Medical Assisting Review Passing the CMA, RMA, and CCMA Exams Fifth Edition © 2015 McGraw-Hill Education. All rights reserved.. Chapter 10 Appointments, Scheduling, Medical Records, Filing, Policies, and Procedures

© 2015 McGraw-Hill Education. All rights reserved. Learning Outcomes 10.1 Recall the different types of appointments and scheduling methods used in the medical office Demonstrate proper filing methods and the correct techniques for the handling of medical records Describe the importance of the policy and procedures manual. 10-2

© 2015 McGraw-Hill Education. All rights reserved Appointments and Schedules Appointment book Legal record Types of appointments –New patient –Follow-up –Admissions –Laboratory tests –Surgery

© 2015 McGraw-Hill Education. All rights reserved. Appointments and Schedules –Physician referrals –Salespersons, including pharmaceutical sales representatives –Returning patients –Specialists –Buffer time 10-4

© 2015 McGraw-Hill Education. All rights reserved Appointments and Schedules Abbreviations

© 2015 McGraw-Hill Education. All rights reserved Appointments and Schedules Scheduling process –Office hours –Matrix –Scheduling guidelines –Considerations –Appointment cards –Phone –Special problems –Cancellations –Rescheduling

© 2015 McGraw-Hill Education. All rights reserved Appointments and Schedules Types of scheduling systems –Open hours –Time-specified scheduling –Double booking –Wave scheduling –Modified wave scheduling –Cluster scheduling

© 2015 McGraw-Hill Education. All rights reserved Appointments and Schedules –Advance scheduling –Grouping –Exceptions –Streaming –Computerized scheduling –Online scheduling

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing Reasons for medical records –Good medical records provide continuity –Supply statistical information –Used in lawsuits to protect patients –For evaluating quality of care in facilities –To facilitate reimbursements

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing STANDARD INFORMATION IN MEDICAL RECORDS –Patient registration form –Patient medical history –Physical exam results –Results of lab tests –Copies and notes for prescriptions –Diagnosis and treatment plan –Patient progress reports and communication with patient –Informed consent forms –Discharge summary –Correspondence with and about patients

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing Six Cs of charting –Client’s words –Clarity –Completeness –Conciseness –Chronological order –Confidentiality

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing Items to exclude from patient’s records –Reports from consulting physicians –Financial information –Transferred records –Prejudicial, personal, or flippant comments

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing Records management –Saving space –Reducing filing equipment expenditures –Preventing unnecessary record creation –Retrieving information faster –Reducing misfiles –Complying with legal safeguards –Saving the physician’s and patient’s time

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing SOAP –Subjective data –Objective data –Assessment –Plan POMR –Problem-oriented medical records

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing Medical transcription –Ensure accurate transcription Dictation –Ask for clarification Confidentiality

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing Filing systems –Alphabetical –Alphanumeric –Subject filing –Chronological filing –Numerical filing –Color-coding –Computer records –Tickler file

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing Filing procedures –Conditioning –Releasing –Indexing and coding –Sorting –Storing and filing

© 2015 McGraw-Hill Education. All rights reserved. Medical Records and Filing Active files Inactive files Closed files Transfer Retention period Identical names Business and organization records Misplaced files 10-18

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing

© 2015 McGraw-Hill Education. All rights reserved Medical Records and Filing Filing equipment –File shelves –File cabinets –Movable file units –Filing supplies File folders Identification labels Guides and captions Out guide

© 2015 McGraw-Hill Education. All rights reserved Policies and Procedures Policies and procedures manual –Policies Office purposes, objectives, and goals Rules and regulations Job descriptions and duties Office hours Dress code Insurance and other benefits Vacation, sick leave, and other time away from the office

© 2015 McGraw-Hill Education. All rights reserved Policies and Procedures Performance evaluations and salary Maintenance of equipment and supplies Mailings Bookkeeping Scheduling appointments Maintaining patient records Health and safety guidelines Organizational chart

© 2015 McGraw-Hill Education. All rights reserved Policies and Procedures Procedures –Developing a Manual Develop an outline Sources for development –Journals –Product literature –Textbooks –Standards publications Manual format – many offices prefer a loose-leaf binder