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Transcript of © 2009 The McGraw-Hill Companies, Inc. All rights reserved 10-1 Managing the Office Medical Records...
10-1
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Managing the Office Medical RecordsManaging the Office Medical Records
PowerPoint® presentation to accompany:
Medical AssistingThird Edition
Booth, Whicker, Wyman, Pugh, Thompson
10-2
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Learning Outcomes10.1 Describe the equipment and supplies needed for
filing medical records.
10.2 List and describe the various types of filingsystems.
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.
10-3
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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.
10-4
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Introduction Medical assistant role
Clinical
Clerical Management of patient records
Vital to patient care and smooth operation of medical office
Requires an organized approach
10-5
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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
A well-organized, easy-to-use system saves time and protects vital medical data.
10-6
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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!
10-7
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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
10-8
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Filing Equipment (cont.)
Filing cabinets Sturdy pieces of office furniture
of metal or wood Both vertical and horizontal
(lateral) 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
10-9
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Rotary circular files Files are stored in a circular
fashion resembling a revolving door Also common when space is
limited
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.)
10-10
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Filing Equipment (cont.) Labeling filing equipment
Label outside of drawer represents its contents
Easily retrievable records
Security measures Protect confidentiality of medical records Cabinets should lock or be in a lockable
room Limit who has keys
A-D
10-11
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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
Filing Equipment (cont.)
10-12
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Apply Your KnowledgeA 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 Answer!
10-13
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Filing Supplies
Referred to as manila folders
Available in 8 ½ by 11 inches and 8 ½ by 14 inches
Tabs are tapered rectangular or rounded extensions at the top of the folder
Tabs on the file folder identify the contents
Smith,A. Adams, G.
File folders Tab
10-14
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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 to for hanging them inside filing drawers Files are placed inside these jackets
10-15
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Filing Supplies (cont.) File guides
Heavy cardboard or plastic inserts that identify groups of files
Out guides Markers made of stiff material;
used as placeholders for removed files
File sorters Large envelope-style folders with
tabs that store files temporarily
10-16
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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 for medical assistants
10-17
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Apply Your Knowledge
Which of the following would you use to mark the place when removing a patient record from the file?
a. File jacket
b. File guide
c. Out guide
d. File sorter
ANSWER:
AGREAT!
10-18
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Filing Systems All use a sequential order
Follow system exactly To avoid losing or misplacing
records
Avoid changing system
10-19
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Filing Systems: Alphabetic
Most common system
Files are arranged in alphabetical order
Files are labeled with the patient’s last name first, first name, then middle initial
Each individual must have a separate file
10-20
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Filing Systems: Alphabetic (cont.)
Indexing rules Guidelines for sequencing files
Each part of name is a unit Last name First name Middle name
Titles (Jr., Sr. etc.) are the fourth indexing unit (to distinguish identical names from each other)
Use for all alphabetizing done by a medical practice
10-21
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Filing Systems: Numeric 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
10-22
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Filing Systems: Numeric (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
10-23
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Filing Systems 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
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Filing Systems 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 0143
10-25
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Filing Systems (cont.)
Tickler files Reminder files
Check on a regular basis
Organized by month, week of month or day of week
Computers systems offer tickler files in the form of a calendar Reminders set to alert prior to event
10-26
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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
10-27
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Today is December 17th. Which of the information listed below could be added to a “tickler” file?
a. Names of patients that missed appointments two days ago
b. June medical conference dates just received in the mail
c. Names of patients seen today for their annual check-up
Apply Your Knowledge
RIGHT!
ANSWER:
10-28
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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
10-29
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The Filing Process (cont.)
Generally the medical assistant files three types of items:
New patientrecordfolders
Individualdocuments
forexistingfolders
Previouslyfiled
patientrecordfolders
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
The Filing Process (cont.)
Place files in order to save time when storing
Add an identifying mark to ensure that the file is put in the correct place
Coding
Storing
Name the file using the office classification system
Make sure document is ready to be filed
Indexing
Sorting
Place the files in the appropriate location for easy retrieval when needed
Inspecting
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
The Filing Process (cont.)
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
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
The Filing Process: 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
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
The Filing Process: 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
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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
The Filing Process – Guidelines (cont.)
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Determine where the file was when last seen or used
Look for the file while retracing steps from that location
Check filing cabinet where it belongs Check neighboring files
The Filing Process: Locating Misplaced Files
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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
The Filing Process: Locating Misplaced Files (cont.)
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Ask if someone inadvertently picked up the file with other materials
Have another person complete the steps to double-check your search
Straighten the office, carefully checking all piles of information
The Filing Process: Locating Misplaced Files (cont.)
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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.
The Filing Process: Locating Misplaced Files (cont.)
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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
The Filing Process: Active vs. Inactive Files
10-40
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Apply Your KnowledgeThe 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 an that they are ready for sorting and storing.
10-41
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Inactive and Closed File Storage
BasicStorageOptions
Computer StorageMicrofilm Paper Storage
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.
Patient records can be scanned and saved on computer tapes, recordable CDs or DVDs, flash drives, or external hard drives.
Microfilm, microfiche and film cartridges offer a paperless way of storing records.
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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
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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
10-44
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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
File Storage: Retaining Files in the Office
10-45
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
Certain records have legal criteria for the length 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
File Storage: Retaining Files in the Office (cont.)
10-46
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Destruction of records
Maintain Confidentiality
Shred
Retain list of documents destroyed
File Storage: Retaining Files in the Office (cont.)
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© 2009 The McGraw-Hill Companies, Inc. All rights reserved
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?
Apply Your Knowledge
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.
ExcellentExcellent!!
10-48
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In Summary Organization of filing system depends on how files
need to be retrieved Two systems: alphabetic and numeric
Color-coding further identifies files Filing process has five steps: inspecting, indexing, coding,
sorting, and storing
Storage of inactive and closed files is often off-site Variety of formats for storage
Retention of stored files depends on legal, state, and federal guidelines
10-49
© 2009 The McGraw-Hill Companies, Inc. All rights reserved
We must try to continue to hear patient voices
above the din of the machinery.
~ Catherine Lopez
From A Daybook for Nurses