2 Managing the Office Medical Records Objectives 10-1 Describe the equipment and supplies needed for filing medical records List and describe the various types of filing systems Discuss the benefits of each type of system Discuss the advantages of color coding the files Explain how to set up and use a tickler file.
3 Managing the Office Medical Records Objectives (cont.) 10-6 Describe each of the five steps in the filing process Explain the steps to take in trying to locate a misplaced file List and describe the basic file storage options and the advantages of each Identify criteria for determining whether files should be retained, stored, or discarded.
4 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.
5 Filing Equipment Filing Shelves Files are stacked upright on shelves in boxes or heavy-duty envelopes Filing Cabinets Sturdy pieces of office furniture Usually made of metal or wood Both vertical and horizontal (lateral) file cabinets are available
6 Compactable Files Kept on rolling shelves that slide along permanent tracks on the floor Seen often in offices with limited space for files Rotary Circular Files Files are stored in a circular fashion resembling a revolving door Also common when space is limited Filing Equipment (cont.)
7 Filing Equipment Plastic or Cardboard Tubs or Boxes Organized like filing cabinet drawers Files can easily be misplaced with this system. Labeling Filing Equipment The outside of the file drawer should be labeled to represent its contents. (cont.) A-D
8 Security Measures Many filing cabinets have locks, and the keys should be available to limited staff personnel. Equipment Safety Post safety equipment for each type of filing system. Purchasing Filing Equipment First determine the amount of space availability Then determine number of files to be included Filing Equipment (cont.)
9 Filing Supplies File Folders 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 have a variety of cuts Tab Tabs on the file folder identify the contents Labeling File Folders Smith,A.Adams, G.
10 File Jackets Resemble file folders but have plastic or metal hooks on both sides to anchor it Files are placed inside these jackets File Guides Heavy cardboard or plastic inserts that identify groups of files Out Guides A marker made of stiff material that is used as a placeholder for removed files Filing Supplies (cont.)
11 File Sorters Large envelope-style folders with tabs that temporarily store files Binders Some offices use three ring binders to keep patient records Tabs are used to separate individual charts Purchasing Filing Supplies A common responsibility for medical assistants Filing Supplies (cont.)
12 Apply Your Knowledge A busy medical office is considering changing their current filing equipment. Which equipment would you recommend to this non-computerized office that will afford more persons to retrieve files at the same time?
13 Answer Apply Your Knowledge - Answer A busy medical office is considering changing their current filing equipment. Which equipment would you recommend to this non-computerized office that will afford more persons to retrieve files at the same time? Filing shelves would be a great system if adequate space is available.
14 Filing Systems Files are arranged in alphabetical order Files are labeled with the patients last name first, then first name and middle initial 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
15 Filing Systems (cont.) Using Classifications First identify how files are to be classified Select a separate color for each classification Color coding can be used with both alphabetic and numeric filing systems. Color Coding Used to distinguish files within a filing system
16 Filing Systems (cont.) Tickler Files A reminder file Should be placed separately and reviewed often Computers now offer tickler files Supplemental Files Separate files containing additional information Prevents cluttering of primary files Contents should be distinguished from the primary file contents
17 Today is December 17 th, 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
18 Today is December 17 th, which of the information listed below could be added to a tickler file? a.Names of patients that missed appointments two-days ago Answer Apply Your Knowledge - Answer b. June medical conference dates just received in the mail c. Names of patients seen today for their annual check-up
19 The Filing Process Generally the medical assistant files three types of items: New Patient Record Folders Individual Documents For Existing Folders Previously Filed Patient Record Folders
20 The Filing Process (cont.) Get the accumulated files in order. This will save time when storing the folders. Place the files in the appropriate location, so they can easily be retrieved when needed. Place an identifying mark to ensure that the file is put in the correct place. Coding Sorting Storing Name the file using the office classification system. Indexing Make sure document is ready to be filed. Inspecting
21 Limiting Access to Files Under no circumstances should original patient records leave the medical office. Identifying information is often recorded when files are retrieved. Limited persons in the medical office have access to patient records.
22 Filing Guidelines Take a close look at the contents of patient records each time you pull them. Keep files neat. Do not overstuff file folders. Take time to properly place documents into the folders to prevent damage. Do not crowd the file drawer. If possible use both upper and lower case letters to label the folders.
23 Use file guides with a different tab position to aid with finding files. It is better to provide too many cross-references than too few. File regularly. Do not store anything other than files in the file storage area. Train all staff that will be able to retrieve files on the system in place. Periodically evaluate your office system to see if it still works. Filing Guidelines (cont.)
24 Locating Misplaced Files Do a complete search of the office to try and locate the file. If the file is not recovered within 24 to 48 hours, it may be considered lost. Lost files can have potentially devastating consequences.
25 Active vs. Inactive Files Active Files Files that you use frequently Inactive Files 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
26 Apply Your Knowledge The medical assistant is training a new employee that 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 this question.
27 The primary reason records should first be inspected is to ensure that all documents are present that belong in the chart. Answer Apply Your Knowledge - Answer Step 1 Step 2 Step 3 Step 4 Step 5 Indexing Sorting Coding Inspecting Storing
28 Storing Files Basic Storage Options Computer StorageMicrofilmPaper Storage Files remain in their original format Good to place in boxes with lids to afford even stacking If the paper becomes brittle, transfer documents to another storage medium. Patient records can be scanned and saved on a disk, tape or computer hard drive. Microfilm, microfiche and cartridges offer a paperless way of storing records.
29 Storage Facilities Some offices have extra closet or 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 at each storage location.
30 Storage Safety Even inactive and closed files must remain safe and secure. Place files in fireproof and waterproof devices. Cardboard is not an option. The storage site should be safe from: Fire & Floods Vandalism & Theft Extremes of temperature
31 Retaining Files in the Office A retention schedule decides how long different types of patient records are to be kept in the office once they become inactive or closed. 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. Legal consultants and the AMA also advise physicians on the length of time patient records should be kept. The best rule of thumb is to seek legal advice before destroying any records.
32 A former employee from two years ago telephones and requests that copies of her annual physical examination forms that she submitted while employed be mailed to her home address. How would you handle this? Apply Your Knowledge
33 A former employee from two years ago telephones and requests that copies of her annual physical examination forms that she submitted while employed be mailed to her home address. How would you handle this? 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. Answer Apply Your Knowledge - Answer