2Managing the Office Medical Records Objectives10-1 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.
3Managing the Office Medical Records Objectives (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.
4Importance 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.
5Filing Equipment Filing Shelves Filing Cabinets Files are stacked upright on shelves in boxes or heavy-duty envelopesFiling CabinetsSturdy pieces of office furnitureUsually made of metal or woodBoth vertical and horizontal (lateral) file cabinets are available
6Filing Equipment (cont.) Compactable Files Rotary Circular Files Kept on rolling shelves that slide along permanent tracks on the floorSeen often in offices with limited space for filesRotary Circular FilesFiles are stored in a circular fashion resembling a revolving doorAlso common when space is limited
7Filing Equipment (cont.) Plastic or Cardboard Tubs or Boxes Organized like filing cabinet drawersFiles can easily be misplaced with this system.Labeling Filing EquipmentThe outside of the file drawer should be labeledto represent its contents.A-D
8Filing Equipment (cont.) Security Measures Equipment Safety Many filing cabinets have locks, and the keys should be available to limited staff personnel.Equipment SafetyPost safety equipment for each type of filing system.Purchasing Filing EquipmentFirst determine the amount of space availabilityThen determine number of files to be included
9 Filing Supplies Tab File Folders Labeling File Folders Referred to as manila foldersAvailable in 8 ½ by 11 inches and 8 ½ by 14 inchesTabs are tapered rectangular or rounded extensionsat the top of the folderTabs have a variety of cutsLabeling File FoldersSmith,A.Adams, G.Tabs on the file folder identify the contents
10Filing Supplies (cont.) File JacketsResemble file folders but have plastic or metal hooks on both sides to anchor itFiles are placed inside these jacketsFile GuidesHeavy cardboard or plastic inserts that identify groups of filesOut GuidesA marker made of stiff material that is used as a placeholder for removed files
11Filing Supplies (cont.) File SortersLarge envelope-style folders with tabs that temporarily store filesBindersSome offices use three ring binders to keep patient recordsTabs are used to separate individual chartsPurchasing Filing SuppliesA common responsibility for medical assistants
12Apply Your KnowledgeA busy medical office is considering changing theircurrent filing equipment. Which equipment wouldyou recommend to this non-computerized office thatwill afford more persons to retrieve files at the sametime?
13Apply Your Knowledge - Answer A busy medical office is considering changing theircurrent filing equipment. Which equipment wouldyou recommend to this non-computerized office thatwill afford more persons to retrieve files at the sametime?Filing shelves would be a great system if adequate space is available.
14Filing Systems Alphabetic 1 2 3 Numeric Files are arranged in alphabetical orderFiles are labeled with the patient’s last name first, then firstname and middle initial1 2 3NumericOrganizes files by numbers instead of namesPatients are assigned sequential numbersThis system is often used with highly confidential informationA master list of patient names and numbers must be kept
15Filing Systems (cont.) Color Coding Using Classifications Used to distinguish files within a filing systemUsing ClassificationsFirst identify how files areto be classifiedSelect a separate color foreach classificationColor coding can be used with both alphabetic and numeric filing systems.
16Filing Systems (cont.) Tickler Files A reminder file Should be placed separately and reviewed oftenComputers now offer tickler filesSupplemental FilesSeparate files containing additional informationPrevents cluttering of primary filesContents should be distinguished from the primary file contents
17Apply Your KnowledgeToday is December 17th , which of the information listed below could be added to a “tickler” file?Names of patients that missed appointments two-days agoJune medical conference dates just received in the mailNames of patients seen today for their annual check-up
18Apply Your Knowledge - Answer 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 agob. June medical conference dates just received in the mailc. Names of patients seen today for their annual check-up
19The Filing ProcessGenerally the medical assistant files three types of items:NewPatientRecordFoldersIndividualDocumentsForExistingFoldersPreviouslyFiledPatientRecordFolders
20The Filing Process (cont.) 5 Steps to FilingPlace the files in the appropriate location, so they can easily be retrieved when needed.StoringGet the accumulated files in order. This will save time when storing the folders.SortingPlace an identifying mark to ensure that the file is put in the correct place.CodingName the file using the office classification system.Make sure document is ready tobe filed.IndexingInspecting
21Limiting 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.
22Filing GuidelinesTake 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.
23Filing Guidelines (cont.) 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.
24Locating 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.
25Active vs. Inactive Files Files that you use frequentlyInactive FilesFiles that you use infrequentlyClosed FilesFiles of patients that no longer consult the officeThe physician determines when a file is deemed inactive or closed
26Apply Your KnowledgeThe 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.
27Apply Your Knowledge- Answer Step 1InspectingStep 2IndexingStep 3CodingStep 4SortingStep 5StoringThe primary reason records should first be inspected is to ensure that all documents are present that belong in the chart.
28Storing Files Basic Storage Options Paper Storage Microfilm Computer StorageBasicStorageOptionsFiles remain in their original formatGood to place in boxes with lids to afford even stackingIf the paper becomes brittle, transfer documents to another storage medium.Microfilm, microfiche and cartridges offer a paperless way of storing records.Patient records can be scanned and saved on a disk, tape or computer hard drive.
29Storage FacilitiesSome 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.
30Storage SafetyEven 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 & FloodsVandalism & TheftExtremes of temperature
31Retaining 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.
32Apply Your KnowledgeA 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?
33Apply Your Knowledge - Answer 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.
34Managing the Office Medical Records End of Chapter