Records Management Presentation

Overview Directories for administrating health care information Integrated records management Making of new records Straight numeric filing Permanent and temporary attachment of reports Storage of patient files Circulation and following of files Maintenance schedule File security Legal and Ethical accountability (Green & Bowie, 2006)

Introduction What is records management? Responsibility for managing records and information Properly document information in time Not duplicating records (Flickr, n.d.)

Indexes for administering health care information Master patient index  Identification data  Record retrieval (Istockphoto, n.d.)

Centralized Records Management One file room Accountability for record keeping is easily recognized Operative use of equipment, supplies, space, and personnel is made Better security (Flickr, n.d.)

Creation of manual records Face Sheet Problem oriented record  Database  Problem list  Initial plan  Progress notes (istockphoto, n.d.)

Straight Numeric Filing System  Office personnel can be easily educated  Improves file security  Files can be lengthened for additional space  Removal is easier  File numbers are prepared from lowest to highest (Flickr, n.d.)

Temporary and Permanent insertion of loose reports Clinical data  Permanent Administrative data  Temporary Organize loose forms according to numeric filing system (istockphoto, n.d.)

Storage of Patient Files Short Term  Two to three days Permanent  Currently under care Archive  Has not been used (flickr, n.d.)

Circulation of records within and outside our facility  Automated chart tracking system  Providers call records from their computer  Clerks sign out patient files from file area  Out-guides are used to indicate elimination  Lab reports are stored in an extra file cabinet (istockphoto, n.d.)

Retention schedule-destruction of records Archived records  Shredding  Certificate of destruction  Maintained permanently (istockphoto, n.d.)

File Security Protect records from fire or water damage  Save records in locked file or room Guard records from theft  Approved personnel in file area  Lock file room when unstaffed  Password protect computers (flickr, n.d.)

Legal and Ethical Responsibilities  Preserving the Patient’s Records  Privacy of Information  Issue of Protected Health Information  Patient admission to records  Secure Health Information must be traced (istockphoto, n.d.)

Review Centralized Records Management Archive files kept 5 years Problem Oriented Records Straight Numeric Filing System Automated Chart Tracking System

References ARMA (2009). What is Records Management?. Retrieved from FotoSearch (n.d.). File Room Stock Photo & Images. Retrieved, from

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, from