Chapter 12: Communication
Katie Baker
Medical charting is the paper or electronic record of the patient’s relationship with the medical organization. This can include patient visit notes, lab results and imaging findings as well as correspondence between providers on the patient’s healthcare team and from the patient and authorizations and other communications from the patient’s third party payor, whether government or private insurance carrier.
Many electronic records have the additional benefit of being shared between healthcare providers as well as providing greater ability to utilize patient data for research. However, to ensure that records are effective they need to include sufficient information, a quality referred to as “meaningful use”. The “Meaningful Use” standard refers to the utilization of medical records in a way that improves quality, safety and efficiency, engages patients and families, improves coordination of care and public health, ensures privacy and reduces health disparities” (Androus, 2023). Practices that use electronic records can qualify for financial incentives to support their adoption. Eligibility for these incentives requires that a provider’s patient loads include a certain percentage of Medicare or Medicaid patients. Providers must meet goals for completion of specific objectives during a majority of their Medicare or Medicaid patient visits. These objectives involve completion of charting components that are intended to ensure their electronic medical charting is complete and provides improvements in healthcare outcomes. Since collection of meaningful use data for these incentives also requires that a certain percentage of patients fall under Medicare or Medicaid coverage many providers will not have patient loads that ensure eligibility, even as they are completing the required charting components.
Medical charting is a legal document and as such can be used in a court of law to determine outcomes of legal cases. So it is very important that charting is accurate, legible and specific. Charting will need to be retained for 7 years in the state of Washington. Destruction of charting must be done through an approved method (such as shredding of documents or removal of electronic charting by an approved company for medical charting disposal).
Paper Vs. Electronic Charting
Paper charting has begun to give way to electronic charting (also known as electronic healthcare records, or EHR) after hundreds of years of use. Both paper and electronic charting have pros and cons. In the section we will discuss the benefits and detriments of both.
Paper charting requires physical storage and supplies such as filing cabinets or bookshelves, file folders, dividers, metal tabs, writing implements and chart stickers but purchasing these may be less expensive for a new practice then an investment in most electronic charting systems Paper charting will also require office staff to make physical copies for mailing and faxing records,