Medical Records Module

Overview

The Medical Records module is the heart of your electronic medical record (EMR) system. It's where you create, store, and manage all clinical documentation for patients. Think of it as your digital patient chart where you record everything from initial consultations to progress notes, test results, and treatment plans. This module ensures complete, accurate, and organized patient documentation for quality care and legal compliance.

Navigating to Medical Records

1. Look for the Medical Records section in your left sidebar menu
2. Click on Medical Records (second in the list)
3. You'll see a chronological list of all medical records in your system

Understanding Medical Records

What is a Medical Record?

A Medical Record is a complete documentation of a patient encounter or clinical event. Each record includes:

• Patient identification: Who the record is about
• Clinical content: What happened during the encounter
• Diagnostic codes: Why the patient was seen
• Procedure codes: What was done for the patient
• Author attribution: Who created the record

Types of Medical Records:

• Consultation Notes: Initial patient visits
• Progress Notes: Follow-up appointments
• Procedure Notes: Documentation of medical procedures
• Test Results: Laboratory and imaging reports
• Referral Letters: Communications to other providers
• Discharge Summaries: Hospital discharge documentation

Creating a New Medical Record

Section 1: Patient & Visit Information

Linking the record to the correct patient and visit:

Selecting the Visit:

• Visit: Choose from a dropdown of all patient visits
• Smart display: Shows patient name + visit date/time
• Auto-link: When you select a visit, the patient is automatically filled
• Searchable: Find visits by patient name or date

Selecting the Patient:

• Patient: Choose the patient (auto-filled from visit)
• Display format: Shows name + phone number
• Manual selection: Can also select patient directly if needed
• Verification: Always double-check patient selection

Section 2: Record Details

Classifying what type of record you're creating:

Record Type:

• Required field: Must select from predefined record types
• Examples: "Consultation Note", "Progress Note", "Laboratory Result"
• Purpose: Determines how the record is categorized and used

Record Title:

• Optional but helpful: Short descriptive title
• Examples: "Initial Consultation", "Post-Op Check", "Diabetes Follow-up"
• Purpose: Makes records easier to identify in lists

Section 3: Clinical Notes

The main content of the medical record:

Rich Text Editor:

• Formatting options: Bold, italic, underline
• Headings: H2, H3 for organization
• Lists: Bulleted and numbered lists
• WYSIWYG: What You See Is What You Get editing

What to Include:

1. History: Patient's story, symptoms, concerns
2. Examination: Physical findings, vital signs
3. Assessment: Diagnosis, differential diagnosis
4. Plan: Treatment, medications, follow-up
5. Education: Patient instructions

Structured Data (JSON):

• Optional technical field: For system data storage
• Format: JSON (JavaScript Object Notation)
• Example: {"blood_pressure":"120/80","temperature":"36.8"}
• Purpose: Stores machine-readable clinical data

Section 4: Medical Coding

Essential for billing, reporting, and statistical analysis:

ICD-10 Diagnosis Code:

• Required: Must select a diagnosis code
• Searchable: Find codes by number or description
• Display: Shows code + description together
• Examples:
  • I10: Essential (primary) hypertension
  • E11: Type 2 diabetes mellitus
  • J06: Acute upper respiratory infection

CPT Procedure Code:

• Required: Must select a procedure code
• Searchable: Find codes by number or description
• Display: Shows code + description together
• Examples:
  • 99213: Office visit, established patient
  • `93000**: Electrocardiogram
  • `80053**: Comprehensive metabolic panel

Auto-author Attribution:

• Authored By: Automatically records who created the record
• Timestamp: System records creation date/time
• Audit trail: Cannot be changed manually

Viewing Medical Records

Main Columns Displayed:

• Record Type: What kind of record it is
• Patient: Who the record is for
• Title: Descriptive title (if provided)
• Authored By: Who created the record
• ICD-10 Code: Diagnosis code
• CPT Code: Procedure code

Sorting and Filtering:

• Default sorting: Most recent records first
• Date filters: Find records within specific date ranges
• Search: Find by patient name, record title, or codes
• Deleted records: Can view and restore deleted records

Hidden Columns (Available if needed):

• Timestamps: Created/updated dates for auditing
• Technical fields: System identifiers

Quick Reference Guide

Clinical Documentation Components:

Component	Purpose	Example
SOAP Format	Standard documentation structure	Subjective, Objective, Assessment, Plan
Diagnosis Code	Why patient was seen	I10 (Hypertension)
Procedure Code	What was done	99213 (Office visit)
Record Type	Category of documentation	Consultation Note
Rich Content	Detailed clinical notes	Patient history, exam findings

Common Record Types and Their Use:

Record Type	When to Use	Typical Content
Consultation	First visit	Full history, comprehensive exam
Progress Note	Follow-up	Update on condition, treatment response
Procedure Note	Medical procedure	Pre-op, procedure details, post-op
Test Result	Lab/imaging results	Findings, interpretation, follow-up
Referral	Sending to specialist	Reason for referral, relevant history

Medical Coding Basics:

Code System	Purpose	Format	Example
ICD-10	Diagnosis	Alphanumeric	I10, E11.9
CPT	Procedures	Numeric	99213, 80053
ICD-10-CM	Clinical Modification	More specific	E11.9 (with complications)

Best Practices for Medical Documentation

Before Creating a Record:

1. Verify patient identity: Double-check you have the right patient
2. Review previous records: Check patient history for context
3. Prepare notes: Have examination findings ready
4. Select appropriate codes: Know diagnosis and procedure codes in advance

During Documentation:

1. Be thorough: Include all relevant information
2. Be objective: Stick to facts, avoid opinions
3. Be timely: Document while information is fresh
4. Be accurate: Double-check measurements, dates, and codes
5. Be professional: Use medical terminology appropriately

After Documentation:

1. Review content: Check for completeness and accuracy
2. Sign/authenticate: Ensure proper attribution
3. File appropriately: Ensure record is saved in correct patient chart
4. Follow up: Note any needed follow-up actions

Legal and Ethical Considerations

Documentation Standards:

• Complete: Include all relevant information
• Accurate: Reflect what actually occurred
• Timely: Document as soon as possible after encounter
• Legible: Clear and understandable (digital advantage)
• Signed: Properly attributed to creator

Privacy and Security:

• HIPAA/PHI compliance: Protect patient health information
• Access controls: Only authorized personnel can view/edit
• Audit trails: All changes are tracked
• Data backup: Regular system backups

Common Scenarios

Scenario 1: Initial Consultation

Situation: New patient with hypertension

Process:

1. Patient & Visit: Select patient and today's visit
2. Record Details: Type: Consultation, Title: "Hypertension Initial Visit"
3. Clinical Notes:
   • History: 45yo male, BP elevated x 3 months
   • Exam: BP 150/95, otherwise normal
   • Assessment: Essential hypertension
   • Plan: Start medication, lifestyle changes
4. Medical Coding:
   • ICD-10: I10 (Hypertension)
   • CPT: 99204 (New patient office visit)

Scenario 2: Follow-up Visit

Situation: Established patient with diabetes follow-up

Process:

1. Patient & Visit: Select patient and visit
2. Record Details: Type: Progress Note, Title: "Diabetes Follow-up"
3. Clinical Notes:
   • Update: Blood sugar control improving
   • Exam: Fasting glucose 110, weight stable
   • Assessment: Type 2 DM, controlled
   • Plan: Continue current regimen
4. Medical Coding:
   • ICD-10: E11.9 (Type 2 diabetes)
   • CPT: 99213 (Established patient visit)

Scenario 3: Laboratory Results Documentation

Situation: Recording and interpreting lab results

Process:

1. Patient & Visit: Link to recent lab visit
2. Record Details: Type: Test Result, Title: "CBC Results"
3. Clinical Notes:
   • Findings: Hb 12.5, WBC normal, platelets normal
   • Interpretation: Mild anemia, otherwise normal
   • Plan: Iron studies, follow-up in 1 month
4. Medical Coding:
   • ICD-10: D64.9 (Anemia unspecified)
   • CPT: 85025 (Complete blood count)

Scenario 4: Procedure Documentation

Situation: Minor surgical procedure

Process:

1. Patient & Visit: Select procedure visit
2. Record Details: Type: Procedure Note, Title: "Wound Suture"
3. Clinical Notes:
   • Pre-op: 5cm laceration, cleaned, anesthetized
   • Procedure: Sutured with 4-0 nylon
   • Post-op: Dressed, instructions given
4. Medical Coding:
   • ICD-10: S81.0 (Open wound of knee)
   • CPT: 12001 (Simple repair superficial wounds)

Troubleshooting Guide

Problem	Solution
Can't find patient visit	Check if visit is recorded in system first
Wrong codes selected	Edit record to correct codes, document change reason
Incomplete documentation	Add missing sections, have supervisor review
Accidental deletion	Use restore function from deleted records
Formatting issues	Use rich text editor tools properly
Duplicate records	Check if record already exists before creating new

Connecting with Other Modules

With Patient Management:

• Medical records are linked to patient profiles
• Complete patient history available in one place
• Continuity of care across multiple visits

With Billing and Coding:

• ICD-10 and CPT codes feed into billing system
• Documentation supports insurance claims
• Audit-ready documentation for reimbursement

With Laboratory/Imaging:

• Test results can be documented as medical records
• Links between orders and results
• Complete diagnostic picture

With Pharmacy:

• Prescriptions documented in medical records
• Medication history tracked
• Treatment plans include pharmaceutical interventions

Reports and Analytics

Useful Medical Record Reports:

• Volume by provider: How many records each clinician creates
• Diagnosis frequency: Most common conditions treated
• Procedure analysis: Most performed procedures
• Documentation completeness: Audit of record quality
• Timeliness report: How quickly records are created

Generating Clinical Reports:

1. Use date filters for specific time periods
2. Filter by provider, department, or record type
3. Export data for quality improvement analysis
4. Create dashboards for key performance indicators

Quality Assurance

Documentation Quality Checks:

• Completeness: All required fields filled
• Accuracy: Information matches other sources
• Timeliness: Created within required timeframe
• Coding accuracy: Correct ICD-10/CPT codes
• Clinical relevance: Appropriate content for situation

Regular Audits:

• Monthly sample reviews: Random record checks
• Provider feedback: Constructive improvement suggestions
• Compliance monitoring: Ensure regulatory requirements met
• Training updates: Based on audit findings

Need Help?

Quick Documentation Tips:

• Always verify patient identity before documenting
• Use SOAP format for consistent organization
• Code accurately - affects billing and statistics
• Document in real-time when possible
• Review before saving to catch errors

Common Questions:

Q: Can I edit a medical record after saving? A: Yes, but all changes are tracked in audit trail

Q: What if I select wrong diagnosis code? A: Edit the record, correct the code, add note explaining correction

Q: How long should clinical notes be? A: Sufficient to support care, but concise - quality over quantity

Q: Who can view medical records? A: Only authorized clinical staff based on role permissions

Q: Are digital signatures valid? A: Yes, system attribution serves as electronic signature

Getting Support:

• System auto-saves at regular intervals
• Rich text editor for professional formatting
• Search functionality to find information quickly
• Audit trails for compliance and security
• Training available for documentation best practices
• Technical support for system issues

Glossary

• EMR: Electronic Medical Record
• SOAP: Subjective, Objective, Assessment, Plan (documentation format)
• ICD-10: International Classification of Diseases, 10th edition
• CPT: Current Procedural Terminology
• PHI: Protected Health Information
• HIPAA: Health Insurance Portability and Accountability Act
• Progress Note: Documentation of ongoing care
• Consultation: Initial comprehensive evaluation
• Authored By: Person who created the record
• Audit Trail: Record of all changes to documentation
• WYSIWYG: What You See Is What You Get (editor type)