Transcript 15 Managing Medical Records CHAPTER

CHAPTER
15
Managing Medical
Records
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15-2
Learning Outcomes (cont.)
15.1 Identify the common equipment used to file
and store paper medical records.
15.2 Outline the security and safety measures
that should be employed when working with
paper medical records.
15.3 List the common filing supplies used in the
medical office.
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15-3
Learning Outcomes (cont.)
15.4 Contrast the methods used for various
filing systems and how color-coding can
assist with the filing systems.
15.5 Recall the steps in the filing process.
15.6 Compare active, inactive, and closed files
and how to set up a records retention
program for the office.
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15-4
Introduction
• Records management system
– Vital to patient care and
office operation
– Must be easily retrievable
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15-5
Filing Equipment
• Filing shelves
• Filing Cabinets
– Vertical files
– Horizontal or lateral files
• Compactable files
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15-6
Filing Equipment (cont.)
• Rotary Circular files
• Plastic or cardboard tubs
or boxes
• Labeling Filing Equipment
– Clearly indicate range of files
– Write directly on boxes
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15-7
Apply Your Knowledge
What are the disadvantages of vertical
filing cabinets?
ANSWER: They take up more room than shelves,
only one person can access the files at a time, and
if more than one drawer is pulled out at a time they
become top heavy and could tip over.
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15-8
Security and Safety Measures
• HIPAA privacy and security
• Medical record security
– Lockable cabinets or room
– Limit key access
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15-9
Equipment Safety
• Purchasing filing equipment
– Base on space and number of files
– Fire proof and secure
• Post safety guidelines
– Keep drawers closed
– Open one drawer at a time
– Step-ladder safety
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15-10
Apply Your Knowledge
A busy medical office is currently using filing boxes for
patient medical records and wants to change to a
different system . What would you recommend to this
non-computerized office that will allow more people to
retrieve files at the same time?
ANSWER: Filing shelves would enable more than
one person to access files if adequate space is
available.
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15-11
Filing Supplies
File folder

Tab

Available in letter and legal sizes

Tabs - extensions used to identify the
contents

Smith, A.
Adams, G.
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15-12
Filing Supplies (cont.)
• Labels
• File jackets
• Binders
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15-13
Filing Supplies (cont.)
• File guides
• Out guides
• File sorters
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15-14
Apply Your Knowledge
Which of the following would you use to mark the
place when removing a patient record from the
file?
a. File jacket
b. File guide
ANSWER:
c. Out guide
d. File sorter
GREAT!
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15-15
Filing Systems
• All use a sequential order
• Follow system exactly to avoid losing
or misplacing records
• Avoid changing system
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15-16
Alphabetic Filing System
• Most common system
• Files are arranged in alphabetical order
• Seven indexing rules – keeps
alphabetizing simple and consistent
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15-17
Alphabetic Filing System (cont.)
• Indexing rules
– Each part of name is a unit
• Last name
• First name
• Middle name / initial
• Titles (Jr., Sr. ,Rev., Dr., etc.) ~ the fourth indexing
unit
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15-18
Chronological Filing
• Based on dates
– Year, month, day
– Used within a patient’s record
– Reverse chronologic order
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15-19
Numeric Filing
• Numeric filing system
– Patients ~ assigned sequential numbers
– Requires a master list of patient names and
associated numbers
– Meets requirements of HIPAA law
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15-20
Numeric Filing (cont.)
• Terminal digit filing
– Filing is done based on last group of numbers
– Number is read from right to left
0 0 2 - 25 - 5 6 5
• Middle digit filing
– Uses the middle group as primary index for filing
– Number is read using the middle number first
– Followed by the left-hand number and right-hand
number
001 - 25 - 667
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15-21
Color-coding
• Using classifications
– Identify how files are to be classified
– Determine method of coding
– Determine color for
each classification
– Post codes
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15-22
Color-coding (cont.)
• With alphabetic filing
– Each letter is assigned a color
– Two or three letters of the
last name are
color-coded
J ON ES
Color-coding helps identify
charts that are out of order.
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15-23
Color-coding (cont.)
• With numeric filing
– Numbers 1 to 9 assigned a distinct color
– Use color-coded “key unit” for each chart
5 6 5
Terminal digit as
“key unit”
2 5
Middle digit as
“key unit”
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15-24
Supplemental Files
• Separate files containing additional
information
– Old patient records
– Financial records
• Stored in a different location than primary
file
• Contents should be distinguished from the
primary file contents
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15-25
Tickler Files
• A date-ordered reminder file
• Organized by month, week
of month, or day of week
• Computer systems
– Calendar
– Reminders to alert prior to
event
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15-26
Apply Your Knowledge
Match the following: ANSWER:
E simplest system
F used for files within a medical
A. Tickler file
B. Color-coding
record
C. Supplemental file
D. Numeric filing
system
E. Alphabetic filing
system
F. Chronologic filing
C
B
A
D
financial records
easy to see out of place records
reminder system
helps the medical office comply
with HIPAA
RIGHT!
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15-27
The Filing Process
• Medical assistant
responsibilities
• Follow practice
policies for returning
records to the files
• Place records to be
filed in a secure file
return area
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15-28
The Filing Process (cont.)
Generally the medical assistant files three types of
items:
New
patient
records
Documents
Existing
patient
records
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15-29
The Filing Process (cont.)
Place the files in the appropriate location for easy retrieval
when needed
Place files in order to save time when storing
Add an identifying mark to ensure
that the file is put in the correct place
Name the file using the
classification system
Make sure
document is
ready for
filing
Storing
Sorting
Coding
Indexing
Inspecting
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15-30
Filing Guidelines
• Check each record when
pulling it
• Keep files neat
• Remove file from drawer
when adding documents
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15-31
Filing Guidelines (cont.)
• Do not crowd the file drawer
• Use file guides with a
different tab position to aid in
finding files
• It is better to provide too
many cross-references than
too few
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15-32
Filing Guidelines (cont.)
• File regularly
• Do not store anything other than files in the file
storage area
• Train all staff who will be retrieving files on the
system in place
• Periodically evaluate your office system
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15-33
Locating Misplaced Files
1. Determine where the
file was last seen or
used
2. Look for the file
while retracing steps
from that location
3. Check filing cabinet
where it belongs
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15-34
Locating Misplaced Files (cont.)
4. Check underneath files in drawer or on
shelf
5. Check items to be filed
6. Check cross-reference or similar indexes
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15-35
Locating Misplaced Files (cont.)
7. Check with other staff members
8. Check other file locations
9. Stand back and look at the top of the
folders
10. Ask another staff member to doublecheck your search.
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15-36
Locating Misplaced Files (cont.)
11. Straighten the office, carefully checking
all piles of information
12. Check charts that have been pulled for
the next day appointments
13. Check physician’s desk
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15-37
Locating Misplaced Files (cont.)
• File may be considered lost if not found
within 24 to 48 hours
• Recreate a new file
– Physicians and staff record recollections of
information in the file
– Duplicate documents from labs, insurance
companies, etc.
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15-38
Limiting Medical Record Access
• Computerized offices
– Access code and password
– Limits what files you may see
• Paper records
– Limit who can retrieve and return files
– Requisition slip used to obtain a file
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15-39
Apply Your Knowledge
The medical assistant is training a new employee who will primarily
be responsible for the medical records. The new employee asks
“Can I first sort the charts, then inspect them?” List the 5 steps to
filing in the correct order and provide an explanation to answer her.
ANSWER: The 5 steps to filing
are:
1. Inspecting
2. Indexing
3. Coding
4. Sorting
The charts should be
inspected first to be sure all
necessary documents are in
the charts and that they are
ready for sorting and storing.
5. Storing
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15-40
Active, Inactive, and Closed Files
• Active files – used frequently
• Inactive files – used infrequently
• Closed files
– Patient may have died or moved away
– No longer come to the office
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15-41
Basic Storage Options
Paper Storage
 Files remain in their original format
 Labeled boxes with lids to allow even stacking
 Preserve the original documents.
 If the paper becomes brittle, transfer
documents to another storage medium
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15-42
Basic Storage Options (cont.)
Computer Storage
 Transfer documents to electronic or
digital form
 Transfer documents from hard drive to
storage medium
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15-43
Basic Storage Options (cont.)
• Other paperless options
– Microfilm
– Microfiche
– Cartridges
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15-44
Retaining Files in the Office
• Retention schedule
– Specifies length of time records are kept in
the office once they are inactive or closed
– Details when to move files to storage and
when they can be destroyed
– Post in file room
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15-45
Retaining Files in the Office (cont.)
• HIPAA law – required retention periods
• State and local requirements
• Count from year after
document produced
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15-46
Retaining Files in the Office (cont.)
• Destruction of records
– Maintain Confidentiality
– Shred
– Retain list of documents
destroyed
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15-47
File Storage Facilities
• On-site storage
• Off-site storage
– Commercial records storage centers
– Maintain list of files
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15-48
Storage Safety
• Evaluate storage sites carefully
• Place files in fireproof and waterproof containers
• The storage site should be safe from
– Fire and floods
– Vandalism and theft
– Extremes of temperature
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15-49
Apply Your Knowledge
A patient who has not been to the office in several years
telephones and requests a copy of his medical record. What
should you do?
ANSWER: First tell him that you need a signed release to
give him a copy of the records. Once you have that you
would check to see if his medical record was in the active
files. If not you should look on the inactive file list to see if
it had been moved to storage.
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15-50
In Summary
15.1
Filing shelves, filing cabinets, compactable files, and
rotary files are all commonly used to store paper
medical records.
A very small office might opt to use storage bins for
its medical records.
15.2 HIPAA requires that filing shelves or cabinets should
be fireproof and locked when the office is closed.
Filing systems must be safe for those using them and
instructions on their proper use should be posted and
understood by all staff members using them.
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15-51
In Summary (cont.)
15.3 Filing supplies used in the medical office
include tabbed file folders, labels, file jackets,
binders, tabs with inserts for labeling, file
guides, out guides, and file sorters.
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15-52
In Summary (cont.)
15.4 Alphabetic filing is the traditional filing
system for medical offices. Color-coding can
enhance this process .
Numeric systems are used more often
because of the confidentiality they provide.
These systems use a medical record
number, which are then filed by the terminal
digit or middle digit format. Color can be
used with numeric filing also.
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15-53
In Summary (cont.)
15.5 The steps in the filing process include
inspecting, indexing (naming), coding,
sorting, and storing.
15.6 Active records are those that are used
frequently. Infrequently used records are
known as inactive records.
Closed files are those of patients who, for
whatever reason, no longer come to the
office.
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15-54
End of Chapter 15
We must try to
continue to hear
patient voices above
the din of the
machinery.
~ Catherine Lopez
From A Daybook for Nurses
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.