1. Jeff Steele, LDO, CPOT, ABOC Spokane Community College
Records Management
Jeff Steele, LDO, CPOT, ABOC
Spokane Community College

2. Objectives
State the basic rules for protection and retrieval of records
Know steps required in transferring records
Describe various filing techniques

3. Overview
A filing system is only as good as the accessibility of everything within the files!
Records management, aka filing, includes classifying and arranging records so they will be protected and can be retrieved quickly and easily

4. Records Protection
The loss of records through fire, flood or other catastrophe could cripple a practice
It is important to protect records at all times:
Original records always remain in the practice
When not in active use, all records are to be in their proper place in the filing system
Return all records at the end of the day
Before closing the file cabinet, pack records tightly together (slows fire damage as air cannot circulate)
Keep all filing cabinets closed and locked
Make computerized records and back them up on a daily basis.
Backup copies of records should be stored away from the office!

5. Records Retrieval
Each misplaced record contains an unnecessary crisis! (and is an expensive waste of time). Misfiling is the most common cause:
Having a record “almost” in the right spot isn’t good enough!
Recognize that filing is an important responsibility and never be careless
Before re-filing, presort the records
Take the time to get it right the first time
Be organized and use adequate filing aids to keep the system in top condition

6. Practice Records Divided into two major groups: Business records
Patient records

7. Business Records
Includes all of the information needed to manage the practice and meet govt. recordkeeping requirements:
All financial data related to patient accts, including insurance claims information
Patient registration forms
Bills to be paid
Expense records and receipts, including bank statements and cancelled checks
Business correspondence and personnel records
Records of practice income
Annual practice summaries and financial statements
Tax records
Professional registrations, licenses and insurance policies

8. Patient Records AKA the patient’s “chart”: Medical history
Progress notes
Laboratory/test results
Correspondence related to the patient’s care
Copies of prescriptions

9. Computerized Records Management
The most common application of computerized records management is in accounts receivable bookkeeping.
Patient is often linked to an account number, usually by last name
Many offices are moving toward a completely paperless system!

10. Legal Documents
Patient records are considered legal documents which must be preserved
Each patient’s chart must be maintained in good order so that all parts are clear and well organized
Financial records, such as insurance claims, are generally considered part of the business record (although copies may be stored in the patient’s chart)

11. Confidentiality Patient records confidentiality must be protected
HIPAA dictates that patient’s records and personal information not be placed in a matter where it may be seen by another patient or unauthorized persons

12. Ownership of Records Q: “Who own the patient’s chart?”
One way of looking at this is that the physician owns the actual chart and the patient owns the information contained within the chart
Under law, the patient should be allowed access to their personal records
Patient’s consent needed for all other transfers of information

13. Transferring of Patient’s Records
The doctor may refuse to allow the original chart to leave the office, except under direct court order
Photocopies may be sent in place of the original (a note is placed in the original chart with the date and where the copies went to)
A doctor may alternatively chose to make a summary of the chart:
A small fee may be charged to cover clerical expenses
Doctor/office cannot refuse to release records due to non-payment

14. Types of Filing Systems
There are numerous filing systems used to store records:
Subject filing: all files are labeled according to the subject of their contents, then filed alphabetically

15. Chronological Filing
Organizes information according to time spans such as months and days
Frequently used for the recall system (March, April, May, etc.)

16. Alphabetical Filing Most common for patient’s charts
Categorized by last name, and often color-coded for first names

17. Numerical Filing
Each chart or document is assigned a number (often crossed reference by computerized systems)
Generally only used for filing patient’s charts when a practice has more than 20,000 active patient charts or when directly linked to a computerized system

18. Filing Aids and Equipment
Vertical files or drawer files
Lateral files, or open shelf filing (often color coded)
File envelopes and folders
Labels

19. Records Retention
Basic Rule: NEVER discard a patient’s records without the doctor’s permission!
Most offices divide records into two categories:
Active files: those that have been to the office in the last X years (usually three to five)
Inactive files: those who have not been to the office for a long period of time (often stored in a basement or storage)

20. Storage Files
A place to put the inactive files (patient’s who are deceased or no longer with the practice)
Must be protected and kept in an organized manner
Often stored in cardboard boxes w/ lids
Box clearly labeled for content

21. Filing Rules
It is vital that everyone involved with handling files know that basic rules for filing:
Unit 1: The surname (last name)
Unit 2: The given name (first name)
Unit 3: The middle name (or initial)
Unit 4: Terms denoting seniority (“Junior”, “Senior”, and “III”
Example: Jones, John D Jr.

22. Examples: John David Jones, Jr.
I II III IV
Jones
Jones J.
Jones John
Jones John D.
Jones John David
Jones John David Jr.

23. Hyphenated Names Indexed as one unit:
Example Henry David Smith-Jones Jr.
Smith-Jones, Henry David Jr.

24. Titles and Degrees
Not indexed units- usually added in column 4 in parentheses (for information only)
Example: Dr. Clarence W. Lawson
Lawson, Clarence W. (M.D.)