1

Running Head : PATIENTS MEDICAL RECORDS

1. Explain regulations or laws that prescribe how health information professionals

are to handle archived or inactive medical records. Your response must be at
least 200 words in length
Answer to Q#1:
A Health Service Provider and its professionals have an obligation to archive and store
their patients medical records, once they become inactive ( and rarely sought). These records
are required to be archived and stored for a particular period which is known as Retention
Period. The archives can be paper which requires huge volumes of space and retrieving is time
consuming. Archiving is therefore done in micro-film or digitally. Other ways of storing are by
magnetic tape and optical drives. As retrieving and sharing is very easy digitally, most Heath
Centers prefer to keep it that way. Digitally, the service provider can either use their own servers
or let out the job to third party companies which specialize in storing data in cyberspace via the
internet and ensuring that no unauthorized access to the records is possible.
Healthcare Professionals running healthcare service centers need to finalize and put on
record a retention policy for a center which spells out storage period, as well as other activities
like type of storage, procedure for retrieval, data protection measures to be adopted, place of
storage, etc. To decide the duration of retention, health care professionals need to focus on the
below-mentioned aspects, as applicable to the institution

Recommendations of the Accreditation Agency

Legal requirements
Federal and State Retention laws.
Requirement for Education /Research
Whether patient care to be continued and if yes, then continuously or intermittently.

2
PATIENTS MEDICAL RECORDS

In case the Health Service Provider closes shop for any reason by selling the company,
then it is the new managements policy take over the duties of record keeping. However, most
heath care professionals are required to follow the State laws, which may vary from state to state.
For example Indiana requires the centre to forward to the Sate Health Department or another
similar Heath Care Service Provider close by. The more common procedure is the center putting
advertisements in the local newspapers and also writing to each patient asking them to collect
their records, from the hospital. Records are destroyed thoroughly once the retention period ends.
*********************

Question #2 : Discuss the various ways that patient records are authenticated. Your response
must be at least 200 words in length.
Before we discuss at length, the various ways by which patients records are authenticated, it will
be of help to assemble a few facts about authentication of medical records.
Authentication is the process by which the entries in the patients record are checked to
ensure that every entry in the record has been made by a professional who is authorized to so e.g.
a physician working for the Health Service Provider. Further AHIMA1 also says that anyone
documenting in the health record should be credentialed or have the authority and right to
document as defined by the organizations policy. This is because incomplete or improper
documentation indirectly raises question marks in the minds of the reader as to whether what has
been written actually occurred, i.e. the reliability of the report. ( Green & Bowie, 2011,pp 76,78).
This is mentioned specifically in The Federal Regulations/Interpretive Guidelines for
Hospitals(482.24(c)(1)(i)) which also says that failure to disapprove an entry within a specific
1 American Health Information Managent Association

3
PATIENTS MEDICAL RECORDS

time period is not acceptable as authentication. (Ibid ) The Guidelines are published by the
Centers of MEDICARE and MEDICAID Services (CMS), a Federal Organization.

Depending on the method, various types of Authentication can be as under

A) By Immediate Endorsement: The Physician gives the order, jots the same on the record
and signs it.
B) By Remote Endorsement: Here the physician is not in hand to endorse the order. The

authentication can then be carried out

Written signatures
Countersignatures
Initials
Fax signatures
Electronic signatures or computer codes/passwords
Signature stamps
The process of countersignature is when; say the physician gives the order to the RN to

administer some process. The RN does so but mentions why she had authored the report despite
not having the credentials. The RNs entry is later countersigned by the physician and so as to
say that the RN did so, under his/hers supervision.
Finally, each health centre is is required as per law to maintain a controlled document
regarding authentication. The document is supposed to contain all information regarding what
types of authentication is permitted under the rules of that particular health center.

***************

3.Discuss the importance of establishing a facility policy and procedure on the

appropriate use of abbreviations in medical document filed in a patients record.
Describe issues that can arise if health information management professionals are not

4
PATIENTS MEDICAL RECORDS

properly trained in the documentation of medical records. Your response must be at

least 200 words in length
Answer
The use of abbreviations for Medical conditions and procedures on the patients Medical
Report, is common but dangerous. This is because abbreviations can mean one thing to a
healthcare professional and another thing to another. It is best if abbreviations are not used at all
or when the same abbreviation are used a number of times to denote a long medical term, then a
note in the report where the meaning of the abbreviation is given, is inserted.
A health facility needs to maintain a record of official abbreviations which is a list of
abbreviations along with the full forms, so that if someone is unable to understand as to what an
abbreviation means, they can than look it up in the record. This book should be obviously
controlled and limited people should have access to it. Shadow copies however can be made
available for use for the RNs and the Junior Doctors.
There are skeptics who scoff at the above and say that in the case of critical cases, a
healthcare professional will never do anything depending on guesswork. However, it needs to be
noted that the professional is not guessing. He thinks that he knows the correct answer and
therefore there is no question of guesswork.
Doctors Sinha, McDermott, Srinivas & Houghton decided to check this statistically in
October, 2008. Over a ten day period, they collected a wide set i.e. of used abbreviations. These
were than organized into a sort of questionnaire and shown to an interdisciplinary team of
healthcare professionals who were asked to explain the meanings. Out of 209 questionnaires,
only 90 was found to be correct, which gives a correct answer to total answer percentage as
43%. Junior doctors were the most knowledgeable where dieticians were the least, the RN being

5
PATIENTS MEDICAL RECORDS

at the center.(Sinha, McDermott, Srininasan & Houghton, 2008) These findings are shocking and
showed to everyone , including the skeptics, is conclusive evidence as to why the use of
abbreviations should be discontinued in the long run. At present, abbreviations which have two
possible full forms or more have been banned from being used by the Joint Commission.
Finally, if this situation is allowed to continue, then hospitals will become unreliable. For
example, a nurse going through a record may find the patient being described as DoA. She will
be shocked as the patient is communicating with her but how can a dead man talk? Actually, the
doctor had meant Date of Discharge, but by the time the confusion is eradicated, a lot of time
will be lost.
*************************
4. Describe each type of patient record format and how it is used. Outline the
advantages and disadvantages of each type. Your response must be at least 200
words in length.
Patient Records can be classified into the following different types, depending upon how
the report is compiled so that a simple glance makes everything clear about that particular aspect.
1. The Source Oriented Report (SOR) or the SOR report is so named as it is maintained exactly as
the origin of the reports(pages). For Blood Test Results, all the physician advises and the result
of the test, for each time a blood test is carried out, is maintained chronologically in the Blood
Test Section. A X-rays, Cat Scans, MRI scan results will be filed in the Imaging Section. This is
the way things are done in SOR Medical Report
2. The problem oriented record (POR) is a more systematic method of documentation,
i.
ii.

which consists of four components:

Database
Problem list

6
PATIENTS MEDICAL RECORDS

iii.
iv.

Initial plan
Progress notes

( Green & Bowie, 2011,pp 90).

The database contains information about the paint. His family background, social
parameters, medical history, main complaint, other ancillary complaints, etc. The problem list
contains all the ailments he has in a numbered fashion which is easier to refer later on. Then,
there is the long time cure / treatments which can be done, which is better, and the final plan for
treatment. Finally the notes give the progress of the cure. Shadow copies of the Record become
something like a Medical Encyclopedia as it becomes thicker.
3. The Integrated keeps all paper generated in a strict chronological order.
Advantages and Disadvantages
SOR

POR

Integrated Record

ADVANTAGE

Same source documents

Links all documentation

Easy to use as report is

structure

are together.

to a specific

like a case Study.

Easy location of same

Facilitates patient

Consumes less time.

Accessibility

source documents
SOR

treatment and education

POR

Integrated Record

DISADVANTAGES

Create many sections in

Filing is time

Time required for

structure

record

consuming and lots of

retrieval

sections are created

Accessibility

Time Consuming way

Accessibility can be

Difficult to compare

of reporting

hard.

information from
same discipline

REFERENCES

7
PATIENTS MEDICAL RECORDS

Green, M A. Bowie, M.J.(2011) Essentials of Health Information Management: Principles and

Practices, 2nd Ed., Clifton Park, NY: Cengage Learning

Sinha, S McDerott,F; Srinivas,G; Houghton, P W J (2011) , Use of

Abbreviations by Healthcare Professionals: Which is the way
forward? Disclosures, Postgrad Med J :87(1029):450-452.