Medical Records - Policy and Guidelines. - book reviews

Healthcare Financial Management, April, 1996 by Denise R. Smith

By Joan Gratto Liebler, RRA, MPA Aspen Publishers, Gaithersburg, Maryland, 1994 447 pages

This book is an excellent guide for developing, reviewing, or updating medical records departmental policies. The book's format is clear and concise, with examples, sample forms, and easily adaptable standard policies. The loose-leaf, three-ring-binder format makes Medical Records--Policy and Guidelines easy to use.

After an introductory section, the book suggests general departmental policies, giving recommendations on scope of service, hours of operation, staffing, compliance with regulations and standards, confidentiality, and staff education and training. A worksheet for customizing general policies is provided. Section 3 offers an overview of the patient/client medical record, general information on the purpose of medical records, documentation, proper authentication, entry guidelines and ownership, review of videotape records, and facsimile transmissions.

Section 4 provides suggestions on content and sequence of medical record/database forms, control, inventory ordering and purchasing, and a listing of recommended, approved abbreviations and symbols. Readers will find 52 detailed document/data entry focuses; eight home health documents; and data entries for rehabilitation and end-stage renal disease, pain management programs, respite care, and spinal cord injury programs. Specific guidelines are included for handling health data regarding the HIV virus, with sample consent forms for information release and billing consent.

The patient/client identification system discussed in Section 5 analyzes the use of unique ID numbers and indexing. Rules, instruction, and examples are given for alphabetical filing, soundex filing, and triple-check automatic indexing systems. The answer to what happens to all the patient data when the patient is discharged or completes an episode of care is found in Section 6. Chart completeness and reviews are explained, with a review of time frames and penalties. Incomplete charts are discussed, with examples of monitoring, notification, use and access, and storage and retrieval. Medical staff committee reports, risk management reports, and billing audits also are introduced.

Section 7 gives details on dictation and transcription, including suggested time and priority designations, staffing and the use of outside contractual services, and an incentive wage program. Worksheets for customizing dictation and transcription policies and guidelines for dictating patient reports are included.

The medical records department is the data center for patient care-related data and statistics. Its key functions include providing for data collection, statistics, indices, registers, and reports. Section 8 discusses these data needs, with details for 12 key indices and registers. Record storage, retrieval, retention, and destruction are discussed in detail in Section 9, with job descriptions and training for staff involved in these tasks. A worksheet is provided for analysis and comparison of storage options, and 11 types of record requests are summarized.

It is a healthcare facility's legal and ethical responsibility to preserve the privacy and confidentiality of patient information at all times, which makes Section 10, concerning information release, especially critical. A wide range of information concerns are addressed, including alcohol and drug abuse, child abuse, and child neglect.

The rapid evolution of technology has increased interest in computer-based patient records, discussed in Section 11. The section offers a thorough examination of requirements and specifications, along with hardware and software considerations, including installation and maintenance. The book's concluding chapters cover medical ethical issues and quality monitoring, measurement, and reporting.

Medical Records--Policies and Guidelines provides excellent information for anyone seeking information on issues related to patient records. It will be especially useful to medical records department managers, administrative staff, and medical staff.

Reviewed by Denise R. Smith, FHFMA, CMPA, vice president of finance and chief financial officer, The McDowell Hospital, Marion, North Carolina, and a member of HFMA's North Carolina Chapter.