Records ManagementPresentation

Overview

Indexes for administrating health care informationCentralized records managementCreation of new recordsStraight numeric filingPermanent and temporary insertion of reportsStorage of patient filesCirculation and tracking of filesRetention scheduleFile securityLegal and Ethical responsibility

Introduction

What is records management?

Responsibility for managing records and information

Properly document information in time

Not duplicating records

Indexes for administering healthcare information

Master patient indexIdentification dataRecord retrieval

Centralized Records Management

One file roomResponsibility for record

keeping is easily identifiedEffective use

of equipment, supplies, space, and personnel's made

Improved security

Creation of manual records

Face SheetProblem oriented recordDatabaseProblem listInitial planProgress notes

Straight Numeric Filing System

Office personnel can be easily trained

Enhances file securityFiles can be expanded for

additional spacePurging is easier File numbers are organized

from lowest to highest

Temporary and Permanentinsertion of loose reports

Clinical dataPermanentAdministrative dataTemporaryOrganize loose for MS

according to numeric filing system

Storage of Patient Files

Short TermTwo to three daysPermanentCurrently under careArchiveHas not been used

Circulation of records within and outside our facility

Automated chart tracking system

Providers request records from their computer 

Clerks sign out patient files from file area

Out guides are used to indicate removal

Lab reports are stored in an extra file cabinet

Retention schedule-destruction of records

Archived recordsShreddingCertificate of destructionMaintained permanently

File Security

Secure records from fire or water damage

Keep records in locked file or room

Protect records from theftAuthorized personnel in file

areaLock file room when

unstaffedPassword protect computers

Legal and Ethical Responsibilities

Maintaining the Patient’s Records

Confidentiality of Information

Release of Protected Health Information

Patient access to recordsProtected Health

Information must be tracked

• CENTRALIZED RECORDS MANAGEMENT• ARCHIVE FILES KEPT FIVE YEARS• PROBLEM ORIENTED RECORDS• STRAIGHT NUMERIC FILING SYSTEM• AUTOMATED CHART TRACKING

SYSTEM

Review

References

ARMA (2009). What is Records Management?. RetrievedMay 24, 2009 fromhttp://www.arma.org/pdf/WhatISRIM.pdf 

FotoSearch (n.d.).  File Room Stock Photo & Images. Retrieved May 24, 2009, from http://www.fotosearch.com/photos-images/file-room_1.html

References Continued

Green, M. A. and Bowie, M. J. (2005).  Essentials of health information management: Principles and practices. Clifton Park, NJ: Thomson

Istockphoto (n.d.). Photos. Retrieved May 25, 2009, from http://www1.istockphoto.com/file_thumbview_approve/457238/2/istockphoto_457238_reviewing_medi cal_chart.jpg