Y khoa - Dược - Chapter 15: Managing medical records

15Managing Medical RecordsLearning Outcomes (cont.)15.1 Identify the common equipment used to file and store paper medical records.15.2 Outline the security and safety measures that should be employed when working with paper medical records.15.3 List the common filing supplies used in the medical office.Learning Outcomes (cont.)15.4 Contrast the methods used for various filing systems and how color-coding can assist with the filing systems.15.5 Recall the steps in the filing process.15.6 Compare active, inactive, and closed files and how to set up a records retention program for the office.IntroductionRecords management systemVital to patient care and office operationMust be easily retrievableFiling Equipment Filing shelvesFiling Cabinets Vertical filesHorizontal or lateral filesCompactable filesFiling Equipment (cont.)Rotary Circular filesPlastic or cardboard tubs or boxesLabeling Filing EquipmentClearly indicate range of filesWrite directly on boxesApply Your KnowledgeWhat are the disadvantages of vertical filing cabinets? ANSWER: They take up more room than shelves, only one person can access the files at a time, and if more than one drawer is pulled out at a time they become top heavy and could tip over.Security and Safety MeasuresHIPAA privacy and securityMedical record securityLockable cabinets or roomLimit key accessEquipment Safety Purchasing filing equipmentBase on space and number of filesFire proof and securePost safety guidelinesKeep drawers closed Open one drawer at a timeStep-ladder safetyApply Your KnowledgeA busy medical office is currently using filing boxes for patient medical records and wants to change to a different system . What would you recommend to this non-computerized office that will allow more people to retrieve files at the same time?ANSWER: Filing shelves would enable more than one person to access files if adequate space is available.Filing Supplies Available in letter and legal sizes Tabs - extensions used to identify the contentsSmith, A.Adams, G.File folderTabFiling Supplies (cont.)LabelsFile jacketsBindersFiling Supplies (cont.)File guidesOut guidesFile sortersApply Your KnowledgeWhich of the following would you use to mark the place when removing a patient record from the file? File jacket File guide Out guide File sorterANSWER:GREAT!Filing SystemsAll use a sequential orderFollow system exactly to avoid losing or misplacing recordsAvoid changing system Alphabetic Filing SystemMost common systemFiles are arranged in alphabetical orderSeven indexing rules – keeps alphabetizing simple and consistentAlphabetic Filing System (cont.) Indexing rules Each part of name is a unit Last nameFirst nameMiddle name / initialTitles (Jr., Sr. ,Rev., Dr., etc.) ~ the fourth indexing unit Chronological FilingBased on datesYear, month, dayUsed within a patient’s recordReverse chronologic orderNumeric FilingNumeric Filing (cont.)Terminal digit filingFiling is done based on last group of numbersNumber is read from right to leftMiddle digit filingUses the middle group as primary index for filingNumber is read using the middle number firstFollowed by the left-hand number and right-hand number001 -25 -667002 -25 -565Color-coding Using classifications Identify how files are to be classifiedDetermine method of codingDetermine color for each classificationPost codesColor-coding (cont.) With alphabetic filing Each letter is assigned a colorTwo or three letters of the last name are color-codedColor-coding helps identify charts that are out of order.JONSEColor-coding (cont.) With numeric filingNumbers 1 to 9 assigned a distinct colorUse color-coded “key unit” for each chart556Terminal digit as “key unit”52Middle digit as “key unit”Supplemental FilesSeparate files containing additional informationOld patient recordsFinancial recordsStored in a different location than primary fileContents should be distinguished from the primary file contentsTickler FilesA date-ordered reminder fileOrganized by month, week of month, or day of weekComputer systems CalendarReminders to alert prior to event Match the following:Apply Your KnowledgeRIGHT!ANSWER:Tickler file Color-codingSupplemental fileNumeric filing systemAlphabetic filing systemChronologic filing simplest system used for files within a medical  record financial records easy to see out of place records reminder system helps the medical office comply  with HIPAAEFCBADThe Filing ProcessMedical assistant responsibilitiesFollow practice policies for returning records to the filesPlace records to be filed in a secure file return areaThe Filing Process (cont.)Generally the medical assistant files three types of items:New patientrecordsDocumentsExistingpatientrecordsThe Filing Process (cont.)Place the files in the appropriate location for easy retrieval when neededPlace files in order to save time when storingAdd an identifying mark to ensure that the file is put in the correct placeName the file using the classification systemMake sure document is ready for filingInspectingIndexingCodingSortingStoringFiling GuidelinesCheck each record when pulling itKeep files neatRemove file from drawer when adding documentsFiling Guidelines (cont.)Do not crowd the file drawerUse file guides with a different tab position to aid in finding filesIt is better to provide too many cross-references than too fewFiling 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 systemLocating Misplaced FilesDetermine where the file was last seen or usedLook for the file while retracing steps from that locationCheck filing cabinet where it belongsLocating Misplaced Files (cont.)Check underneath files in drawer or on shelfCheck items to be filedCheck cross-reference or similar indexesLocating Misplaced Files (cont.)Check with other staff membersCheck other file locations Stand back and look at the top of the folders Ask another staff member to double-check your search.Locating Misplaced Files (cont.) Straighten the office, carefully checking  all piles of information Check charts that have been pulled for  the next day appointments Check physician’s deskLocating Misplaced Files (cont.)File may be considered lost if not found within 24 to 48 hoursRecreate a new file Physicians and staff record recollections of information in the fileDuplicate documents from labs, insurance companies, etc.Limiting Medical Record AccessComputerized officesAccess code and password Limits what files you may seePaper recordsLimit who can retrieve and return filesRequisition slip used to obtain a fileApply Your KnowledgeThe 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. Storing The charts should be inspected first to be sure all necessary documents are in the charts and that they are ready for sorting and storing.Terrific!Active, Inactive, and Closed FilesActive files – used frequentlyInactive files – used infrequentlyClosed files Patient may have died or moved awayNo longer come to the officeBasic Storage Options Files remain in their original format Labeled boxes with lids to allow even stacking Preserve the original documents. If the paper becomes brittle, transfer  documents to another storage mediumPaper Storage Basic Storage Options (cont.) Transfer documents to electronic or digital form Transfer documents from hard drive to storage mediumComputer StorageBasic Storage Options (cont.)Other paperless options MicrofilmMicrofiche Cartridges Retaining Files in the OfficeRetention schedule Specifies length of time records are kept in the office once they are inactive or closedDetails when to move files to storage and when they can be destroyedPost in file roomRetaining Files in the Office (cont.)HIPAA law – required retention periodsState and local requirementsCount from year after document producedRetaining Files in the Office (cont.)Destruction of recordsMaintain ConfidentialityShredRetain list of documents destroyedFile Storage FacilitiesOn-site storageOff-site storageCommercial records storage centersMaintain list of filesStorage SafetyEvaluate storage sites carefullyPlace files in fireproof and waterproof containersThe storage site should be safe fromFire and floodsVandalism and theftExtremes of temperature A patient who has not been to the office in several years telephones and requests a copy of his medical record. What should you do?Apply Your KnowledgeANSWER: First tell him that you need a signed release to give him a copy of the records. Once you have that you would check to see if his medical record was in the active files. If not you should look on the inactive file list to see if it had been moved to storage. In Summary15.1 Filing shelves, filing cabinets, compactable files, and rotary files are all commonly used to store paper medical records. A very small office might opt to use storage bins for its medical records. 15.2 HIPAA requires that filing shelves or cabinets should be fireproof and locked when the office is closed. Filing systems must be safe for those using them and instructions on their proper use should be posted and understood by all staff members using them. In Summary (cont.)15.3 Filing supplies used in the medical office include tabbed file folders, labels, file jackets, binders, tabs with inserts for labeling, file guides, out guides, and file sorters.In Summary (cont.)15.4 Alphabetic filing is the traditional filing system for medical offices. Color-coding can enhance this process . Numeric systems are used more often because of the confidentiality they provide. These systems use a medical record number, which are then filed by the terminal digit or middle digit format. Color can be used with numeric filing also.In Summary (cont.)15.5 The steps in the filing process include inspecting, indexing (naming), coding, sorting, and storing.15.6 Active records are those that are used frequently. Infrequently used records are known as inactive records. Closed files are those of patients who, for whatever reason, no longer come to the office. We must try to continue to hear patient voices above the din of the machinery. ~ Catherine LopezFrom A Daybook for Nurses End of Chapter 15