Table of Contents• Introduction• The importance of getting new information into

a patient’s record as timely as possible.• The importance of not duplicating medical

records for the same person • Why tracking systems are important• Indexes for administering health care

information • The Pros and Cons of Centralized or

decentralized records management• Creation of new records—record formats • Types of filing systems• Basic rules of the system• Examples to clarify names or numbers that

might be confusing in that system

oTable of Contents

• Temporary and permanent insertion of loose forms and care reports

• Handling clinical data that a doctor needs to see

• Handling administrative data that a doctor does not need to see

• Short-term storage for patient files (patient returns in 2 to 3 days)

• Permanent storage for patient files (patient is not due back soon but is currently under care)

• Archive (patient record has not been used for some time)

• The physical circulation of records within your facility, and between your facility and X-ray

Table of Contents • Routing and tracking records

within areas of your department and out to X-ray

• Storing lab reports that come in when a patient’s file is at X-ray

• Retention schedule—destruction of records

• File security • Legal and ethical responsibilities • Conclusion• References

Introduction• Type of medical facility• Size• Number• Location• This presentation is about

The importance of getting new information into a patient’s record as timely as possible

The importance of not duplicating medical records for the same person

A “duplicate patient record” occurs when a single patient is associated with more than one patient record. Duplicate patient records are often caused by patient names that have complex spellings and/ or variations of a name, data entry input errors by hospital staff, identity sharing among patients, and unenforced admissions quality standards across different locations of a given provider. Just one mistyped digit in al security number, birth date, or address can lead to a duplicate record.

Why tracking systems are important

Indexes for administering health care information

This resolution is intended to emphasize the importance of accurate identification of individuals contained in a master patient (person) index (MPI) in a healthcare environment.i An MPI may be found at the single electronic system level, facility level, enterprise or health information exchange (HIE) level.ii An accurate MPI, whether in paper or electronic format, may be considered the most important resource in a healthcare setting because it is the link that tracks an individual's activity within an organization and across the continuum of care. Those individuals may be patients, providers, or members of a health plan.

The MPI serves as the foundation for managing an individual's data to ensure identity integrity and to accurately link the individual's information. The MPI serves as an essential component of accurate patient identification and therefore demands active data stewardship, data governance and many collaborative processes. Today's patient centric focus highlights the importance of standards and interoperability in building and maintaining the MPI.

A key to locating and linking records, a complete, accurate MPI/EMPI is a critical part of patient information systems within and across healthcare organizations.

The Pros and Cons of Centralized or decentralized records managementCentralized records management

Decentralized records management

I picked decentralized record management opposed to centralized for my facility because

Creation of new records—record formats

Types of filing systems

Alphabetical FilingStraight Numeric FilingMiddle- Digit FilingTerminal Digit FilingSubject Filing SystemMiddle Digit Filing

Basic rules of the system

Examples to clarify names or numbers that might be confusing in that system Examples to clarify names or numbers thatmight be confusing in that

system•Temporary and permanent insertion of looseforms and care reportsoHandling clinical data that a doctor needs toseeoHandling administrative data that a doctor doesnot need to see•Storage for patient files:oShort-term (patient will return in 2-3 days)oPermanent (patient is not due back soon but iscurrently under care)oArchive (patient record has not been used forsome time)•The physical circulation of records within thefacility, and between the facility and X-rayoRouting and tracking records within areas ofthe department and out to X-rayoStoring lab reports that come in when apatient’s file is at X-ray•Retention schedule—destruction of records•File security•Legal and ethical responsibilities•Presentation consists of 12 to 15 slidesappropriate for the speaker’s audience..The content is comprehensive, accurate, andpersuasive.•Presentation includes visual aids and utilizeselegant graphics.•Text is limited to approximately five lines per slide,approximately five words per bulleted item.•Appropriate font sizes are used.•Detailed TYPED speaker’s notes explain bulleteditems and rationale behind policy decisions.•The presentation includes at least one completeparagraph of detailed speaker’s notes per contentslide.The presentation develops a central theme or ideadirected toward the appropriate audience.The presentation links theory to relevant examples ofcurrent experience and industry practice and uses thevocabulary of the theory correctly.5

Temporary and permanent insertion of loose forms and care reportsPurpose: To ensure that all information is filed

accurately and available at the time of patient care services. Policy: All loose reports received are sorted and lined up in strict terminal digit order for filing on first and third shift. Procedure: 1. Locate, in the active file room, the medical record number section of the loose report to be filed in the patient's medical record. 2. Locate the patient’s medical record folder using the medical record number documented on the report using the terminal digit filing system. 3. Verify the patient's name and medical record number by comparing the information on the loose report against the patient identifying information on the folder.

Handling clinical data that a doctor needs to see

Handling administrative data that a doctor does not need to see  In the US, there are two kinds of healthcare data -

clinical data in Electronic Health Records (EHRs) and administrative billing data that is used by payers, researchers, and the government. Billing data is imprecise, but it is a starting point to describe the care given by a doctor or hospital. The only thing that's new in 2009 is that PHRs now enable patients to see the kind of billing data that's been used for 20 years for reimbursement, quality measurement, and population health. Blue Cross of Massachusetts and Medicare (in a few pilot states) share billing data with patients via Google Health, so this is not just a BIDMC implementation.

As a society we're likely to see increased data transparency between patients and providers, which will lead to several improvements:

Short-term storage for patient files (patient returns in 2 to 3 days)  Short term 

1. Short term storage is for records that are active, are accessed on a regular basis, and need to be retrieved quickly.  These records are usually stored at the worksite. 

2. Some inactive records (no longer accessed on a regular basis) may be maintained in appropriate on-campus space, such as a storage room, as determined by each Program Center Administrator.   Consideration should be given to space limitations and the physical safety of the records and buildings. 

3. University Archives are not to be used for short-term storage. 

Permanent storage for patient files (patient is not due back soon but is currently under care)

 Permanent 

1. Records that are determined not to have historical or archival value and are mandated for permanent retention should be sent to the State Records Center for storage as soon as they are not needed in proximity to the work site.  (See Archiving, below.) 

2. University Archives is the site for permanent storage of records that have archival value. 

Archive (patient record has not been used for some time)

The physical circulation of records within your facility, and between your facility and X-ray

Routing and tracking records within areas of your department and out to X-ray

Storing lab reports that come in when a patient’s file is at X-ray

Retention schedule—destruction of records

File security

Legal and ethical responsibilities

Basic rules of ethics   1.      Put the saving of life and the promotion of health above all else. 2.      Treat all patients equally. ·        Regardless of race, age, sex, religion, socioeconomic status or nationality ·        Avoid bias, prejudice and discrimination 3.      Maintain a competent level of skill consistent with the             occupation. 4.      Maintain confidentiality and respect for the privacy of others. 5.      Refrain from immoral and illegal practices. ·         Report illegal actions of others to the proper authority 6.      Show loyalty to patients, co-workers, and employer. 7.      Be sincere, honest and caring. ·        Treat others the way you want to be treated    “The Golden Rule”   LAW   The rules of conduct established and enforced by the authority, legislation, or custom of a given

community or other group.   Criminal Law – deals with wrongs against a person, property or society.  The offender can go to jail or

prison.             Examples of criminal laws:                ·        Practicing in a health care profession without a license ·        Misuse of narcotics ·        Theft ·        Murder   Civil Law – deals with legal relationships between people and t

Conclusion

References