Managing Medical Records

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15

• Managing Medical Records

2
Learning 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.

3
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.

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Introduction

• Records management system
• Vital to patient care and office operation
• Must be easily retrievable

5
Filing Equipment

• Filing shelves
• Filing Cabinets
• Vertical files
• Horizontal or lateral files
• Compactable files

6
Filing Equipment (cont.)

• Rotary Circular files
• Plastic or cardboard tubs or boxes
• Labeling Filing Equipment
• Clearly indicate range of files
• Write directly on boxes

7
Apply Your Knowledge
What 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.
Super!
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Security and Safety Measures

• HIPAA privacy and security
• Medical record security
• Lockable cabinets or room
• Limit key access

9
Equipment Safety

• Purchasing filing equipment
• Base on space and number of files
• Fire proof and secure
• Post safety guidelines
• Keep drawers closed
• Open one drawer at a time
• Step-ladder safety

10
Apply Your Knowledge
A 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.
Good Answer!
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Filing Supplies

• Available in letter and legal sizes
• Tabs - extensions used to identify the
  contents

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Filing Supplies (cont.)

• Labels
• File jackets
• Binders

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Filing Supplies (cont.)

• File guides
• Out guides
• File sorters

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Apply Your Knowledge

• Which 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 sorter

GREAT!
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Filing Systems

• All use a sequential order
• Follow system exactly to avoid losing or
  misplacing records
• Avoid changing system

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Alphabetic Filing System

• Most common system
• Files are arranged in alphabetical order
• Seven indexing rules keeps alphabetizing simple
  and consistent

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Alphabetic Filing System (cont.)

• Indexing rules
• Each part of name is a unit
• Last name
• First name
• Middle name / initial
• Titles (Jr., Sr. ,Rev., Dr., etc.) the fourth
  indexing unit

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Chronological Filing

• Based on dates
• Year, month, day
• Used within a patients record
• Reverse chronologic order

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Numeric Filing

• Numeric filing system
• Patients assigned sequential numbers
• Requires a master list of patient names and
  associated numbers
• Meets requirements of HIPAA law

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Numeric Filing (cont.)

• Terminal digit filing
• Filing is done based on last group of numbers
• Number is read from right to left
• Middle digit filing
• Uses the middle group as primary index for filing
• Number is read using the middle number first
• Followed by the left-hand number and right-hand
  number

0
0
2 -
2
5 -
5
6
5
001 -
25 -
667
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Color-coding

• Using classifications
• Identify how files are to be classified
• Determine method of coding
• Determine color for each classification
• Post codes

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Color-coding (cont.)

• With alphabetic filing
• Each letter is assigned a color
• Two or three letters of the last name are
  color-coded

E
J
O
N
S
Color-coding helps identify charts that are out
of order.
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Color-coding (cont.)

• With numeric filing
• Numbers 1 to 9 assigned a distinct color
• Use color-coded key unit for each chart

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Supplemental Files

• Separate files containing additional information
• Old patient records
• Financial records
• Stored in a different location than primary file
• Contents should be distinguished from the primary
  file contents

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Tickler Files

• A date-ordered reminder file
• Organized by month, week of month, or day of
  week
• Computer systems
• Calendar
• Reminders to alert prior to event

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Apply Your Knowledge
Match the following
ANSWER
E

1. Tickler file
2. Color-coding
3. Supplemental file
4. Numeric filing system
5. Alphabetic filing system
6. Chronologic 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 HIPAA
F
C
B
A
D
RIGHT!
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The Filing Process

• Medical assistant responsibilities
• Follow practice policies for returning records to
  the files
• Place records to be filed in a secure file return
  area

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The Filing Process (cont.)
Generally the medical assistant files three types
of items
New patient records
Documents
Existingpatient records
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The Filing Process (cont.)
Place the files in the appropriate location for
easy retrieval when needed
Place files in order to save time when storing
Add an identifying mark to ensure that the file
is put in the correct place
Name the file using the classification system
5 Steps in Filing
Make sure document is ready for filing
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Filing Guidelines

• Check each record when pulling it
• Keep files neat
• Remove file from drawer when adding documents

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Filing Guidelines (cont.)

• Do not crowd the file drawer
• Use file guides with a different tab position to
  aid in finding files
• It is better to provide too many cross-references
  than too few

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Filing Guidelines (cont.)

• File regularly
• Do not store anything other than files in the
  file storage area
• Train all staff who will be retrieving files on
  the system in place
• Periodically evaluate your office system

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Locating Misplaced Files

• Determine where the file was last seen or used
• Look for the file while retracing steps from that
  location
• Check filing cabinet where it belongs

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Locating Misplaced Files (cont.)

1. Check underneath files in drawer or on shelf
2. Check items to be filed
3. Check cross-reference or similar indexes

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Locating Misplaced Files (cont.)

1. Check with other staff members
2. Check other file locations
3. Stand back and look at the top of the folders
4. Ask another staff member to double-check your
   search.

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Locating Misplaced Files (cont.)

1. Straighten the office, carefully checking
   all piles of information
2. Check charts that have been pulled for the
   next day appointments
3. Check physicians desk

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Locating Misplaced Files (cont.)

• File may be considered lost if not found within
  24 to 48 hours
• Recreate a new file
• Physicians and staff record recollections of
  information in the file
• Duplicate documents from labs, insurance
  companies, etc.

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Limiting Medical Record Access

• Computerized offices
• Access code and password
• Limits what files you may see
• Paper records
• Limit who can retrieve and return files
• Requisition slip used to obtain a file

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Apply Your Knowledge
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. Indexing 3. Coding 4. Sorting 5.
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!
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Active, Inactive, and Closed Files

• Active files used frequently
• Inactive files used infrequently
• Closed files
• Patient may have died or moved away
• No longer come to the office

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Basic 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 medium

Paper Storage
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Basic Storage Options (cont.)

• Transfer documents to electronic or digital
  form
• Transfer documents from hard drive to storage
  medium

Computer Storage
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Basic Storage Options (cont.)

• Other paperless options
• Microfilm
• Microfiche
• Cartridges

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Retaining Files in the Office

• Retention schedule
• Specifies length of time records are kept in the
  office once they are inactive or closed
• Details when to move files to storage and when
  they can be destroyed
• Post in file room

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Retaining Files in the Office (cont.)

• HIPAA law required retention periods
• State and local requirements
• Count from year after document produced

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Retaining Files in the Office (cont.)

• Destruction of records
• Maintain Confidentiality
• Shred
• Retain list of documents destroyed

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File Storage Facilities

• On-site storage
• Off-site storage
• Commercial records storage centers
• Maintain list of files

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Storage Safety

• Evaluate storage sites carefully
• Place files in fireproof and waterproof
  containers
• The storage site should be safe from
• Fire and floods
• Vandalism and theft
• Extremes of temperature

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Apply Your Knowledge
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?
ANSWER 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.
Excellent!
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In Summary

• 15.1 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.

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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.

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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.

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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.
  

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End of Chapter 15
We must try to continue to hear patient voices
above the din of the machinery. Catherine
Lopez From A Daybook for Nurses