Medical Records Overview and Workspace

The Medical Records application area is used to manage a patient’s documentation and prepare visits for billing. Physicians, nurses, and staff are sometimes required to obtain specific information for a patient’s medical record for proper diagnosis and later reimbursement.

Medical Records helps manage that process, from maintaining and applying a variety of diagnosis, procedure, and payment codes to abstracting visits to prepare them for billing. Abstraction is the process of validating the complete and accurate medical record. Abstracting includes coding the account with illness classifications and treatment information (APC, HCPCS, DRG, etc.) that provides statistical analysis along with payment and reimbursement information. Once the account is abstracted, it is then ready for Billing.

Learn more about the Medical Records workspace, scorecards, and dashboards, by reading below.

Medical Records Workspace

The Medical Records workspace gives the user access to work queues, tabs, and Quick Actions related to coding. The data panel displays patient data (name, status, balance, etc.) and the User Productivity chart.

The Medical Records workspace is used to abstract visits and complete any required information for billing, including HCPCS coding, DRG code, diagnoses, physicians, etc. Patient information, including death information, can also be managed.

Quick Actions allow users to merge medical records and interact with external coders.

Medical Records Scorecards

The Medical Records application area has multiple scorecards that measure productivity by work queue and by event.

Medical Records Scorecard

The Registration scorecard displays the following information in the primary panel:

• Period – The selected Date Grain (Day, Month, or Quarter).
• Prev. Balance – Ending balance from prior period.
• End Balance – Sum of balances of all open items in the selected work queue or queues.
• Attrition Rate – The difference between the previous balance and ending balance, divided by days in the period.
• Turnover (Days) – Records processed divided by ending records.
• Prev. Records – Ending record from the previous period.
• Comp. Records – Completed records for the period.
• End Records – Count of all records in the selected work queue or queues.
• Avg. Queue Age – Total days of open records in queue(s) divided by ending records.
• Avg. Work Time – Average amount of time (in minutes) to perform actions in queue(s).
• Max Queue Age – Maximum age of a record in queue(s).

The other panels and charts allow the user to drill down to totals by work queue and user.

Medical Records – Event Scorecard

The Registration – Event scorecard displays the following information in the primary panel:

• Period – The selected Date Grain (Day, Month, or Quarter).
• Total Events – Total number of events during the period.
• Avg. Time – Total events divided by total minutes worked.
• Total Min – Total time in minutes worked.
• Daily Events – Total events divided by number of days in the period.
• Daily Time – Total time divided by number of days in the period.

The other panels and charts allow the user to drill down to totals by event () and user.

Medical Records Dashboards

The Medical Records application area includes dashboards that display a variety of financial, performance, and trending information. The following dashboards are available in Medical Records:

• A/R Amount in Coding – Displays the sum of visit balances (charges + adjustments + payments) for visits that have been discharged but have not been coded and are not final billed.
• A/R Days in Coding – Displays the length of time it takes to code visits that are discharged but not coded and not final billed.
• Days in Coding – Displays days between discharge date and current date for visits that have not been coded.
• MR Quality – Displays how often coding-related fields are updated after they were initially coded. There are 7 fields monitored, including diagnosis, HCPCS codes, physicians, procedures, charges RUG score, discharge date/time, and discharge disposition.

Medical Records Work Queues

The Medical Records workspace includes a variety of standard work queues designed to complete tasks on visits related to admissions.

Medical Records’s base set of work queues includes:

• ER Coding – Displays visits that are discharged, have not been abstracted, have not been final billed, and that have a patient type of “E” for emergency.
• IP Coding – Displays visits that are discharged, have not been abstracted, have not been final billed, and that have a patient type of “I” for inpatient.
• OP Coding – Displays visits that are discharged, have not been abstracted, have not been final billed, and that have a patient type of “O” for outpatient or are admitted, have not been abstracted or final billed, and have a patient type of “S” for series.
• Med Rec Duplicate Patients – Displays visits along with a percentage comparison of the names. The criteria includes:
  • Patients have the same gender.
  • Patients have the same Social Security Number or one is missing.
  • Patients have the same middle initial or one is missing.
  • First/last names sound alike.
  • First letter of first names are the same or first letter of last names are the same.
  • Patients have the same birth date or one is missing.
  • Characters in the last name are a 75-percent match.
  • Characters in the first name are a 60-percent match.