1. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Unit 3 Records Management

2. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Chapter 8 Filing Procedures 2

3. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Objectives Review the learning and performance objectives for this chapter By the end of this chapter, demonstrate the procedures in the textbook and the job skills in the workbook 3

4. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Heart of the Health Care Professional Service –Having information at your fingertips and being able to locate documents quickly are a great service to patients 4

5. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Considerations –Number of active records –Number of inactive records –Frequency of record retrieval –Amount of filing space –Convenience of file locations –Cost of the system 5

6. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Alphabetic Filing System –Easy to understand –No cross-reference index needed Alphabetic Color-Coding –Colored tab for each letter First three letters of last name –Reduces misfiles –Speeds retrieval 6

7. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Subject Filing System –Alphabetic arrangement by topic –In Office Reference Files Medical articles Example 8-1 –File Using a Subject Filing System Procedure 8-1 7

8. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Indirect Filing System (numeric filing) –Privacy, convenience, expansion Patient load exceeds 10,000 Hospitals, X-rays –Cross-reference provides access Middle-digit numbering Terminal-digit system Triple-digit system Serial numbering 8

9. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Indirect Filing System –Master patient index (MPI) Usually computerized Cross-reference –Chronological files Numbers used based on dates File documents within chart 9

10. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Electronic Filing System –Bar codes Swiped like a credit card Easy tracking –Scanners Scan and index documents Store on CDs 10

11. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Electronic Filing System –Databases Electronic collections of information Easily searchable –Electronic security Confidentiality Passwords Access codes Encryption 11

12. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Electronic Filing System –Maintaining computer files Sort, label, and file –Set Up an E-Mail Filing System Procedure 8-2 12

13. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Electronic Filing System –Backing up computer files Done on regular schedule –Electronic confidentiality guidelines Protects computer access 13

14. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Tickler Filing System –Organize a tickler file Procedure 8-3 –Short-notice reminder file –Temporary reminder file 14

15. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Commercial Filing Systems Tickler Filing System 15

16. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Alphabetic Filing Rules General Guidelines –Rule 1: Individual names –Rule 2: Prefixes –Rule 3: Hyphenated names –Rule 4: Abbreviated names and nicknames 16

17. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Alphabetic Filing Rules 17

18. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Alphabetic Filing Rules General Guidelines –Rule 5: Titles and degrees –Rule 6: Married women –Rule 7: Hospitals, medical facilities, and businesses –Rule 8: Addresses when names are identical 18

19. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Alphabetic Filing Rules 19

20. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Alphabetic Filing Rules General Guidelines –Determine Filing Units and Indexing Order to Alphabetically File a Patient’s Medical Record Procedure 8-4 20

21. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Filing Equipment Lateral Files –Popular –Space saver –Adaptable Full-Suspension Drawer Files –Useful for storage of business records 21

22. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Filing Supplies and Their Uses Guides –Pressboard, manila, metal, plastic –Provide support for folders –Visual guide for labeled sections 22

23. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Filing Supplies and Their Uses Folders –Open Holds 8 ½ X 11 documents Stapled and shingled documents –Binder File fasteners or clamps Prevents lost items 23

24. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Filing Supplies and Their Uses Color-Coding File Folders –Miscellaneous colored labels Tabs –Staggered projections Labels –Label and Color-Code Patient Charts Procedure 8-5 24

25. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Charge-Out and Control Systems Charge-Out System –Indicates when and by whom a record has been removed Outguide –Substitution card 25

26. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Charge-Out and Control Systems Outfolder –Substitution folder –Stores incoming items 26

27. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Filing Documents in Patient Records Prepare, Sort, and File Documents in Patient Records –Procedure 8-6 Misfiling –Keep headings simple –Type names legibly –Use adequate number of guides –Do not overcrowd 27

28. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Filing Documents in Patient Records Misplaced or Lost Records –Organized search –Locate a Misfiled Patient Medical-Record File Folder Procedure 8-7 28

29. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Record Retention and Storage Sort according to type Prepare inventory list Refer to schedule of retention Determine length of retention Obtain physician’s approval 29

30. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Record Retention and Storage Move records from active to inactive Conduct random inspection to ensure compliance Financial and Legal Records –Financial reports and legal documents – permanent 30

31. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Record Retention and Storage Active and Inactive Patient Files –Active files – on shelves Purge every 3 to 5 years –Inactive files – in storage Destroy when retention time is up –State statute of limitations vary 31

32. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Record Retention and Storage Electronic Storage –Flash drive, external hard drive, DVD –Online record storage Google Health website Health Vault Dossia 32

33. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Destroying Documents Contract with outside vendors Shred Purging Computer Files –Remove or delete data File superseded by another file Temporary file Older version Infrequently used file 33

34. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Recycling and the Green Team Evaluate office for: –Water conservation –Energy efficiency –Environmental purchasing –Shredding confidential documents –Recycling Regular waste Paper waste Biohazard waste 34

35. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Stop and Think Case Scenarios Review the scenario “Locate a Missing Record” –You have methodically checked the file cabinet –What staff members might have the file and for what purpose? –What procedures can be used to prevent missing records? 35

36. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Stop and Think Case Scenarios Review the scenario “Determine Document Types and Filing Systems” –Decide what type of documents these are –Decide how these documents should be filed –Decide where these documents should be filed –Suggest and note file names 36