Chapter 5 RECORDS MANAGEMENT

Records Management Learning Objectives Discuss the importance of maintaining accurate medical records. List the steps in filing a document. Compare alphabetic, numeric, and subject filing systems. Describe two advantages and two disadvantages of the alphabetic filing system. List five suggestions for locating a missing file. Discuss the purpose of a retention plan. Chapter 5

Key Terms Accession book Active files AHIMA Alphabetic filing ARMA Closed files Coding Color-coding Cross-reference sheet Cuts Dead storage Folders Guides Inactive files Indexing Inspecting documents Labels Lateral files Micrographics Mobile-aisle files Chapter 5

Key Terms (cont’d) Numeric filing Open-shelf files Out guide Patient medical record Records management Releasing Retention Rotary circular file Sorting Storing Subject filing Tabs Tickler file Vertical files Chapter 5

Records Management Systematic control of records from their creation through maintenance to storage or destruction Record is recorded information in any form—paper, disk, or tape ARMA Sets standards for filing and retention of records Chapter 5

Medical Records Patient medical records (charts) Clinical data sheets, medical and laboratory reports, correspondence about patient Correspondence related to health care Information on supplies, professional organizations, medical research Practice management records Insurance policies, financial statements, tax documents, leases, contracts Chapter 5

Filing Equipment Open-shelf files Filing cabinets Rotary circular file Vertical files Lateral files Mobile-aisle files Chapter 5

Filing Supplies Folders Labels Guides Out guides Tabs and tab cuts Labels Color coding Guides Visual clues Out guides Cross-reference sheets Chapter 5

Filing Steps Inspecting documents Indexing Coding Sorting Storing Release mark Indexing Mental process of identifying classification Coding Physical process of marking classification Sorting Storing Chapter 5

Follow-Up Procedures Tickler file Small file used to store notes regarding files that need follow-up action Chronological order Electronic tickler files Reminder message appears on screen Colored tabs attached to patient files Color indicates type of action required Chapter 5

Filing Systems Alphabetic filing Based on alphabet Most popular Direct reference system Less confidentiality Limited expansion of filing system Typographical errors cause misfiles Chapter 5

Filing Systems (cont’d) Numeric filing Straight numeric filing; terminal digit filing Number assigned from accession book Increased confidentiality and accuracy Unlimited expansion Alphabetic cross-index needed Transposing numbers causes misfiles; requires training Alphanumeric filing Chapter 5

Filing Systems (cont’d) Subject filing Often used for nonpatient records Subject categories depend on specific needs Direct reference system Easy to expand Extensive cross-referencing may be needed Time consuming Chapter 5

Filing Rules 1. Each filing segment is a unit 2. Alphabetize units by comparing letter-by-letter 3. Ignore punctuation marks 4. “Nothing comes before something” 5. Numbers are filed before letters; Arabic numerals before roman numerals Source: ARMA Chapter 5

Locating Missing Files Look directly in front of or behind where item should be filed Look between files and in bottom of file drawer Check for a transposition of letters or numbers Check alternate spellings Check with previous users Check with other office personnel Chapter 5

File Classification Active files Inactive files Closed files Pertain to current patients Inactive files Pertain to patients who have not been seen in six months or longer Closed files Pertain to patients who have died, moved, or terminated relationship Chapter 5

Records Retention State laws must be observed No specific federal law regarding retention time frames Medicare guidelines for retention AHIMA 1997 Develop a schedule that complies with legal, regulatory, and accreditation requirements Specify what, how long, and what media Chapter 5

Retention Periods Patient health records Diagnostic images 2005 1997 Patient health records Adults - 10 years after last encounter Minors - age of majority plus statute of limitations on malpractice Diagnostic images 5 years Master patient index, register of births and deaths, register of surgeries Permanently Source: AHIMA Chapter 5

Retention Periods (cont’d) Practice management records Professional liability policies - permanently Tax records - for three latest years Receipts for equipment - until completely depreciated Personal records and licenses - permanently Source: AHIMA Chapter 5

Paper vs. Electronic Records Micrographics Microfilm/microfiche Electronic files Hard disks CD/DVD Less storage space Maintained for same retention period as paper files Chapter 5

Records Disposal Dead storage Records destruction; AHIMA guidelines Closed records Records to be kept permanently Records destruction; AHIMA guidelines Paper records may be burned, shredded, or pulped beyond reconstruction Electronic files need to be overwritten Microfilm/microfiche and CD-ROM/DVD should be pulverized Chapter 5

Quiz Files of patient seen within the last six months are _______files. active ___________ is mentally determining the classification of a file. Indexing __________________ are the most popular type of filing equipment used in medical offices. Open-shelf files The physical act of marking the file classification is __________. coding Chapter 5

Critical Thinking Which filing system would you choose for patient records? Why? Students should choose between alphabetic and numeric filing systems; subject filing would not be appropriate. Reasons for alphabetic would be ease of access, initial familiarity, and ease of locating misfiles. Reasons for numeric would be patient confidentiality and ease of expanding system. Chapter 5