© 2009 the mcgraw-hill companies, inc. all rights reserved 10-1 managing the office medical records...

10-1

© 2009 The McGraw-Hill Companies, Inc. All rights reserved

Managing the Office Medical RecordsManaging the Office Medical Records

PowerPoint® presentation to accompany:

Medical AssistingThird Edition

Booth, Whicker, Wyman, Pugh, Thompson

10-2


Learning Outcomes10.1 Describe the equipment and supplies needed for

filing medical records.

10.2 List and describe the various types of filingsystems.

10.3 Discuss the benefits of each type of system.

10.4 Discuss the advantages of color coding the files.

10.5 Explain how to set up and use a tickler file.

10-3


Learning Outcomes (cont.)

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

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

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

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

10-4


Introduction Medical assistant role

Clinical

Clerical Management of patient records

Vital to patient care and smooth operation of medical office

Requires an organized approach

10-5


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.

10-6


Apply Your Knowledge

What is a records management system?

ANSWER: A records management system is the way patient records are created, filed, and maintained.

Super!

10-7


Filing Equipment Place where the medical

records are housed

Choice of type is based on space consideration and personal preference

Filing shelves Files are stacked upright on shelves in boxes or heavy-

duty envelopes Allow more than one person at a time to retrieve files

10-8


Filing Equipment (cont.)

Filing cabinets Sturdy pieces of office furniture

of metal or wood Both vertical and horizontal

(lateral) file cabinets are available

Compactable files Kept on rolling shelves that slide along permanent tracks

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

10-9


Rotary circular files Files are stored in a circular

fashion resembling a revolving door Also common when space is

limited

Plastic or cardboard tubs or boxes Organized like filing cabinet drawers Inefficient for a large number of files

Files can easily be misplaced with this system Heavy to carry around


10-10


Filing Equipment (cont.) Labeling filing equipment

Label outside of drawer represents its contents

Easily retrievable records

Security measures Protect confidentiality of medical records Cabinets should lock or be in a lockable

room Limit who has keys

A-D

10-11


Equipment safety Post safety guidelines Ensure that everyone

follows rules to prevent injury

Purchasing filing equipment First determine space availability Then determine number of files to store


10-12


Apply Your KnowledgeA busy medical office is considering changing the current filing equipment. Which equipment would you recommend to this non-computerized office that will allow more people to retrieve files at the same time?

ANSWER: Filing shelves would be a great system if adequate space is available.

Good Answer!

10-13


Filing Supplies

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 on the file folder identify the contents

Smith,A. Adams, G.

File folders Tab

10-14


Filing Supplies (cont.) Labels

Identify contents Print clearly or use computer-

generated labels Cover with tape to prevent

smearing

File jackets Resemble file folders but have plastic or metal hooks on

both sides to for hanging them inside filing drawers Files are placed inside these jackets

10-15


Filing Supplies (cont.) File guides

Heavy cardboard or plastic inserts that identify groups of files

Out guides Markers made of stiff material;

used as placeholders for removed files

File sorters Large envelope-style folders with

tabs that store files temporarily

10-16


Filing Supplies (cont.) Binders

Some offices use three-ring binders to keep patient records

Tabs are used to separate individual charts

Require more storage Effective for management of active patient records

Purchasing filing supplies is a common responsibility for medical assistants

10-17



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:

AGREAT!

10-18


Filing Systems All use a sequential order

Follow system exactly To avoid losing or misplacing

records

Avoid changing system

10-19


Filing Systems: Alphabetic

Most common system

Files are arranged in alphabetical order

Files are labeled with the patient’s last name first, first name, then middle initial

Each individual must have a separate file

10-20


Filing Systems: Alphabetic (cont.)

Indexing rules Guidelines for sequencing files

Each part of name is a unit Last name First name Middle name

Titles (Jr., Sr. etc.) are the fourth indexing unit (to distinguish identical names from each other)

Use for all alphabetizing done by a medical practice

10-21


Filing Systems: Numeric 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

10-22


Filing Systems: Numeric (cont.)

Terminal digit filing Treat the last 2, 3, or 4 digits in a number as a single unit

For example, the numbers 024 represent the last three digits of a longer number

The numbers 024 are then considered ending or terminal digits, so all folders ending in 024 are grouped together

Filing is done based on last group of numbers

Middle digit filing Uses the middle group as primary index for filing

10-23


Filing Systems Used to distinguish files within a filing system

Can be used with either alphabetic or numeric filing systems

Using classification with color coding Identify how files are to be classified Select a separate color for each classification

Post codes so all are aware of them

10-24


Filing Systems With alphabetic filing

systems Each letter is assigned a

color The first two letters of

the last name are color-coded with colored tabs

Can easily tell if files are filed correctly

With numeric filing systems Numbers 1 to 9

assigned a distinct color Helps identify numeric

files that are out of place

51 61 0143

10-25


Filing Systems (cont.)

Tickler files Reminder files

Check on a regular basis

Organized by month, week of month or day of week

Computers systems offer tickler files in the form of a calendar Reminders set to alert prior to event

10-26


Filing Systems (cont.)

Supplemental files Separate files containing

additional information

Prevents cluttering of primary files

Stored in a different location than primary file

Contents should be distinguished from the primary file contents

10-27


Today is December 17th. Which of the information listed below could be added to a “tickler” file?

a. Names of patients that missed appointments two days ago

b. June medical conference dates just received in the mail

c. Names of patients seen today for their annual check-up


RIGHT!

ANSWER:

10-28


The Filing Process Medical assistant responsibilities

Pulling and filing patient records Filing documents

Follow practice policies for returning records to the files Immediately vs. at the end of day

Place records to be filed in a secure file return area

10-29


The Filing Process (cont.)

Generally the medical assistant files three types of items:

New patientrecordfolders

Individualdocuments

forexistingfolders

Previouslyfiled

patientrecordfolders

10-30



Place files in order to save time when storing

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

Coding

Storing

Name the file using the office classification system

Make sure document is ready to be filed

Indexing

Sorting

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

Inspecting

10-31



Limiting access to files Limit the number of people in the medical office who

have access to patient records

Original patient records should not leave the medical office (Exceptions noted in Chapter 9)

Identifying information is often recorded when files are retrieved

10-32


The Filing Process: Guidelines Take a close look at the contents of

patient records each time you pull or file them

Keep files neat Do not overstuff file folders Papers should not extend beyond edge of

folder

Remove file from drawer when adding documents Prevents damage to documents

10-33


The Filing Process: Guidelines (cont.)

Do not crowd the file drawer Allow space for retrieving and replacing

files easily If possible, use both uppercase and

lowercase letters to label the folders

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

10-34


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

The Filing Process – Guidelines (cont.)

10-35


Determine where the file was when last seen or used

Look for the file while retracing steps from that location

Check filing cabinet where it belongs Check neighboring files

The Filing Process: Locating Misplaced Files

10-36


Check underneath files in drawer or on shelf

Check items to be filed Check with other staff

members Check other file locations

Similar indexes Under patient’s first name Misfiled chart color

The Filing Process: Locating Misplaced Files (cont.)

10-37


Ask if someone inadvertently picked up the file with other materials

Have another person complete the steps to double-check your search

Straighten the office, carefully checking all piles of information


10-38


File may be considered lost if not found within 24 to 48 hours

Lost files can have potentially devastating consequences

Recreate a new file Physicians and staff record recollections of information in

the file Duplicate documents from labs, insurance companies, etc.


10-39


Active files are files that you use frequently

Inactive files are 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

The Filing Process: Active vs. Inactive Files

10-40


Apply Your KnowledgeThe 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 an that they are ready for sorting and storing.

10-41


Inactive and Closed File Storage

BasicStorageOptions

Computer StorageMicrofilm Paper Storage

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

Patient records can be scanned and saved on computer tapes, recordable CDs or DVDs, flash drives, or external hard drives.

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

10-42


File Storage Facilities Some offices have extra 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 stored at off-site

locations

10-43


File Storage Safety Inactive and closed files must remain safe and secure

Evaluate storage sites carefully

Preferably place files in fireproof and waterproof containers

The storage site should be safe from Fire and floods Vandalism and theft Extremes of temperature

10-44


Retention schedule Specifies how long patient records are to be kept

once they become inactive or closed Details when files should be moved to storage and

when they can be destroyed

Generally determined by the physician

File Storage: Retaining Files in the Office

10-45


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

Criteria from IRS – financial records AMA, American Hospital Association HIPAA law Federal and state laws

File Storage: Retaining Files in the Office (cont.)

10-46


Destruction of records

Maintain Confidentiality

Shred

Retain list of documents destroyed

File Storage: Retaining Files in the Office (cont.)

10-47


An employee who quit two years ago telephones and requests that copies of her annual physical examination forms, which she submitted while employed, be mailed to her home address. How would you handle this?


ANSWER: You should get this request in writing and then proceed to locate the records. The Labor Standards Act specifies that employee health records must be kept for three years, so they should be on hand at the office.

ExcellentExcellent!!

10-48


In Summary Organization of filing system depends on how files

need to be retrieved Two systems: alphabetic and numeric

Color-coding further identifies files Filing process has five steps: inspecting, indexing, coding,

sorting, and storing

Storage of inactive and closed files is often off-site Variety of formats for storage

Retention of stored files depends on legal, state, and federal guidelines

10-49


We must try to continue to hear patient voices

above the din of the machinery.

~ Catherine Lopez

From A Daybook for Nurses

© 2009 the mcgraw-hill companies, inc. all rights reserved 10-1 managing the office medical records...

Documents

mcgrawhill companies

filing drawers files

filing supplies

filing equipment place

current filing equipment

filing process

file folderstab slide

thompson slide