Records Management Records Management PresentationPresentation

AXIA College of University of PhoenixAXIA College of University of Phoenix

OverviewOverview

• Indexes for administrating health care informationIndexes for administrating health care information• Centralized records managementCentralized records management• Creation of new recordsCreation of new records• Straight numeric filingStraight numeric filing• Permanent and temporary insertion of reportsPermanent and temporary insertion of reports• Storage of patient filesStorage of patient files• Circulation and tracking of filesCirculation and tracking of files• Retention scheduleRetention schedule• File securityFile security• Legal and Ethical responsibilityLegal and Ethical responsibility

(Green & Bowie, 2006)

IntroductionIntroduction

• What is records What is records management?management?

• Responsibility for Responsibility for managing records managing records and informationand information

• Properly document Properly document information in timeinformation in time

• Not duplicating Not duplicating recordsrecords

(Flickr, n.d.)

Indexes for administering health Indexes for administering health care informationcare information

• Master patient indexMaster patient index• Identification dataIdentification data• Record retrievalRecord retrieval

(Istockphoto, n.d.)

Centralized Records ManagementCentralized Records Management

• One file roomOne file room• Responsibility for Responsibility for

record keeping is record keeping is easily identifiedeasily identified

• Effective use of Effective use of equipment, supplies, equipment, supplies, space, and personnel space, and personnel is madeis made

• Improved securityImproved security

(Flickr, n.d.)

Creation of manual recordsCreation of manual records

• Face SheetFace Sheet

• Problem oriented recordProblem oriented record• DatabaseDatabase• Problem listProblem list• Initial planInitial plan• Progress notesProgress notes

(istockphoto, n.d.)

Straight Numeric Filing SystemStraight Numeric Filing System

• Office personnel can Office personnel can be easily trainedbe easily trained

• Enhances file securityEnhances file security• Files can be expanded Files can be expanded

for additional spacefor additional space• Purging is easierPurging is easier• File numbers are File numbers are

organized from lowest organized from lowest to highestto highest

(Flickr, n.d.)

Temporary and Permanent Temporary and Permanent insertion of loose reportsinsertion of loose reports

• Clinical dataClinical data• PermanentPermanent

• Administrative dataAdministrative data• Temporary Temporary

• Organize loose forms Organize loose forms according to numeric according to numeric filing systemfiling system

(istockphoto, n.d.)

Storage of Patient FilesStorage of Patient Files

• Short TermShort Term• Two to three daysTwo to three days

• PermanentPermanent• Currently under careCurrently under care

• ArchiveArchive• Has not been usedHas not been used

(flickr, n.d.)

Circulation of records within and Circulation of records within and outside our facilityoutside our facility

• Automated chart Automated chart tracking systemtracking system• Providers request records Providers request records

from their computerfrom their computer

• Clerks sign out patient Clerks sign out patient files from file areafiles from file area

• Outguides are used to Outguides are used to indicate removalindicate removal

• Lab reports are stored in Lab reports are stored in an extra file cabinetan extra file cabinet

(istockphoto, n.d.)

Retention schedule-destruction of Retention schedule-destruction of recordsrecords

• Archived recordsArchived records• ShreddingShredding• Certificate of destructionCertificate of destruction

• Maintained permanentlyMaintained permanently

(istockphoto, n.d.)

File SecurityFile Security• Secure records from fire or Secure records from fire or

water damagewater damage• Keep records in locked Keep records in locked

file or roomfile or room• Protect records from theftProtect records from theft

• Authorized personnel in Authorized personnel in file areafile area

• Lock file room when Lock file room when unstaffedunstaffed

• Password protect Password protect computerscomputers

(flickr, n.d.)

Legal and Ethical Legal and Ethical ResponsibilitiesResponsibilities

• Maintaining the Maintaining the Patient’s RecordsPatient’s Records

• Confidentiality of Confidentiality of InformationInformation

• Release of Release of Protected Health Protected Health InformationInformation

• Patient access to Patient access to recordsrecords

• Protected Health Protected Health Information must Information must be trackedbe tracked

(istockphoto, n.d.)

ReviewReview

• Centralized Records ManagementCentralized Records Management

• Archive files kept Five yearsArchive files kept Five years

• Problem Oriented RecordsProblem Oriented Records

• Straight Numeric Filing SystemStraight Numeric Filing System

• Automated Chart Tracking SystemAutomated Chart Tracking System

ReferencesReferences

• ARMA (2009). ARMA (2009). What is Records Management?. What is Records Management?. RetrievedRetrieved

May 24, 2009, fromMay 24, 2009, from

http://www.arma.org/pdf/WhatISRIM.pdfhttp://www.arma.org/pdf/WhatISRIM.pdf

• FotoSearch (n.d.). FotoSearch (n.d.). File Room Stock Photo & Images. File Room Stock Photo & Images.

Retrieved May 24, 2009, fromRetrieved May 24, 2009, fromhttp://www.fotosearch.com/photos-images/file-room_1.htmlhttp://www.fotosearch.com/photos-images/file-room_1.html

References ContinuedReferences Continued

• Green, M. A. and Bowie, M. J. (2005). Green, M. A. and Bowie, M. J. (2005). Essentials of Essentials of

health information management:health information management: Principles and Principles and

practices. Clifton Park, NJ: Thomsonpractices. Clifton Park, NJ: Thomson..

• Istockphoto (n.d.). Istockphoto (n.d.). Photos. Photos. Retrieved May 25, 2009, fromRetrieved May 25, 2009, fromhttp://www1.istockphoto.com/file_thumbview_approve/457238/2/http://www1.istockphoto.com/file_thumbview_approve/457238/2/

istockphoto_457238_reviewing_medical_chart.jpgistockphoto_457238_reviewing_medical_chart.jpg