Managing Medical Records Lesson 2: Filing 13 Managing Medical Records Lesson 2: Filing

Lesson Objectives Lesson Objectives Upon completion of this lesson, students should be able to … Define and spell the terms to learn for this chapter. Identify the three types of file storage units. Name the “Rules for Filing.” List and discuss five types of numerical filing systems. 2

Lesson Objectives Lesson Objectives Compare and contrast the alphabetic, numeric, and color-coded filing systems. State an effective system used for cross-referencing. Understand how to find a missing file. Describe a tickler file. 3

Categories of Medical Records Active records Inactive records Closed records 4

Active Records Relate to patients who have been seen within the past three years and are currently being treated Each medical practice may have its own policy regarding what constitutes an “active” file, but it is usually from three to five years

Inactive Records Relate to patients who have not been seen within the past three years or another time period determined by office policy Files are still maintained by the office but are generally kept in a separate storage file cabinet that may be off-site Patients have not received a formal notification that the physician has terminated caring for them. They may return when a medical problem develops.

Closed Records Records of patients who have actively terminated their contact with the physician Files can be placed in storage boxes or converted and saved on a computer disk Files are referred to as archives, since they are no longer needed but must be kept for legal reasons

Types of File Storage Vertical Lateral Movable 8

Vertical File Cabinet Set up with two to four stacked pullout drawers holding up to 100 files per drawer Heavy and space-consuming

Lateral File Cabinet Set up with shelves allowing for easy access to files by pulling them off the shelves Uses a color-coded method for visual recognition of files

Movable File Cabinet Set up with electrically powered or manually controlled file units that move on tracks in the floor Type of open filing system Space-saving since the file units can be moved close together when they are not needed Useful for books and journals since the floor can be reinforced when the track is installed

Traditional Hard Copy Patient Record Patient file typically has tabs on the top or side edge These tabs are marked with identification labels If files are stored with alternating tab cuts, it is easier to read the labels in the file drawer Identification label is attached to the top tab in a vertical file cabinet or to the side edge of the file in a lateral file cabinet

Traditional Hard Copy Patient Record May be placed within a separate tabbed folder that remains in the filing cabinet File folders may be color-coded to indicate the primary care physician Each physician may be assigned a folder color as well as special indicators This helps keep files in order in large clinics

Divider Guides Divides the files into subsections using a letter or by patient number

Out Guide Placed in the file when a file is removed to indicate where the file should be returned Can be used to indicate who has removed the file and when it was removed Especially helpful in a large office when trying to locate charts Usually a distinctive color, such as red, is used to indicate a file is missing

Purpose of Labels on File Folders Main purpose is to identify what is in the file Label can include a color-coding stripe that can be used for other purposes, such as identifying the primary care physician Offices use special labels on charts to bring attention to patient allergies, required co-pays, and year of last visit Special labels help the staff find pertinent information at a glance

Systems Used for Filing Alphabetic system Numeric system Subject filing Color-coding Let’s take a closer look at each of these! 17

Rules for Alphabetic System Name with only an initial first name is filed before a full name Hyphenated names are treated as one unit Apostrophes are disregarded Titles and initials are disregarded, but placed in parentheses after the name Married women are to be indexed using their legal name. Husband’s name can be cross-referenced. 18

Rules for Alphabetic System Seniority units are filed numerically Numeric seniority terms are filed before alphabetic terms 19

Numerical Filing or Patient Identification System Used in hospitals and many larger clinics Number is assigned to each patient’s medical record Generally a six-digit number divided into three sections of two digits each 20

Types of Numerical Filing Straight numerical filing Terminal digit filing Middle digit filing Unit numbering Serial numbering 21

Straight Numerical Filing Simplest numerical method Each record is filed sequentially based on its assigned number Numbers used in this system begin at 01 and continue upward File space becomes depleted rapidly as new files are added to one section requiring constant reshifting of files to make room for the new files

Terminal Digit Filing Based on the last digits of the ID number Evenly distributes the files within the entire filing system, eliminating the need for frequent reshifting of files Requires dividing the files into 100 primary sections, starting with 00 and ending with 99 Three sections of numbers assigned to each file are designated as tertiary, secondary, and primary sections respectively

Let’s review the steps for using the terminal digit filing system! Find the file section matching the patient’s primary digits (21) Within that section, match up the secondary digits (72) File the record according to the tertiary digits (05) Let’s review the steps for using the terminal digit filing system!

Steps for Using the Terminal Digit Filing System Step 1: Locate medical record files or medical record room. Step 2: Observe the numbers on the record to be filed. Step 3: Locate the set of files with the same tertiary numbers as the record to be filed. Step 4: Within the set of records with the same tertiary numbers, locate the row of records with the same secondary numbers as the record to be filed.

Steps for Using the Terminal Digit Filing System Step 7: If there is a marker or out guide in place of the removed record, then remove the marker when replacing the file. Step 6: After placing the file in numerical order by primary numbers, check once more to be sure the file is properly placed. Step 5: Within the set of records with the same tertiary and secondary numbers as the record to be filed, place the record to be filed in numerical order by primary numbers.

Middle Digit Filing Using the same six-digit numbering system as with the terminal digit system Middle digit filing system places the middle digits as the primary numbers

Unit Numbering Assigns a number to patients the first time they are seen or admitted to a hospital All other hospitalizations or hospital visits use the same number Requires that all the records be kept at the same location

Serial Numbering With this system the patient receives a different medical record number for each hospital visit The patient acquires multiple records that are stored at different locations The assigned numbers are kept in an accession record in which numbers in sequential order (1, 2, 3, 4, 5, 6…) have a name placed next to them as each new name is entered This record can also be maintained on the computer

Subject Matter Filing Used for general files, such as invoices, correspondence, resumes, and personnel records Method is adequate as long as the files are relatively small If these files become large, then another method, alphabetic or numerical, will have to be devised

Color-Coding Systems Assigns a color for each number from 0-9 Color bars on files correspond with the medical record number Typically only the three primary digits are color-coded System allows for misfiles to be easily seen 31

Color-Coding Methods Numerical system Alphabetic system Ames Color File system Smead Manufacturing Company’s method Alphabetic system Alpha-Z system 32

Alpha-Z System System is based on 13 colors using white letters on a colored background for the first one-half of the alphabet, and the addition of a white stripe on the colored background for the second half of the alphabet Uses file labels to denote the patient’s name, and a color label with the letter of the alphabet to indicate the index unit

Alpha-Z System Ideal for the large practice with many patients having the same surnames Can be adapted to a particular office’s needs In large practices with several physicians, each physician may have a color assigned to him or her

Critical Thinking Question What would be some advantages of cross-referencing files?

Advantages of Cross-Referencing Files Helps in busy offices that have large number of files processed and who may have confusion occur over surnames Alerts the health care worker that a file may be found under another name Useful tool for finding and avoiding “lost” records

Methods to Ensure Location of Records is Known Write down the name of the removed file on a master file sheet Use an out guide to indicate the removal of a record

Guidelines for Locating Missing Files Look for a file with a “sound-alike” or “look-alike” name For color-coded files, look for a folder with the same color-coding For files filed numerically, look for transposed numbers. Look for transposed letters Look for different spellings 38

Guidelines for Locating Missing Files Look at folders filed before and after missing record Look in other areas throughout the office For a video on locating lost files click here, go to MyHealthProfessionsKit.com, or insert the DVD-ROM found in the back of your book. 39

Tickler Files Reminders for future events Should be reviewed daily Contents include: Patient’s names Telephone numbers Dates when action or activities should occur Action to be taken 40

Questions? 41