Presentation on theme: "Managing the Office Medical Records"— Presentation transcript:
1Managing the Office Medical Records Chapter 10Managing the Office Medical RecordsPowerPoint® presentation to accompany:Medical AssistingThird EditionBooth, Whicker, Wyman, Pugh, Thompson
2Learning Outcomes10.1 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.
3Learning Outcomes (cont.) 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.
4Introduction Medical assistant role Clinical Clerical Management of patient recordsVital to patient care and smooth operation of medical officeRequires an organized approach
5Importance 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 areCreatedFiledMaintainedA well-organized, easy-to-use system saves time and protects vital medical data.
6Super! 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!
7Filing Equipment Place where the medical records are housed Choice of type is based on space consideration and personal preferenceFiling shelvesFiles are stacked upright on shelves in boxes or heavy-duty envelopesAllow more than one person at a time to retrieve files
8Filing Equipment (cont.) Filing cabinetsSturdy pieces of office furniture of metal or woodBoth vertical and horizontal (lateral) file cabinets are availableCompactable filesKept on rolling shelves that slide along permanent tracks on the floorSeen often in offices with limited space for files
9Filing Equipment (cont.) Rotary circular filesFiles are stored in a circular fashion resembling a revolving doorAlso common when space is limitedPlastic or cardboard tubs or boxesOrganized like filing cabinet drawersInefficient for a large number of filesFiles can easily be misplaced with this systemHeavy to carry around
10Filing Equipment (cont.) Labeling filing equipmentLabel outside of drawer represents its contentsEasily retrievable recordsA-DSecurity measuresProtect confidentiality of medical recordsCabinets should lock or be in a lockable roomLimit who has keys
11Filing Equipment (cont.) Equipment safetyPost safety guidelinesEnsure that everyone follows rules to prevent injuryPurchasing filing equipmentFirst determine space availabilityThen determine number of files to store
12Good Answer! Apply Your Knowledge A 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!
13 Filing Supplies File folders Tab Referred to as manila folders Available in 8 ½ by 11 inches and 8 ½ by 14 inchesTabs are tapered rectangular or rounded extensions at the top of the folderTabs on the file folder identify the contentsSmith,A.Adams, G.
14Filing Supplies (cont.) LabelsIdentify contentsPrint clearly or use computer- generated labelsCover with tape to prevent smearingFile jacketsResemble file folders but have plastic or metal hooks on both sides to for hanging them inside filing drawersFiles are placed inside these jackets
15Filing Supplies (cont.) File guidesHeavy cardboard or plastic inserts that identify groups of filesOut guidesMarkers made of stiff material; used as placeholders for removed filesFile sortersLarge envelope-style folders with tabs that store files temporarily
16Filing Supplies (cont.) BindersSome offices use three-ring binders to keep patient recordsTabs are used to separate individual chartsRequire more storageEffective for management of active patient recordsPurchasing filing supplies is a common responsibility for medical assistants
17Apply Your KnowledgeWhich of the following would you use to mark the place when removing a patient record from the file?File jacketFile guideOut guideFile sorterANSWER:AGREAT!
18Filing Systems All use a sequential order Follow system exactly To avoid losing or misplacing recordsAvoid changing system
19Filing Systems: Alphabetic Most common systemFiles are arranged in alphabetical orderFiles are labeled with the patient’s last name first, first name, then middle initialEach individual must have a separate file
20Filing Systems: Alphabetic (cont.) Indexing rulesGuidelines for sequencing filesEach part of name is a unitLast nameFirst nameMiddle nameTitles (Jr., Sr. etc.) are the fourth indexing unit (to distinguish identical names from each other)Use for all alphabetizing done by a medical practice
21Filing Systems: Numeric Organizes 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
22Filing Systems: Numeric (cont.) Terminal digit filingTreat the last 2, 3, or 4 digits in a number as a single unitFor example, the numbers 024 represent the last three digits of a longer numberThe numbers 024 are then considered ending or terminal digits, so all folders ending in 024 are grouped togetherFiling is done based on last group of numbersMiddle digit filingUses the middle group as primary index for filing
23Filing Systems Color Coding Used to distinguish files within a filing systemCan be used with either alphabetic or numeric filing systemsUsing classification with color codingIdentify how files are to be classifiedSelect a separate color for each classificationPost codes so all are aware of them
24Filing Systems Color Coding 51 61 01 43 With alphabetic filing systems Each letter is assigned a colorThe first two letters of the last name are color-coded with colored tabsCan easily tell if files are filed correctlyWith numeric filing systemsNumbers 1 to 9 assigned a distinct colorHelps identify numeric files that are out of place51610143
25Filing Systems (cont.) Tickler files Reminder files Check on a regular basisOrganized by month, week of month or day of weekComputers systems offer tickler files in the form of a calendarReminders set to alert prior to event
26Filing Systems (cont.) Supplemental files Separate files containing additional informationPrevents cluttering of primary filesStored in a different location than primary fileContents should be distinguished from the primary file contents
27Apply Your Knowledge RIGHT! 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 agoJune medical conference dates just received in the mailNames of patients seen today for their annual check-upANSWER:RIGHT!
28The Filing Process Medical assistant responsibilities Pulling and filing patient recordsFiling documentsFollow practice policies for returning records to the filesImmediately vs. at the end of dayPlace records to be filed in a secure file return area
29The Filing Process (cont.) Generally the medical assistant files three types of items:NewpatientrecordfoldersIndividualdocumentsforexistingfoldersPreviouslyfiledpatientrecordfolders
30The Filing Process (cont.) Place the files in the appropriate location for easy retrieval when neededStoringPlace files in order to save time when storingSortingAdd an identifying mark to ensure that the file is put in the correct placeCodingName the file using the office classification systemIndexingInspectingMake sure document is ready tobe filed5 Steps to Filing
31The Filing Process (cont.) Limiting access to filesLimit the number of people in the medical office who have access to patient recordsOriginal patient records should not leave the medical office (Exceptions noted in Chapter 9)Identifying information is often recorded when files are retrieved
32The Filing Process: Guidelines Take a close look at the contents of patient records each time you pull or file themKeep files neatDo not overstuff file foldersPapers should not extend beyond edge of folderRemove file from drawer when adding documentsPrevents damage to documents
33The Filing Process: Guidelines (cont.) Do not crowd the file drawerAllow space for retrieving and replacing files easilyIf possible, use both uppercase and lowercase letters to label the foldersUse file guides with a different tab position to aid in finding filesIt is better to provide too many cross-references than too few
34The Filing Process – Guidelines (cont.) File regularlyDo not store anything other than files in the file storage areaTrain all staff who will be retrieving files on the system in placePeriodically evaluate your office system
35The Filing Process: Locating Misplaced Files Determine where the file was when last seen or usedLook for the file while retracing steps from that locationCheck filing cabinet where it belongsCheck neighboring files
36The Filing Process: Locating Misplaced Files (cont.) Check underneath files in drawer or on shelfCheck items to be filedCheck with other staff membersCheck other file locationsSimilar indexesUnder patient’s first nameMisfiled chart color
37The Filing Process: Locating Misplaced Files (cont.) Ask if someone inadvertently picked up the file with other materialsHave another person complete the steps to double-check your searchStraighten the office, carefully checking all piles of information
38The Filing Process: Locating Misplaced Files (cont.) File may be considered lost if not found within 24 to 48 hoursLost files can have potentially devastating consequencesRecreate a new filePhysicians and staff record recollections of information in the fileDuplicate documents from labs, insurance companies, etc.
39The Filing Process: Active vs. Inactive Files Active files are files that you use frequentlyInactive files are files that you use infrequentlyClosed filesFiles of patients that no longer consult the officeThe physician determines when a file is deemed inactive or closed
40Apply Your Knowledge Terrific! The 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. Indexing3. Coding 4. Sorting5. StoringThe charts should be inspected first to be sure all necessary documents are in the charts an that they are ready for sorting and storing.Terrific!
41Inactive and Closed File Storage Paper StorageMicrofilmComputer StorageBasicStorageOptionsMicrofilm, microfiche and film cartridges offer a paperless way of storing records.Files remain in their original formatLabeled boxes with lids to allow even stackingIf 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.
42File Storage Facilities Some offices have extra storage space on-siteSmaller offices require the use of off-site storageUse a facility that takes precautions against fires and floodsMaintain a list of all files stored at off-site locations
43File Storage SafetyInactive and closed files must remain safe and secureEvaluate storage sites carefullyPreferably place files in fireproof and waterproof containersThe storage site should be safe fromFire and floodsVandalism and theftExtremes of temperature
44File Storage: Retaining Files in the Office Retention scheduleSpecifies how long patient records are to be kept once they become inactive or closedDetails when files should be moved to storage and when they can be destroyedGenerally determined by the physician
45File Storage: Retaining Files in the Office (cont.) Certain records have legal criteria for the length they must be maintained in the office, such asImmunizationsEmployee health recordsMedical office financial recordsCriteria fromIRS – financial recordsAMA, American Hospital AssociationHIPAA lawFederal and state laws
46File Storage: Retaining Files in the Office (cont.) Destruction of recordsMaintain ConfidentialityShredRetain list of documents destroyed
47Excellent! Apply Your Knowledge 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?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.Excellent!
48In SummaryOrganization of filing system depends on how files need to be retrievedTwo systems: alphabetic and numericColor-coding further identifies filesFiling process has five steps: inspecting, indexing, coding, sorting, and storingStorage of inactive and closed files is often off-siteVariety of formats for storageRetention of stored files depends on legal, state, and federal guidelines
49End of Chapter 10We must try to continue to hear patient voices above the din of the machinery.~ Catherine LopezFrom A Daybook for Nurses