 The medical record is a legal document and provides evidence of the continuity of care of a patient. Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.1 Organizing a Patient’s Medical Record

Contents usually include selections from the following: ◦ Patient Information Sheet ◦ Problem List ◦ History and Physical Examination Form ◦ Progress Notes ◦ Flow Sheets (continued) Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.2 Contents are dictated by individual office policy.

Contents usually include selections from the following: ◦ Results of Diagnostic Tests ◦ Consultation Reports ◦ Hospitalization Reports ◦ Laboratory Reports ◦ Correspondence ◦ Insurance Claims Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.3

On some medical records: Stickers for allergies and special instructions are needed. Special forms for history and physical exams are needed. Forms for special situations are needed, such as OB flow sheets. All forms should agree with the routine of the office. Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.4

Preparing new records for established patients: Always follow office policy when preparing new records for established patients. Remove the needed materials from the old record as per office policy. Place the needed information into a new record. Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.5

Preparing new records for established patients (cont.): Mark the medical records as #1, #2, etc. Mark the medical records with dates of service. File both medical records with the new record in the front. Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.6

To properly maintain medical records: Be sure the medical report has been signed or initialed by the physician prior to filing. Repair any damage to records prior to filing. If a record is damaged, take the time to make necessary repairs to prevent further damage. Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.7

To properly maintain medical records (cont.): Prepare a new file folder when needed because of damage. Prepare a second medical record when established patients’ medical records are too large to be easily handled. Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.8

Filing Medical Records Prevents loss of continuity of medical care Allows for time management Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.9

Filing of Medical Records in Ambulatory Care Facilities Filed alphabetically Filed numeric ally Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.10

Supplies That Assist with Proper Filing of Medical Records Color-coded labels Outguides Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.11

Effects of Medical Records Being Incorrectly Filed Loss of time finding the record Possible loss of continuity of care Legal implications if not found Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.12

Purging Medical Records Medical records are purged: ◦ After time specified in Policy Manual ◦ To prevent time loss in finding current medical records ◦ To minimize the number of file system components needed Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.13

Purging Medical Records Color-coded date tabs assist with purging records. Purged records should be stored for the time indicated in the Policy Manual. Copyright © 2007 by Saunders, an imprint of Elsevier Inc. All rights reserved.14