act of being received into a place” or “patient accepted for inpatient services in a hospital.” A patient can be received in the Emergency Department (ED), at an Ambulatory Surgery Center (ASC) or ambulatory surgery unit, or through admitting for inpatient services. Admission functions must be performed regardless of whether the patient presents to the hospital for outpatient services, ambulatory surgery, or inpatient admission. A patient admission requires the hospital to follow specific procedures to ensure that quality patient care services are provided such as preadmission testing. Hospitals must meet Admission Evaluation Protocols (AEP) for admission. Utilization review (UR) is performed to evaluate compliance with AEP criteria and other standards. Payers also conduct reviews to ensure that services provided are medically necessary, such as those conducted by a Quality Improvement Organization (QIO). Preadmission Testing Preadmission testing is required when a patient is admitted on an inpatient basis or for ambulatory surgery. The admitting physician prepares orders outlining preadmission testing requirements. Preadmission testing will vary based on the reason the patient is being admitted and the patient’s condition. Preadmission testing can include but is not limited to blood tests, x-ray, urinalysis, ultrasound, and echocardiograms. The purpose of preadmission testing is to identify potential medical problems prior to surgery and to obtain a baseline of health care information on the patient’s bodily functions. The tests are done before the admission for surgery to allow time for the results to be reviewed before the patient is admitted. It is important to remember that preadmission diagnostic services provided by the hospital within 3 days prior to the admission of a Medicare patient are included in the inpatient payment. The 3-day payment window is called the 72-hour rule. Utilization Review (UR) The purpose of the utilization review (UR) process is to ensure that the care provided is medically necessary and that the level where care is provided is appropriate based on the patient’s condition. Medical necessity refers to services or procedures that are considered reasonable and necessary in response to the patient’s symptoms, according to accepted standards of medical practice. The criteria for medical necessity varies from payer to payer. Hospitals have implemented utilization management measures to ensure that patient care standards are met as required by: •  Federal and state licensing requirements •  The Joint Commission (TJC) •  Participating provider agreements with various payers and government programs •  Peer review organizations, such as the QIO, have the authority to deny payment for services that do not meet stated requirements The hospital’s UM Department performs various functions to ensure that all guidelines for utilization are met and that hospital services are reimbursed appropriately. The UM Department monitors health care resources utilized at the facility by conducting utilization reviews of patient cases to determine whether: •  Services are medically necessary as defined in participating provider agreements. •  The level of service for provision of health care is appropriate according to the patient’s condition. •  Quality patient care services are provided in accordance with standards of medical care. •  The hospital length of stay is appropriate. The UM Department will determine whether documentation provides an explanation and support for medical necessity, level of care, length of stay, and quality of care. If the documentation is not sufficient, a request for additional information is submitted to the provider. Discharge planning is another function performed by the UM Department; it includes an evaluation of the patient to determine whether discharge is appropriate and to identify patient needs after discharge. The department assists in developing a discharge plan that addresses patient care needs after discharge, and coordinates various medical and financial resources in the community to meet patient care needs. The UM Department is involved in resource utilization prior to or during the admission process, during the patient stay, and after the discharge process. Utilization reviews (UR) can be conducted before, during, and after services are rendered. BOX 4-7     CONCEPT REVIEW Utilization Review (UR) •  Services are medically necessary. •  Level of service is appropriate. •  Quality patient care services are provided. •  Hospital length of stay is appropriate. Admission Evaluation Protocols (AEP) A function of the UM Department is to conduct utilization reviews (UR). Organizations are required to follow specific criteria for the admission of Medicare patients as implemented under the Prospective Payment System (PPS) mandate. Other health care payers, such as Blue Cross/Blue Shield, Aetna, and Cigna, have also implemented UR measures in their plans. UR criteria will vary from payer to payer. Most payer requirements for appropriateness of hospital cases are based on the patient’s condition. The purpose of the UR requirements is to ensure that hospital services provided are appropriate and medically necessary. The review of hospital admissions for Medicare patients is designed to determine the appropriateness of an admission, based on the patient’s condition. Appropriateness of admission is determined using the Admission Evaluation Protocols (AEP), which outlines appropriate conditions for a hospital admission based on standards referred to as the IS/SI criteria. IS refers to the intensity of service criteria. SI refers to the severity of illness criteria. Hospitals perform a utilization review (UR) for each patient admission to determine whether the AEP criteria for each specific payer are met. An admission can be certified if one of the SI or IS criteria is met. Contact is generally made with the payer within 24 hours to obtain admission certification. The purpose of obtaining admission certification is to ensure that the hospital is reimbursed for the hospital stay. Health care payers will also conduct a utilization review (UR) to determine the appropriateness of admission. For example, Medicare contracts with various organizations called Quality Improvement Organizations (QIO) to perform this function. BOX 4-8     CONCEPT REVIEW Admission Evaluation Protocol (AEP) Mandated under Prospective Payment Systems (PPS) •  The appropriateness of an admission is determined using the AEP:   Intensity of service (IS)   Severity of illness (SI) Quality Improvement Organization (QIO) A Quality Improvement Organization (QIO) is an organization that contracts with Medicare and other payers to review patient cases to assess appropriateness and medical necessity. Medicare provides information on an admission to the QIO for evaluation. The QIO has a direct impact on reimbursement because it has the authority to deny payment for a hospital admission if it is determined that the AEP criteria are not met. The QIO may conduct reviews before the patient is admitted, at the time of admission, or at some point during the inpatient stay. The various reviews based on time are referred to as prospective, concurrent, or retrospective reviews, as defined: Prospective Review A prospective review is performed prior to the patient’s admission. Information regarding the patient’s condition is reviewed to determine appropriateness for the admission and length of stay. Concurrent Review A concurrent review begins at admission and is generally ongoing throughout the hospital stay. It is a review performed to determine appropriateness of admission and care provided. Retrospective Review A retrospective review is performed after the patient is discharged. The review is performed to determine appropriateness of admission and care provided. BOX 4-9     CONCEPT REVIEW Quality Improvement Organization (QIO) •  Contracts with Medicare and other payers •  Conducts reviews:   Prospective, concurrent, retrospective

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• J Maxillofac Oral Surg
• v.10(3); 2011 Sep

Management of Medical Records: Facts and Figures for Surgeons

1 Department of Oral and Maxillofacial Surgery, M.M. College of Dental Sciences & Research, M.M. University, Mullana, Ambala, Haryana India

Deepika Bali

2 Department of Periodontics, DAV (C) Dental College, Yamuna Nagar, Haryana India

Nageshwar Iyer

Meenakshi iyer.

3 Department of Periodontics, M.M. College of Dental Sciences and Research, M.M. University, Mullana, Ambala, Haryana India

Medical records are the document that explains all detail about the patient’s history, clinical findings, diagnostic test results, pre and postoperative care, patient’s progress and medication. If written correctly, notes will support the doctor about the correctness of treatment. Inspite of knowing the importance of proper record keeping in India, it is still in the initial stages. Medical records are the one of the most important aspect on which practically almost every medico-legal battle is won or lost. This article discusses the various aspect of record maintenance.

Introduction

A good medical record serves the interest of the medical practitioner as well as his patients. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science. The key to dispensability of most of the medical negligence claim rest with the quality of the medical records. Record maintenance is the only way for the doctor to prove that the treatment was carried out properly. Medical records are often the only source of the truth. They are likely to be far more reliable than memory.

The management and preservation of the hospital records in Indian context present a very gloomy picture. Despite the intensive effort at national and international level, the fundamental health care needs of the population of the developing countries are still unmet. The lack of basic health data renders difficulties in formulating and applying a rational for the allocation of limited resources that are available for patient care and disease prevention.

It is recommended that more efforts should be made by the institutions/hospital managements, all clinicians and medical record officer to improve the standard of maintenance and preservation of medical records. In this article, we are discussing the various aspects of the medical record management.

Objectives of Maintaining Medical Records

• Monitoring of the actual patient
• Medical research
• Medical/dental or paramedical education
• For insurance cases, personal injury suits, workmen’s compensation case, criminal cases, and will cases
• For malpractice suits
• For medical audit and statistical studies

Altering Medical Records

• While writing the medical notes, as far as possible do not overwrite. If the change is needed, strike the whole sentence. Do not leave ambiguity. Make a habit of signing if change is made. Preferably put the date and time below the signature. Attempting to obliterate the erroneous entry by applying the whitener or scratching through the entry in such a way that the person cannot determine what was written originally written raises the suspicion of someone looking for negligent or inappropriate care [ 1 ].
• Do not alter the notes retrospectively. If something written was inaccurate, misleading or incomplete then insert an additional note as a correction [ 2 ].
• Entries in a medical record should be made on every line. Skipping lines leave the room for tampering with the records [ 1 ].
• Amend on electric record by striking through rather than deleting and overwriting the original entry. After inserting the new note, add date, time and doctor name [ 3 ].
• Correction of the personal identification data of the patient like name, age, father/husband name, and address should only be made on the basis of affidavit attested by notary or 1st class magistrate [ 3 ].

Who has Access to Medical Records?

• Medical records are the property of the hospital or patient’s medical practitioner. It is a confidential communication of the patient and cannot be released without his permission [ 1 ].
• All patients have right to access their records and obtain copy of those records [ 1 ].
• Patient’s legal representative has the right to those records as long as patient has signed a release of records to accompany any request from the legal representative [ 4 ].
• Other health care providers have the right to the records of the patient, if they are directly involved in the care and treatment of the patient [ 4 ].
• Parents of a minor also have access to patient’s medical records [ 4 ].
• Medical records are usually summoned in a court of law in certain cases like-road traffic accident, medical negligence, insurance claim etc. [ 2 ].
• The impersonal documents have been used for research purposes as the identity of the patient is not revealed. Though the identity is not revealed, the research team is privy to patient records and a cause of concern about the confidentiality of the information. Recently a need has been felt to regulate the need of medical research, effectively restricting the manner in which this type of research is conducting. An ethical review is required for using the patient’s data [ 3 ].

Release of Records

• Request for medical records by patient or authorized attendant should be acknowledged and documents should be issued within 72 h [ 3 ].
• Maintain the register of certificates with the detail of medical records issued with at least one identification mark of the patient and his signature [ 5 ].
• Effort should be made to computerize the records for quick retrieval [ 2 ].
• Certain document must be given to the patient as a matter of right. Discharge summary, referral notes, or death summary are important document for the patient. Therefore, these documents must be given without any charge for all including patients who discharge themselves against medical advice [ 3 ].
• Doctors are not under any obligation to produce or surrender their medical records to the police in the absence of valid court warrant [ 6 ].
• A subpoena to produce clinical records is a form of court order. Failure to comply is in contempt of court and may be punished. Medical records which are subpoenaed are to be made over to the court and not to the solicitor who sought the subpoena [ 6 ].

Care while Issuing certain Medical Records

Prescription.

The prescription should be preferably on the OPD slip of the institution or on the letter pad of the doctor. Drug company or chemist prescription pad should never be used. Prescription must contain—patient’s name, age, sex, address and institution/hospital name. Prescribed drug should be preferably in capital letter or else clearly visible. One should mention its strength (especially in paediatric age group), its dose frequency, duration in days, and total quantity (number of tablets and capsules). Below the main drug, also mention other instructions of precautions and what to avoid. If any investigation is advised, do not forget to mention it on the prescription slip and call the patient after the investigation. If patient fails to keep follow up date and if then some complication occurs, then patient is also considered negligent (contributory negligence) [ 1 ].

All reports i.e. lab investigation, X-ray reports, ultrasound reports, computed tomography (CT-scan)/magnetic imaging resonance (MRI) reports, and histo-pathological reports should be issued by a qualified person. Biopsy report should preferably be issued in duplicate so that the referring doctor/hospital can keep the original copy. If the pathologist does not give a duplicate copy the referring doctor should get it xeroxed and should be handed over to the patient.

Referral Notes

Always keep the carbon copy of referral note especially in case of critically ill patient. Referral note should mention the date and time of writing the note. Also write the treatment given.

Discharge Card

Consultant in-charge should himself fill or supervise the discharge card. Condition of the patient on the admission, investigation done, the treatment given and detail advice on discharge should be written on discharge card. Operation notes if mentioned have to be correct otherwise just mention the name of the operation and give separate note in detail if asked for. If any complication is expected after discharge ask the patient to report immediately. Instructions while discharge must be very clear and elaborative. Keep in mind that abbreviations may not be understood by others. Also do not use code messages, sarcasm or poor opinion to the patient.

Certificates

A medical certificate is defined as a document of written evidence vouching for the truth of a fact as determined by the doctor issuing such a document. If medical certificate is admitted in a court of law as evidence and is proved to be false, the issuing doctor is liable for punishment. While issuing a medical certificate following things should be kept in mind,

• Medical certificate should be on institution/doctor letter pad.
• Date, time, and place should be mentioned.
• Issue it only for legitimate purpose and only when necessary.
• It has to be true and clear without any ambiguity.
• There should be an identification mark of the patient, preferably a thumb impression.
• Period of illness should be clearly mentioned.
• Diagnosis disclosure of the diagnosis should be only after the patient’s express consent, unless required by the law
• Doctor should maintain the duplicate copy of every certificate.

How Long to Maintain the Records

• Ideally records of adult patient are maintained for 3 year.
• 21 year for neonatal patient (3 + 18 year).
• For children 18 year of age + 3 year.
• For mentally retarded patient forever till hospital/institution is working.
• From income tax point of view for 7 years.

How to Destroy the Records

• Public notice of destroying the records in English news paper and in one vernacular paper mentioning the specific date up to which destruction will be sought [ 1 ].
• Give a time limit of 1 month for taking away records for those who want the records with written consent [ 1 ].
• Where litigation is going on.
• Where future trouble is expected.
• Mentally ill or retarded patient.
• Pre-litigation process of notice exchange is going on.

Hard Copy Only

Computers are now widely used in institution/hospitals for electronic patient records but still hard copy is required for following documents [ 1 ]

• Consent need to be on hard copy.
• Referral to doctor need hard copy.
• Police case need hard copy.
• Certificate of fitness should be on hard copy.

Problem of Record Management

There are many problems faced by institution/hospital for the proper maintenance of the records. 1. Constant revision of the outdated form is needed [ 2 ]. 2. Always trained personnel are needed for the maintenance [ 2 ]. 3. Inactive records need storage at appropriate place [ 7 ]. 4. There must be a need of determination of record retention [ 7 ]. 5. Unwanted records must be destroyed [ 8 ]. 6. Record storage entail into 2 stages. A. Moving the records from active to inactive file and from there to storage room. B. Destruction and disposal of the unimportant records [ 8 ].

There are various type of damage which may be found in paper documentation like-aged paper may become weak, colour alteration from white to yellow, dirt and dust may be present on the surface, insect and fungus is a big threat for the records, if paper is kept folded, it may become weak at the crease, dampness and water leakage in storage room also destroy the paper.

Proper Preservation of the Medical Records

Collect all the records and classify them according to the different section [ 7 ]. Protect the records from insect attack. Spray insecticide or place naphthalene balls over shelves to preserve the records. Plan a periodical checking for the records [ 3 ]. Proper care should be observed while handling the records. Fire extinguisher should be available in record room. Protect all records from dampness, water, and from hot and dry climate [ 8 ]. Records should be kept in dust free area. Windows and ventilators should be properly covered with frames as safeguard against sabotage. Destroy the records as per the regulation established for retention of records.

Medical records form an important part of a patient management. It is important for the doctor and medical establishment to properly maintain the records of the patient for 2 important reasons. First one is that it helps in proper evaluation of the patient and to plan treatment protocol. Second is that the legal system relies mainly on documentary evidence in cases of medical negligence. Therefore, medical records should be properly written and preserved to serve the interest of doctor as well as his patient.