chapter 15 managing medical records 15-2 learning outcomes (cont.) 15.1identify the common equipment...

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15Managing Medical

Records

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.

15-3


Learning Outcomes (cont.)

15.4 Contrast the methods used for variousfiling 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.

15-4


Introduction

• Records management system

– Vital to patient care and office operation

– Must be easily retrievable

15-5


Filing Equipment

• Filing shelves

• Filing Cabinets

– Vertical files

– Horizontal or lateral files

• Compactable files

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

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.

15-8


Security and Safety Measures

• HIPAA privacy and security

• Medical record security

– Lockable cabinets or room

– Limit key access

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

15-10



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.

15-11


Filing Supplies

Available in letter and legal sizes

Tabs - extensions used to identify the contents

Smith, A. Adams, G.

File folder Tab

15-12


Filing Supplies (cont.)

• Labels

• File jackets

• Binders

15-13


Filing Supplies (cont.)

• File guides

• Out guides

• File sorters

15-14



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

c. Out guide

d. File sorter

ANSWER:

GREAT!

15-15


Filing Systems

• All use a sequential order

• Follow system exactly to avoid losing or misplacing records

• Avoid changing system

15-16


Alphabetic Filing System

• Most common system

• Files are arranged in alphabetical order

• Seven indexing rules – keeps alphabetizing simple and consistent

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

15-18


Chronological Filing

• Based on dates

– Year, month, day

– Used within a patient’s record

– Reverse chronologic order

15-19


Numeric Filing

15-20


Numeric Filing (cont.)

• Terminal digit filing– Filing is done based on last group of numbers

– Number is read from right to left

• 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

0 0 2 - 25 - 5 6 5

15-21


Color-coding

• Using classifications

– Identify how files are to be classified

– Determine method of coding

– Determine color for each classification

– Post codes

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

Color-coding helps identify charts that are out of order.Color-coding helps identify charts that are out of order.

J O N SE

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 56

Terminal digit as “key unit”

52

Middle digit as “key unit”

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

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

15-26


Match the following:


RIGHT!

ANSWER:

A. Tickler file

B. Color-coding

C.Supplemental file

D.Numeric filing system

E. Alphabetic filing system

F. Chronologic filing

simplest system

used for files within a medical record

financial records

easy to see out of place records

reminder system

helps the medical office comply with HIPAA

E

F

CB

A

D

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

15-28


The Filing Process (cont.)

Generally the medical assistant files three types of items:

New patientrecords

Documents

Existingpatientrecords

15-29


The Filing Process (cont.)

Place the files in the appropriate location for easy retrieval when neededPlace the files in the appropriate location for easy retrieval when needed

Place files in order to save time when storingPlace files in order to save time when storingAdd an identifying mark to ensure that the file is put in the correct place

Add an identifying mark to ensure that the file is put in the correct place

Name the file using the classification systemName the file using the classification system

Make sure document is ready for filing

Make sure document is ready for filing

Inspecting

Indexing

Coding

Sorting

Storing

15-30


Filing Guidelines

• Check each record when pulling it

• Keep files neat

• Remove file from drawer when adding documents

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

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

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

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

15-35



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 double-check your search.

15-36



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

15-37



• 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.

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

15-39



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

5. Storing

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.

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

15-41


Basic Storage Options

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

Paper Storage Paper Storage

15-42


Basic Storage Options (cont.)

Transfer documents to electronic or digital form

Transfer documents from hard drive to storage medium

Computer Storage

Computer Storage

15-43


Basic Storage Options (cont.)

• Other paperless options

– Microfilm

– Microfiche

– Cartridges

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

15-45


Retaining Files in the Office (cont.)

• HIPAA law – required retention periods

• State and local requirements

• Count from year after document produced

15-46


Retaining Files in the Office (cont.)

• Destruction of records

– Maintain Confidentiality

– Shred

– Retain list of documents destroyed

15-47


File Storage Facilities

• On-site storage

• Off-site storage

– Commercial records storage centers

– Maintain list of files

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

15-49


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.

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.

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.

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.

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.

15-54


We must try to continue to hear patient voices

above the din of the machinery.

~ Catherine Lopez

From A Daybook for Nurses

End of Chapter 15