Managing the Office Medical Records 10 Managing the Office Medical Records

Learning Outcomes 10.1 Describe the equipment and supplies needed for filing medical records. 10.2 List and describe the various types of filing systems. 10.3 Discuss the benefits of each type of system. 10.4 Discuss the advantages of color coding the files. 10.5 Explain how to set up and use a tickler file.

Learning Outcomes (cont.) 10.6 Describe each of the five steps in the filing process. 10.7 Explain the steps to take in trying to locate a misplaced file. 10.8 List and describe the basic file storage options and the advantages of each. 10.9 Identify criteria for determining whether files should be retained, stored, or discarded.

Introduction Management of patient records Vital to patient care and smooth operation of medical office Paper-based medical records Electronic Health Record (EHR) or Electronic Medical Record (EMR)

Importance of Records Management The medical records are the most valuable information in the medical office. A records management system refers to the way patient records are Created Filed Maintained

Super! Apply Your Knowledge What is a records management system? ANSWER: A records management system is the way patient records are created, filed, and maintained. Super!

Filing Equipment Place where the medical records are housed Choice of type is based on space consideration and personal preference Filing shelves Files are stacked upright on shelves in boxes or heavy-duty envelopes Allow more than one person at a time to retrieve files

Filing Equipment (cont.) Filing cabinets Sturdy pieces of office furniture Both vertical and lateral (horizontal) file cabinets are available Compactable files Kept on rolling shelves that slide along permanent tracks on the floor Seen often in offices with limited space for files

Filing Equipment (cont.) Rotary circular files – files are stored in a circular fashion resembling a revolving door Plastic or cardboard tubs or boxes Organized like filing cabinet drawers Inefficient for a large number of files Files can easily be misplaced with this system Heavy to carry around

Filing Equipment (cont.) Labeling filing equipment Label outside of drawer represents its contents Easily retrievable records A-D Security measures Protect confidentiality of medical records Cabinets should lock or be in a lockable room Limit who has keys

Ergonomics Science of adjusting the elements of the working environment to the human body Maintain a healthy and safe posture while working Overexertion – increases risk of injury Common causes of workplace injury Improper lifting Repetitive motions Being struck by an object Slipping and bending

Ergonomics (cont.) Tips Place a footstool next to the examination table Take a course in proper lifting Ensure good lighting Wear proper shoes Select storage and shelving that will aid in reducing muscular strain

Filing Equipment (cont.) Equipment safety Post safety guidelines Ensure that everyone follows rules to prevent injury Purchasing filing equipment First determine space availability Then determine number of files to store

Apply Your Knowledge 1. When restocking the examination rooms in your workplace, you are constantly having to obtain frequently used items from the lowest shelves in the supply room. At the end of the day, you notice that your lower back is achy. What can you do about this situation? ANSWER: Rearrange the supply room so that the more frequently used items are on waist-level shelves to eliminate the need to bend down.

Apply Your Knowledge Good Answers! 2. A busy medical office is considering changing the current filing equipment. Which equipment would you recommend to this non-computerized office that will allow more people to retrieve files at the same time? ANSWER: Filing shelves would be a great system if adequate space is available. Good Answers!

  Filing Supplies File folders Tab Referred to as manila folders Available in 8 ½ by 11 inches and 8 ½ by 14 inches Tabs - extensions at the top or side of the folder and used to identify the contents  Smith, A. Adams, G.

Filing Supplies (cont.) Labels Identify contents Print clearly or use computer- generated labels Cover with tape to prevent smearing File jackets Resemble file folders but have plastic or metal hooks on both sides for hanging them inside filing drawers Files are placed inside these jackets

Filing Supplies (cont.) File guides Heavy cardboard or plastic inserts that identify groups of files Out guides – used as placeholders for removed files File sorters – large envelope-style folders with tabs that store files temporarily

Filing Supplies (cont.) Binders Some offices use three-ring binders to keep patient records Tabs are used to separate individual charts Require more storage Effective for management of active patient records Purchasing filing supplies is a common responsibility of medical assistants

Apply Your Knowledge Which of the following would you use to mark the place when removing a patient record from the file? File jacket File guide Out guide File sorter ANSWER: A GREAT!

Filing Systems All use a sequential order Follow system exactly to avoid losing or misplacing records Avoid changing system

Alphabetic Filing System Most common system Files are arranged in alphabetical order Follow indexing guidelines Each individual must have a separate file

Alphabetic Filing System (cont.) Indexing rules – guidelines for sequencing files Each part of name is a unit Last name First name Middle name / initial Titles (Jr., Sr. ,Rev., Dr., etc.) are the fourth indexing unit

Numeric Filing Systems Organizes files by numbers instead of names Patients are assigned sequential numbers This system is often used with highly confidential information A master list of patient names and numbers must be kept

Numeric Filing Systems (cont.) Terminal digit filing Treat the last 2, 3, or 4 digits in a number as a single unit For example, the numbers 024 represent the last three digits of a longer number The numbers 024 are then considered ending or terminal digits, so all folders ending in 024 are grouped together Filing is done based on last group of numbers Middle digit filing Uses the middle group as primary index for filing

Filing System Color Coding Used to distinguish files within a filing system Can be used with either alphabetic or numeric filing systems Using classification with color coding Identify how files are to be classified Select a separate color for each classification Post codes so all are aware of them

Filing System (cont.) Color Coding 51 61 01 43 With alphabetic filing systems Each letter is assigned a color The first two letters of the last name are color-coded with colored tabs Can easily tell if files are filed correctly With numeric filing systems Numbers 1 to 9 assigned a distinct color Helps identify numeric files that are out of place 51 61 01 43

Filing Systems (cont.) Tickler files Reminder files Check on a regular basis Organized by month, week of month, or day of week Computer systems offer tickler files in the form of a calendar Reminders set to alert prior to event

Filing Systems (cont.) Supplemental files Separate files containing additional information Prevents cluttering of primary files Stored in a different location than primary file Contents should be distinguished from the primary file contents

RIGHT! Apply Your Knowledge Today is December 17th. Which of the information listed below could be added to a “tickler” file? Names of patients that missed appointments two days ago June medical conference dates just received in the mail Names of patients seen today for their annual check-up ANSWER: RIGHT!

The Filing Process Medical assistant responsibilities Pulling and filing patient records Filing documents Follow practice policies for returning records to the files Immediately vs. at the end of day Place records to be filed in a secure file return area

The Filing Process (cont.) Generally the medical assistant files three types of items: New patient record folders Individual documents for existing folders Previously filed patient record folders

The Filing Process (cont.) Place the files in the appropriate location for easy retrieval when needed Storing Place files in order to save time when storing Sorting Add an identifying mark to ensure that the file is put in the correct place Coding Name the file using the office classification system Indexing Inspecting Make sure document is ready to be filed 5 Steps to Filing

Limiting Access to Files Limit the number of people in the medical office who have access to patient records Original patient records should not leave the medical office (Exceptions noted in Chapter 9) Identifying information is often recorded when files are retrieved

Filing Guidelines Take a close look at the contents of patient records each time you pull or file them Keep files neat Do not overstuff file folders Papers should not extend beyond edge of folder Remove file from drawer when adding documents Prevents damage to documents

Filing Guidelines (cont.) Do not crowd the file drawer Allow space for retrieving and replacing files easily If possible, use both uppercase and lowercase letters to label the folders Use file guides with a different tab position to aid in finding files It is better to provide too many cross-references than too few

Filing Guidelines (cont.) File regularly Do not store anything other than files in the file storage area Train all staff who will be retrieving files on the system in place Periodically evaluate your office system

Locating Misplaced Files (cont.) Determine where the file was when it was last seen or used Look for the file while retracing steps from that location Check filing cabinet where it belongs Check neighboring files

Locating Misplaced Files (cont.) Check underneath files in drawer or on shelf Check items to be filed Check with other staff members Check other file locations Similar indexes Under patient’s first name Misfiled chart color Ask if someone inadvertently picked up the file with other materials

Locating Misplaced Files (cont.) Have another person complete the steps to double-check your search Straighten the office, carefully checking all piles of information Check charts that have been pulled for the next day appointments Check physician’s desk

Locating Misplaced Files (cont.) File may be considered lost if not found within 24 to 48 hours Lost files can have potentially devastating consequences Recreate a new file Physicians and staff record recollections of information in the file Duplicate documents from labs, insurance companies, etc.

Active vs. Inactive Files Active files are files that you use frequently Inactive files are files that you use infrequently Closed files – files of patients that no longer consult the office The physician determines when a file is deemed inactive or closed

Apply Your Knowledge Terrific! The medical assistant is training a new employee who will primarily be responsible for the medical records. The new employee asks “Can I first sort the charts, then inspect them?” List the 5 steps to filing in the correct order and provide an explanation to answer her. ANSWER: The 5 steps to filing are: 1. Inspecting 2. Indexing 3. Coding 4. Sorting 5. Storing The charts should be inspected first to be sure all necessary documents are in the charts and that they are ready for sorting and storing. Terrific!

Inactive and Closed File Storage Paper Storage Microfilm Computer Storage Basic Storage Options Files remain in their original format Labeled boxes with lids to allow even stacking If the paper becomes brittle, transfer documents to another storage medium. Microfilm, microfiche, and film cartridges offer a paperless way of storing records. Patient records can be scanned and saved on computer tapes, recordable CDs or DVDs, flash drives, or external hard drives.

File Storage Facilities Some offices have extra storage space on-site Smaller offices require the use of off-site storage Use a facility that takes precautions against fires and floods Maintain a list of all files stored at off-site locations

File Storage Safety Inactive and closed files must remain safe and secure Evaluate storage sites carefully Preferably place files in fireproof and waterproof containers The storage site should be safe from Fire and floods Vandalism and theft Extremes of temperature

Retaining Files in the Office Retention schedule Specifies how long patient records are to be kept once they become inactive or closed Details when files should be moved to storage and when they can be destroyed Generally determined by the physician

Retaining Files in the Office (cont.) Certain records have legal criteria for the length of time they must be maintained in the office, such as Immunizations Employee health records Medical office financial records Criteria from IRS – financial records AMA, American Hospital Association HIPAA law Federal and state laws

Retaining Files in the Office (cont.) Destruction of records Maintain Confidentiality Shred Retain list of documents destroyed

Excellent! Apply Your Knowledge An employee who quit two years ago telephones and requests that copies of her annual physical examination forms, which she submitted while employed, be mailed to her home address. How would you handle this? ANSWER: You should get this request in writing and then proceed to locate the records. The Labor Standards Act specifies that employee health records must be kept for three years, so they should be on hand at the office. Excellent!

In Summary 10.1 Equipment and supplies needed for filing medical records are Filing shelves and cabinets, rotary circular files, plastic index boxes Labeling equipment Hanging file folders and filing supplies such as folders and binders 10.2 There are various types of filing systems, including alphabetic, numeric and color coding.

In Summary (cont.) 10.3 The benefit of using an alphabetic system is that it is simple to use, but you have to make sure that you know the spelling of the person’s name in order to retrieve the file. The numeric system keeps files confidential, and names are recorded elsewhere. 10.4 The advantage of color coding the filing system is that it distinguishes files within a system and can add additional information to the system.

In Summary (cont.) 10.5 Set up 12 file folders (one per month) and arrange with current file on top. Make a list of upcoming responsibilities and activities, file notes by month, and check tickler file at least weekly. 10.6 The five steps in the filing process are: Inspect a file Index or name a file Code a file Sort Store documents neatly within a proper sequence.

In Summary (cont.) 10.7 Steps to assist in locating a misplaced file: Determine the last time you saw the file and retrace steps Look in the filing cabinet where the file belongs Check underneath the files in the drawer or shelf Check the pile of items to be filed Consider whether it might be cross-referenced Check with other staff members

In Summary (cont.) 10.7 More steps to assist in locating a misplaced file: Check under the person’s first name Stand back from the file cabinet Check to see if someone else has taken it out Ask other staff members to do the previous steps that you have done.

In Summary (cont.) 10.8 There are many ways to store inactive files. Paper storage, computer storage and microfilm, microfiche, and cartridges are basic storage options. 10.9 The criteria for retaining, storing, and discarding files vary from state to state. It is always advisable for doctors to request legal advice before destroying records Employee health records – retained for three years Immunization records should be on file permanently Financial records must be kept up to 10 years.

End of Chapter 10 We must try to continue to hear patient voices above the din of the machinery. ~ Catherine Lopez From A Daybook for Nurses