Malone, Medical Office Management - Chapter 7 Notes

CHAPTER 7: MEDICAL RECORDS MANAGEMENT INSTRUCTIONAL AND LEARNING OBJECTIVES FOR CHAPTER 7 Upon completion of this chapter, the student should be able to: Spell and define the key terms in this chapter. Describe the purpose and the various types of information found within the medical record. Understand how to keep professional notes in the medical record. Define the various forms of medical charting techniques, including the importance of standardizing the abbreviations used in charting. Understand why charting communications with patients in the medical chart is important. Understand how to cross-reference medical records and how to locate a missing medical record. Describe the types of filing systems and file storage systems used in medical offices. Understand how to determine the length of time for retaining medical records Define active, inactive, and closed patient files. Outline the process of converting paper records to electronic storage and how to properly dispose of medical records once converted. Discuss Medicare guidelines for the retention of medical records. Outline the process for correcting medical records. Understand the process for making additions to medical records. Understand what to chart when charting conflicts occur. Define ownership of the medical record. Describe the role of the electronic medical record in today’s medical office environment. Describe the process for releasing medical records. Outline the process to follow in mandatory reporting situations. Document advance directives in the medical chart. Understand when it is appropriate to fax medical records. Describe the impact of improper disclosure of the medical record on the medical office. Describe the use of online medical records. Document prescription refill requests in the medical record. Understand the importance of documenting patient participation in medical research. CHAPTER OUTLINE Information Contained in the Medical Record Purpose of the Medical Record Signing Off on the Medical Record Keeping Chart Notes Professional Forms of Charting Using Abbreviations in Charting Charting Communications with Patients Filing and Filing Systems Cross-Referencing Medical Records Locating Misfiled Medical Records File Storage Systems Retention of Medical Records Active, Inactive, and Closed Patient Files Converting Paper Records to Electronic Storage Properly Disposing of Medical Records Medicare Guidelines Regarding Retention of Medical Records Making Corrections or Additions to Medical Records Charting Conflicting Orders Ownership of the Medical Record Electronic Medical Records Releasing Medical Records Mandatory Reporting Requirements Documenting Advance Directives Faxing Medical Records Improper Disclosure of Medical Records Online Medical Records Documentation of Prescription Refill Requests Medical Records in Research RESOURCES Student textbook, Chapter 7 Instructor’s Manual with Lesson Plans Chapter 7 PowerPoint Lecture MyTest MyHealthProfessionsKit Detailed Lesson Plans Learning Objective 7.1: Spell and define the key terms in this chapter. Teaching Notes Text Pages: 135–158 Concepts for Lecture The key terms listed at the beginning of the chapter are important concepts for students to know and appear in bold on first introduction in the student text. Terms are defined in the margins and in the comprehensive glossary at the end of the book. Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 12–17 In-Class Activities Review key terms and answer any questions students may have regarding understanding. Teaching Notes/Tips Encourage struggling students to make flashcards of the key terms in the chapters. Flashcards can be a great memory tool. Learning Objective 7.2: Describe the purpose and the various types of information found within the medical record. Teaching Notes Text Pages: 136–137 Concepts for Lecture 1. Purpose of the Medical Record Contains information about all care received. Legal document Must be kept confidential Most important tool used to defend against malpractice lawsuits 2. Types of Information Found in the Medical Record Personal information Financial information Medical information Social information Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 18–20 In-Class Activities Provide a list of information that a patient would provide to a physician’s office. Then have students determine in which category each piece of information should be placed in the medical record. The categories are: -Personal information -Financial information -Medical information -Social information Teaching Notes/Tips Some students may not be as comfortable as others in getting involved in class activities. Watch for these students and take advantage of opportunities where involvement can be encouraged. Homework Assignment Have students read Chapter 7. Learning Objective 7.3: Understand how to keep professional notes in the medical record. Teaching Notes Text Pages: 137–141 Concepts for Lecture 1. Five Charting Rules Concise Complete Clear Correct Chronological 2. How to Sign Off on a Medical Record Entry in patient record must include an identifying mark Mark should at minimum be the initials and credentials of person making entry Electronic signature or rubber-stamp may be used 3. Keeping Chart Notes Professional Always be objective. Never contain conjecture or opinion of the author. Only contain facts as stated or observed. Always use proper spelling and grammar. Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 21–24 In-Class Activities Have students practice charting. Provide worksheets with items for them to chart. Teaching Notes/Tips The Five Cs of charting may require clarification, so make sure students understand the definition of each of the Five Cs and how to check their charting for matching these criteria. Learning Objective 7.4: Define the various forms of medical charting techniques, including the importance of standardizing the abbreviations used in charting. Teaching Notes Text Pages: 141–142 Concepts for Lecture 1. Forms of Charting Narrative chart notes SOAP note charting POMR charting 2. Parts of a SOAP Note Subjective Objective Assessment Plan 3. The POMR Tracks a patient’s problems throughout medical care Each problem is assigned a number Number is referenced when patient comes in for care 4. The Use of Abbreviations a. Can cause errors b. Use only accepted abbreviations c. The Joint Commission provides a list of abbreviations that should not be used Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 25–29 In-Class Activities Divide the class into small groups of four to five students. Ask each group to create a scenario of a patient visit to the doctor. Have the groups trade scenarios and create both SOAP and POMR notes for the scenario. Teaching Notes/Tips An electronic method of charting might include choosing from a list of items like symptoms, severity, and so on. Be sure to include this possibility in your lecture. Homework Assignment Have students find out how their personal physician charts and write a one-page summary of their findings to share with the class. Learning Objective 7.5: Understand why charting communications with patients in the medical chart is important Teaching Notes Text Page: 142 Concepts for Lecture 1. Charting Communications with Patients Important to chart exchanges with patients accurately Charting helps avoid potential errors in communicating information Office should have policy regarding type of communication that requires charting Charting helps safeguard the office from malpractice claims. Not all communication must be charted. Staff should use best judgment to determine if conversations are medically relevant Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 30–32 In-Class Activities Ask each student to write one conversation that must be documented in the medical record and one that does not need to be documented in the medical record. Put all of these writings in a hat and pull them out one at a time for students to determine as a group if it should be charted or not. Teaching Notes/Tips For those students struggling with this learning objective, provide a criterion to judge if a conversation is medically relevant and should be charted. Homework Assignment Have students research medical malpractice lawsuits to find cases where communication was written incorrectly or correctly and the impact this had on the case. Print the information and bring to share with the class. Learning Objective 7.6: Understand how to cross-reference medical records and how to locate a missing medical record. Teaching Notes Text Pages: 144–146 Concepts for Lecture 1. Cross-Referencing Medical Files Can help direct staff to location of files 2. Suggestions for Locating Missing Files Look first under the patient’s first name instead of last Determine when patient was last seen in the office and then look under other patient names who were seen on the same day Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 33–35 In-Class Activities Create a scavenger hunt for students to find a missing file in the classroom. Make it fun, and then discuss the importance of using reasoning and clues to find misplaced records. Teaching Notes/Tips Emphasize how electronic medical records help prevent missing record events from occurring. Homework Assignment Have students interview family members or friends about what they would do if their medical record was lost. Have students present their findings to the class. Learning Objective 7.7: Describe the types of filing systems and file storage systems used in medical offices. Teaching Notes Text Pages: 144–145 Concepts for Lecture 1. Types of Filing Systems Metal cabinets that hold paper patient charts in alphabetical order Old-style filing cabinets designed in a tower shape, with drawers that pull out Space-saving filing system allows the entire cabinet to move for accessing Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 36–40 In-Class Activities Invite a medical records professional to come and talk to the class about filing systems and the advantages and disadvantages of each. Teaching Notes/Tips Emphasize that electronic medical records relieve many of the filing duties for medical assistants and take up much less space Homework Assignment Have students reflect on what the disadvantages of electronic health records may be and report their findings to the class. Learning Objective 7.8: Understand how to determine the length of time for retaining medical records. Teaching Notes Text Page: 147 Concepts for Lecture 1. Length of Time to Retain Medical Records Dictated by state and federal regulations Need to know statutes of limitations in the state where practice is located Discovery rule can greatly alter the statute of limitations Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 41–42 In-Class Activities Divide the class into five groups. Have each group select five states in the United States (each group’s states should be different). Have each group then conduct research on the state’s requirements for retention of medical records. Once the research is complete, have each group share their findings. Teaching Notes/Tips Some students may feel very comfortable with using technology and others may not. When students are performing research on the computer, be sure and provide any support necessary. Homework Assignment Ask students to write a one-page paper describing why being convicted of certain crimes makes it difficult to be hired for a healthcare position. Learning Objective 7.9: Define active, inactive, and closed patient files. Teaching Notes Text Page: 147 Concepts for Lecture 1. Types of Patient Files Active -Patients who actively have appointments or who have been in to see the physician recently Inactive -Patients who have not been in to see the physician for a period between 2 and 5 years depending on the type of practice, number of files the practice must store, and office policy C. Closed -Typically moved to other storage facilities, leaving available space for active patient files Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 43–45 In-Class Activities In groups of four to five students, have groups determine where in an office layout would be the most strategic place to put the active files, inactive files, and closed files. Have them assume they must put all files in the office somewhere. Teaching Notes/Tips Bring in one of each type of file: active, inactive, and closed. Without labeling them, have the students determine what stage the file is in by looking at the contents. Learning Objective 7.10: Outline the process of converting paper records to electronic storage and how to dispose of medical records properly once converted. Teaching Notes Text Pages: 147–148 Concepts for Lecture 1. Purging Records Entails moving files to other locations or scanning documents in the files and then digitally storing the data Storage options include microfilm, microfiche, CD, and DVD Once purging is done, files can be shredded. 2. Converting from Paper to Electronic Records Once paper records are converted to electronic, the paper records are typically no longer needed. Records no longer needed must be destroyed. Typically, paper records are shredded after being copied or scanned. Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 46–48 In-Class Activities Divide the class into three groups and have each group create one of the following office policies for record conversion: Ensuring confidentiality during scanning Storage of files until destruction Final verification that records are safe to be destroyed Teaching Notes/Tips Encourage students to consider the logistical difficulties during a transition from hard-copy files to electronic records. Help students brainstorm solutions concerning how to make this transition smoother. Homework Assignment Have students research the cost of shredding services and/or services that convert hard-copy medical records to electronic format and bring their results to share with the class. Learning Objective 7.11: Discuss Medicare guidelines for the retention of medical records. Teaching Notes Text Pages: 148–149 Concepts for Lecture 1. Medicare Guidelines for Retention of Medical Records Medical records must be retained for at least 5 years. Due to the statute of limitations and other legal purposes of the record, it is wise to keep records for as long as possible. Records should be stored in a secure environment, safe from water or fire damage. Stored records should be easily accessible to the healthcare team as needed. Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 49–51 In-Class Activities Have students conduct online research to learn the most up-to-date Medicare guidelines for record retention and share their findings with each other. Teaching Notes/Tips Emphasize the importance of students being up to date on the laws that affect tasks performed in the medical office. Learning Objective 7.12: Outline the process for correcting medical records. Teaching Notes Text Page: 149 Concepts for Lecture 1. Correcting a Paper Record Draw one line through the error. Initial and date the correction. Write the correct information above or beside the inserted line. 2. Correcting Other Forms of Errors Correcting an entire line or several lines: -Draw a single line through the entire portion of the entry that is in error. Correcting an entire entry error: -Draw a single line through the entire entry. -Make a notation such as “Wrong patient’s chart.” -Include the date and author’s initials and credentials. Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 52–56 In-Class Activities Provide students with charting to be corrected. Instruct students to use appropriate method of correction. Teaching Notes/Tips Emphasize the legality of correcting medical records. Learning Objective 7.13: Understand the process for making additions to medical records. Teaching Notes Text Page: 149 Concepts for Lecture 1. Adding Information to the Record Begin entry with the date addition is being added. Follow date with the words “Late Entry.” Indicate the date of the visit the late entry pertains to, notes that were originally omitted, and signature of person making entry. When correction exceeds space where error is, insert an addendum to the medical record. Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 57–59 In-Class Activities Divide the class into groups of four to five students. Give each group examples of documentation. Ask each group to determine which of the examples requires an addendum. Each group should create an appropriate addendum for the chart. Teaching Notes/Tips Emphasize that late entries should be rare and completed as soon as they realize they have missed documenting something. Homework Assignment Remind students to use days without specific homework to review the chapter for upcoming quiz. Learning Objective 7.14: Understand what to chart when charting conflicts occur. Teaching Notes Text Page: 150 Concepts for Lecture 1. What to Chart When Charting Conflicts Occur Events Fact that the physician has been questioned regarding the accuracy of the orders Physician’s responses to the inquiry Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 60–61 In-Class Activities In small groups of four to five students, have the groups brainstorm scenarios where there could be a conflict in orders from the physician. Have students discuss how to address these conflicts. Teaching Notes/Tips Encourage students to think about how difficult it could be to ask a physician if his or her order is accurate. Role-play to demonstrate this issue. Homework Assignment Assign students to write a one-page essay on how they can approach conflicting orders. Learning Objective 7.15: Define ownership of the medical record. Teaching Notes Text Page: 150 Concepts for Lecture 1. Ownership of the Medical Record Records belong to the physician or facilities where created. Inside information belongs to patients. Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 62–63 In-Class Activities Research ownership issues as a class to understand why the physician or facility owns the medical record and the patient does not. Teaching Notes/Tips Emphasize the importance of the ownership of the medical record for legal proceedings. Learning Objective 7.16: Describe the role of the electronic medical record in today’s medical office environment. Teaching Notes Text Pages: 150–152 Concepts for Lecture 1. Role of the Electronic Medical Record Lower medical mistakes Reduce costs Improve care Improve communication Increase accessibility Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 64–65 In-Class Activities Divide the class into two groups. Hold a contest to see which group can come up with the most advantages to electronic medical records in 5 minutes. Teaching Notes/Tips Provide examples of electronic medical records for students to view. Homework Assignment Ask the students to research common electronic medical record software programs and report to the class on the functionality of the software. Learning Objective 7.17: Describe the process for releasing medical records. Teaching Notes Text Pages: 152–154 Concepts for Lecture 1. Process for Releasing Medical Records Any request for copies must be accompanied by patient’s signed authorization Authorization must be directed to the correct facility and contain a date indicating when signature was made Nature of the request must be clear Alert physician to request for records when required Before sending, review the file 2. Releasing an Original Medical Record Rarely done Requests are most often received via subpoena When requested, make a complete copy of every item. Keep copies in the office as proof of the contents at time of release. 3. Disclosing a Minor’s Medical Record Information In most states, children under 18 years of age may receive certain types of medical treatment without parents’ consent. Because laws vary from state to state, very important to know the law Minors may receive copies of only those documents parents cannot see Parents could receive only copies of children’s vaccinations, not STI treatments Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 66–71 In-Class Activities Have students write the process of releasing medical records, both for adults and for minors. Have them exchange papers with a partner and correct any errors. Teaching Notes/Tips Emphasize the importance of always following the correct process in releasing medical records and the consequences of not doing so. Learning Objective 7.18: Outline the process to follow in mandatory reporting situations. Teaching Notes Text Page: 154 Concepts for Lecture 1. Mandatory Reporting Requirements Reporting vaccine injuries -Obtain patient’s name and age, as well as name and lot number of vaccine -Call must be documented in patient’s file Reporting cases of abuse Need to report violent cases, including injuries from gunshots or knives, or criminal acts such as assault, attempted suicide, or rape 2. Reporting Certain Illness and Injuries Each state determines type of illness and injury that must be reported Examples of illnesses and injuries include anthrax, certain STIs, and dog bites Each state determines maximum length of time that can elapse from time when a patient is seen to when provider must file a report Some illnesses and injuries must be reported the same day they are seen; others must be reported within 2 weeks. Teaching Resource: Chapter 7: Medical Records Management PowerPoint Lecture Slides: 72–76 In-Class Activities: Provide examples of mandatory reporting mixed with examples of incidents that are not required to be reported. Ask students to take turns identifying if the example provided is reportable or not, and have them explain why. Teaching Notes/Tips Provide the class with information on what is done with information reported in abuse cases. Homework Assignment Assign students to research the reportable items in their area and write up this information to put in their resource manual. Learning Objective 7.19: Understand and document advance directives in the medical chart. Teaching Notes Text Pages: 154–155 Concepts for Lecture 1. Document Advance Directives in the Medical Record 2. Documenting a Do Not Resuscitate Order Must be written and signed by patient’s doctor Copy should be kept in patient’s file Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 77–81 In-Class Activities Allow students time to contemplate end-of-life decisions and what they would say to a patient wanting information on creating advance directives. Ask for volunteers to share their reflections. Teaching Notes/Tips Provide examples of living will formats, advance directives, and Do Not Resuscitate order forms. An example of a living will is provided in the text (Figure 7-12). Homework Assignment Have students research the laws regarding advance directives in their local area and write a one-page paper on their findings. Learning Objective 7.20: Understand when it is appropriate to fax medical records. Teaching Notes Text Page: 156 Concepts for Lecture 1. Faxing Medical Records Records should be faxed only when no other method of data transfer is available. AHIMA recommends fax use for confidential patient information only when sending copies via postal service or messenger is not possible. HIPAA-compliant fax cover sheet should be used when faxing (Figure 7.13). Teaching Resource Chapter 7: Medical Records Management. PowerPoint Lecture Slides: 82–83 In-Class Activities In small groups of four to five students, instruct students to write a HIPAA-compliant fax cover sheet. Teaching Notes/Tips Provide information on alternatives to faxing that are more secure. Learning Objective 7.21: Describe the impact of improper disclosure of the medical record on the medical office. Teaching Notes Text Page: 157 Concepts for Lecture 1. Improperly Disclosing Medical Records Disclosing without proper authorization is cause for a lawsuit Patients believing information has been disclosed inappropriately may contact the Office of Civil Rights Every office must have complaint forms on file and help patients file proper paperwork Fines for HIPAA violations range from $100 to $25,000, and criminal penalties may apply. Teaching Resource Chapter 7: Medical Records Management. PowerPoint Lecture Slides: 84–86 In-Class Activities Provide a complaint form from the Office of Civil Rights. In dyads, have students complete the form for a pretend complaint violation. Check student work for thoroughness. Teaching Notes/Tips Emphasize the fines and imprisonment that can occur for HIPAA violations. Homework Assignment Have students search for news stories related to HIPAA violations. Students should print the story and bring to class to share. Learning Objective 7.22: Describe the use of online medical records. Teaching Notes Text Page: 157 Concepts for Lecture 1. Online Medical Records Allow patients to look up portions of their electronic medical records via the Internet Other services include online storage of medical information, such as immunizations, medications, and surgeries Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 87–88 In-Class Activities Divide students into two groups. Assign one group to be the “Pro” group and one to be the “Con” group. Have students debate the allowance of making electronic medical records available via the Internet. Teaching Notes/Tips Bring up the risk of hacking as part of the debate materials. Learning Objective 7.23: Document prescription refill requests in the medical record. Teaching Notes Text Page: 158 Concepts for Lecture 1. Filling a Prescription Refill Pull the patient’s file. Place request and patient file on physician’s desk for review. If EMR is being used, enter prescription request into the EMR and forward request to prescribing physician. If physician believes patient should be seen before refill is made, call the pharmacy first to alert them to the delay, then call the patient to schedule an appointment. If physician authorizes the refill request, call pharmacy or fax the approval with appropriate information. Document all information about the refill request, authorized or not, in the patient file. Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 89–92 In-Class Activities Provide students with a sample prescription. Instruct students to write a chart note indicating the patient calling in to get a refill on the prescription and the physician approving the refill. Teaching Notes/Tips Review the chart notes for accuracy. Emphasize the scope of practice for the profession the students are entering, and relate this to calling the pharmacy with prescription refill requests. Learning Objective 7.24: Understand the importance of documenting patient participation in medical research. Teaching Notes Text Page: 158 Concepts for Lecture 1. Use of Medical Records in Research Documentation is critical. Patients participating in research programs must be fully aware of the risks. Patients must sign consent forms. Consent forms are important if later adverse effects are experienced and participation in the program is ever questioned. Teaching Resource Chapter 7: Medical Records Management PowerPoint Lecture Slides: 93–94 In-Class Activities As a class, have students find a recent research study that is being conducted either at a local hospital or one that has been written about on the Internet. Challenge students to see if they can determine how patients were provided the appropriate consent form and were aware of the potential risks of the study. Teaching Notes/Tips Provide example consent forms for research study participation. Homework Assignment Have students answer the end-of-chapter review questions for Chapter 7 and complete the case study. CORE TEXTBOOK ANSWER KEY Note: Answers to the case study questions appear in Appendix E of the student text. Multiple Choice b a d b g a c a b j True/False False False True True True False True True True True Matching d b e f g b f a h g Critical-Thinking Questions 7.1 Think about the reasons why patients may be uneasy revealing information such as their Social Security number or date of birth. Once you have some reasons in mind, what might you say to a patient who is having just that concern? Some patients are nervous about giving out their Social Security number or birthdate because the patient may feel they are at risk for identity theft. To place that patient at ease, the medical office manager can let the patient know that their information is protected, and describe the various ways the protection works (computer passwords, etc.) 7.2 Why might a patient’s social information be pertinent to his or her medical care? How might knowledge of social information assist the physician in treating the patient? A patient’s social information may be relevant to the type of care needed. A patient who smokes or engages in risky behaviors may have different healthcare needs than a patient who is a vegetarian or one who works in a high-stress job. 7.3 Imagine you are an office manager who has been handed a patient’s chart in preparation for calling the patient regarding a complaint. The outside of the chart has a notation from a clinical staff member stating that the patient is “impossible to please.” How might seeing that notation affect the way you converse with the patient when you call him? Seeing such a note may predispose the manager to assume the patient will be difficult or hard to satisfy. This predisposition may alter the way the manager approaches the call, and may actually prejudice the manager against the patient. 7.4 How might incomplete or unclear patient records affect a provider who is asked for a consultation on a patient’s condition? As the office manager, how might the lack of complete information in the patient’s medical record affect your ability to do your job? Unclear patient records may cause difficulty for a provider in providing the best quality care. Without all of the pertinent information, a provider may be missing details that affect how the patient may be best cared for. Missing information may also affect the office manager in that he or she may be unable to address a patient’s concern clearly about the type or quality of care received, if the chart notes are not complete or clear. 7.5 Why do you think the lack of proper spelling and grammar on behalf of the medical office staff may be seen as problematic? Misspelled words may be mistaken for a different meaning than what was intended. Poor grammar and spelling are often seen as unprofessional or careless, two traits the medical office staff do not want to project. 7.6 Think of the types of calls the office manager takes from patients in the medical office. How should you determine which calls must be charted in the patient’s medical record? Any calls that pertain to the patient’s medical care or condition should be charted in the patient’s medical record. 7.7 In many medical offices, patients from the same families see the same provider. This is especially true in a family practice facility. Imagine that your office sees William H. Smith, Sr., and William H. Smith, Jr. How should you alert staff to the existence of these similar names so that the correct chart is used? Each of the charts for these two patients should be marked with a notation alerting staff to the existence of another patient in the practice with the same name. 7.8 Imagine you are working in a practice in a state where the statute of limitations is 7 years. How long must you keep Medicare records in that practice? Any medical record should always be kept for at least 5 years or the number of years instructed in each state’s statute of limitations, whichever is greater. 7.9 What are some circumstances you can think of when it might be necessary to make a late entry or addendum to a patient’s chart? A late entry may be necessary when a clinical staff member realizes something was inadvertently missed in the charting for a particular visit. 7.10 Why do you think it may be useful for more than one provider or medical staff member to access the same patient’s file at the same time? One example is that a patient may be in the exam room with a physician at the same time a billing office staff member is accessing the chart while calling the patient’s insurance carrier. 7.11 Why do you think some illnesses and injuries must be reported sooner than others? Some conditions are highly contagious or very dangerous. In these cases, the department of health must act quickly to contain a possible outbreak of infection. 7.12 As a patient yourself, would you like the opportunity to access some or all of your own medical record online? What portions would you find useful? Many patients find the ability to access part of their medical record online to be very helpful. Some of the more useful data includes, for example, lab work.