Health Record Identification and Filing Systems

Objectives•Describe the equipment and supplies needed for filing medical records.•List and describe the various types of filing systems.•Discuss the benefits of each type of system.•Discuss the advantages of color coding the files.•Explain how to set up and use a tickler file.

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Objectives (cont.)

• Describe each of the five steps in the filing process.

• Explain the steps to take in trying to locate a misplaced file.

• List and describe the basic file storage options and the advantages of each.

• Identify criteria for determining whether files should be retained, stored, or discarded

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Importance of Records Management

• The medical records are the most valuable information in the medical office.

• A records management system refers to the way patient records are:– Created.– Filed.– Maintained.

• A well-organized, easy-to-use system saves time and protects vital medical data

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Filing Equipment • Filing Shelves– Files are stacked upright on shelves in boxes or

heavy-duty envelopes• Filing Cabinets– Sturdy pieces of office furniture– Usually made of metal or wood– Both vertical and horizontal (lateral) file cabinets

are available

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Filing Equipment con’t

• Compactable Files– Kept on rolling shelves that slide along permanent

tracks on the floor– Seen often in offices with limited space for files

• Rotary Circular Files– Files are stored in a circular fashion resembling a

revolving door– Also common when space is limited

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Filing Equipment • Plastic or Cardboard Tubs or Boxes–Organized like filing cabinet drawers– Files can easily be misplaced with this

system.• Labeling Filing Equipment– The outside of the file drawer should be labeled to represent its contents.

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(cont.)

A-D

Filing Equipment • Security Measures– Many filing cabinets have locks, and the keys

should be available to limited staff personnel.• Equipment Safety– Post safety equipment for each type of filing

system.• Purchasing Filing Equipment– First determine the amount of space availability– Then determine number of files to be included

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(cont.)

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Filing SuppliesFile Folders

• Referred to as manila folders• Available in 8 ½ by 11 inches and 8 ½ by 14 inches• Tabs are tapered rectangular or rounded extensions at the top of the folder• Tabs have a variety of cuts

Tab

• Tabs on the file folder identify the contents

Labeling File Folders Smith,A. Adams, G.

Filing Supplies (cont.)

• File Jackets– Resemble file folders but have plastic or

metal hooks on both sides to anchor it– Files are placed inside these jackets

• File Guides– Heavy cardboard or plastic inserts that

identify groups of files• Out Guides– A marker made of stiff material that is

used as a placeholder for removed files10

Filing Supplies (cont.)

• File Sorters– Large envelope-style folders with tabs

that temporarily store files• Binders– Some offices use three ring binders to

keep patient records – Tabs are used to separate individual

charts• Purchasing Filing Supplies– A common responsibility for medical

assistants11

Apply Your Knowledge - AnswerAnswer

A busy medical office is considering changing their current filing equipment. Which equipment would you recommend to this non-computerized office that will afford more persons to retrieve files at the same time?

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Filing Systems

•Files are arranged in alphabetical order•Files are labeled with the patient’s last name first, then first name and middle initial

•Organizes files by numbers instead of names•Patients are assigned sequential numbers•This system is often used with highly confidential information•A master list of patient names and numbers must be kept

Filing Systems (cont.)

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Using Classifications

• First identify how files are to be classified• Select a separate color for each classification

Color coding can be used with both alphabetic and numeric filing systems.

ColorCoding

Used to distinguish files within a filing system

Filing Systems (cont.)

• Tickler Files– A reminder file– Should be placed separately and reviewed often– Computers now offer tickler files

• Supplemental Files– Separate files containing additional information– Prevents cluttering of primary files– Contents should be distinguished from the primary

file contents15

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The Filing ProcessGenerally the medical assistant files three types of items:

New PatientRecordFolders

IndividualDocuments

ForExistingFolders

PreviouslyFiled

PatientRecordFolders

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The Filing Process (cont.)

Get the accumulated files in order. This will save time when storing the folders.

Place the files in the appropriate location, so they can easily be retrieved when needed.

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

Coding

Sorting

Storing

Name the file using the office classification system.

IndexingMake sure document is ready to be filed.

Inspecting

Limiting Access to Files• Under no circumstances should original

patient records leave the medical office. • Identifying information is often recorded

when files are retrieved.• Limited persons in the medical office

have access to patient records.

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Filing Guidelines• Take a close look at the contents of patient

records each time you pull them.• Keep files neat.• Do not overstuff file folders.• Take time to properly place documents into

the folders to prevent damage.• Do not crowd the file drawer.• If possible use both upper and lower case

letters to label the folders.19

Filing Guidelines (cont.)• Use file guides with a different tab position to aid

with finding files.• It is better to provide too many cross-references

than too few.• File regularly.• Do not store anything other than files in the file

storage area.• Train all staff that will be able to retrieve files on the

system in place.• Periodically evaluate your office system to see if it

still works.

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Locating Misplaced FilesDo a complete search of the office to try and locate the file. If the file is not recovered within 24 to 48 hours, it may be considered lost.

Lost files can have potentially devastating consequences.

Active vs. Inactive Files• Active Files– Files that you use frequently

• Inactive Files– Files that you use infrequently

• Closed Files– Files of patients that no longer consult the office– The physician determines when a file is deemed

inactive or closed

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Apply Your Knowledge- AnswerAnswer

The primary reason records should first be inspected is to ensure that all documents are present that belong in the chart.

Step 1Step 2Step 3Step 4Step 5

Indexing

SortingCoding

Inspecting

Storing

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Storing Files

BasicStorageOptions

Computer StorageMicrofilm Paper Storage

• Files remain in their original format• Good to place in boxes with lids to afford even stacking• If the paper becomes brittle, transfer documents to another storage medium.

Patient records can be scanned and saved on a disk, tape or computer hard drive.

Microfilm, microfiche and cartridges offer a paperless way of storing records.

Storage Facilities• Some offices have extra closet or storage

space on site.• Smaller offices require the use of off-site

storage.• Use a facility that takes precautions against

fires and floods.• Maintain a list of all files at each storage

location.25

Storage Safety• Even inactive and closed files must remain

safe and secure.• Place files in fireproof and waterproof devices.

Cardboard is not an option.• The storage site should be safe from:– Fire & Floods– Vandalism & Theft– Extremes of temperature

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Retaining Files in the Office• A retention schedule decides how long different types of

patient records are to be kept in the office once they become inactive or closed.

• Certain records have legal criteria for the length they must be maintained in the office such as:– Immunizations.– Employee health records.– Medical Office Financial Records.

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Health Record Identification and Filing Systems

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