CHAPTER 10 Managing the Office Medical Records © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-2 Learning Outcomes 10.1 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-3 Learning Outcomes (cont.) 10.6 Describe each of the five steps in the filing process 10.7 Explain the steps to take in trying to locate a misplaced file 10.8 List and describe the basic file storage options and the advantages of each 10.9 Identify criteria for determining whether files should be retained, stored, or discarded © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-4 Introduction • Management of patient records – Vital to patient care and smooth operation of medical office – Paper-based medical records – Electronic Health Record (EHR) or Electronic Medical Record (EMR) © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-5 Importance 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 are – Created – Filed – Maintained © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-6 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 ! © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-7 Filing Equipment • Place where the medical records are housed • Choice of type is based on space consideration and personal preference • Filing shelves – Files are stacked upright on shelves in boxes or heavy-duty envelopes – Allow more than one person at a time to retrieve files © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-8 Filing Equipment (cont.) • Filing cabinets – Sturdy pieces of office furniture Both vertical and lateral (horizontal) file cabinets are available • Compactable files – Kept on rolling shelves that slide along permanent tracks on the floor – Seen often in offices with limited space for files © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-9 Filing Equipment (cont.) • Rotary circular files – files are stored in a circular fashion resembling a revolving door • Plastic or cardboard tubs or boxes – Organized like filing cabinet drawers – Inefficient for a large number of files – Files can easily be misplaced with this system – Heavy to carry around © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-10 Filing Equipment (cont.) • Labeling filing equipment – Label outside of drawer represents its contents – Easily retrievable records A-D • Security measures – Protect confidentiality of medical records – Cabinets should lock or be in a lockable room – Limit who has keys © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-43 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 steps to filing in the correct order and provide an explanation to answer her ANSWER: The steps to filing are: Inspecting Indexing Coding Sorting 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-44 Inactive and Closed File Storage Paper Storage Microfilm Computer Storage Basic Storage Options Files remain in their original format Labeled boxes with lids to allow even stacking If the paper becomes brittle, transfer documents to another storage medium Microfilm, microfiche, and film cartridges offer a paperless way of storing records Patient records can be scanned and saved on computer tapes, recordable CDs or DVDs, flash drives, or external hard drives © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-45 File Storage Facilities • Some offices have extra storage space on-site • Smaller offices require the use of off-site storage – Use a facility that takes precautions against fires and floods – Maintain a list of all files stored at off-site locations © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-46 File Storage Safety • Inactive and closed files must remain safe and secure • Evaluate storage sites carefully • Preferably place files in fireproof and waterproof containers • The storage site should be safe from – Fire and floods – Vandalism and theft – Extremes of temperature © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-47 Retaining Files in the Office • Retention schedule – Specifies how long patient records are to be kept once they become inactive or closed – Details when files should be moved to storage and when they can be destroyed • Generally determined by the physician © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-48 Retaining Files in the Office (cont.) • Certain records have legal criteria for the length of time they must be maintained in the office, such as – Immunizations – Employee health records – Medical office financial records • Criteria from – – – – IRS – financial records AMA, American Hospital Association HIPAA law Federal and state laws © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-49 Retaining Files in the Office (cont.) • Destruction of records – Maintain Confidentiality – Shred – Retain list of documents destroyed © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-50 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 © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-51 In Summary 10.1 Equipment and supplies needed for filing medical records are – Filing shelves and cabinets, rotary circular files, plastic index boxes – Labeling equipment – Hanging file folders and filing supplies such as folders and binders 10.2 There are various types of filing systems, including alphabetic, numeric and color coding © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-52 In Summary (cont.) 10.3 The benefit of using an alphabetic system is that it is simple to use, but you have to make sure that you know the spelling of the person’s name in order to retrieve the file The numeric system keeps files confidential, and names are recorded elsewhere 10.4 The advantage of color coding the filing system is that it distinguishes files within a system and can add additional information to the system © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-53 In Summary (cont.) 10.5 Set up 12 file folders (one per month) and arrange with current file on top Make a list of upcoming responsibilities and activities, file notes by month, and check tickler file at least weekly 10.6 The five steps in the filing process are: – – – – – Inspect a file Index or name a file Code a file Sort Store documents neatly within a proper sequence © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-54 In Summary (cont.) 10.7 Steps to assist in locating a misplaced file: • Determine the last time you saw the file and retrace steps • Look in the filing cabinet where the file belongs • Check underneath the files in the drawer or shelf • Check the pile of items to be filed • Consider whether it might be cross-referenced • Check with other staff members © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-55 In Summary (cont.) 10.7 More steps to assist in locating a misplaced file: • Check under the person’s first name • Stand back from the file cabinet • Check to see if someone else has taken it out • Ask other staff members to the previous steps that you have done © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-56 In Summary (cont.) 10.8 There are many ways to store inactive files Paper storage, computer storage and microfilm, microfiche, and cartridges are basic storage options 10.9 The criteria for retaining, storing, and discarding files vary from state to state It is always advisable for doctors to request legal advice before destroying records – Employee health records – retained for three years – Immunization records should be on file permanently – Financial records must be kept up to 10 years © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10-57 End of Chapter 10 We must try to continue to hear patient voices above the din of the machinery ~ Catherine Lopez From A Daybook for Nurses © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed [...]... 10- 12 Ergonomics (cont.) • Tips – Place a footstool next to the examination table – Take a course in proper lifting – Ensure good lighting – Wear proper shoes – Select storage and shelving that will aid in reducing muscular strain © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 13 Filing Equipment (cont.) • Equipment safety – Post safety guidelines – Ensure that everyone follows... – Select a separate color for each classification • Post codes so all are aware of them © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 27 Filing System (cont.) • With alphabetic filing systems – Each letter is assigned a color – The first two letters of the last name are color-coded with colored tabs – Can easily tell if files are filed correctly • With numeric filing systems –. .. Available in 8 ½ by 11 inches and 8 ½ by 14 inches Smith, A Tabs Adams, G - extensions at the top or side of the folder and used to identify the contents © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 17 Filing Supplies (cont.) • Labels – Identify contents – Print clearly or use computergenerated labels – Cover with tape to prevent smearing • File jackets – Resemble file folders... files neat – Do not overstuff file folders – Papers should not extend beyond edge of folder • Remove file from drawer when adding documents – Prevents damage to documents © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 36 Filing Guidelines (cont.) • Do not crowd the file drawer – Allow space for retrieving and replacing files easily – If possible, use both uppercase and lowercase... McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 23 Alphabetic Filing System (cont.) • Indexing rules – guidelines for sequencing files • Each part of name is a unit – – – – Last name First name Middle name / initial Titles (Jr., Sr ,Rev., Dr., etc.) are the fourth indexing unit © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 24 Numeric Filing Systems • Organizes files by numbers... are grouped together – Filing is done based on last group of numbers • Middle digit filing – Uses the middle group as primary index for filing © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 26 Filing System • Used to distinguish files within a filing system • Can be used with either alphabetic or numeric filing systems • Using classification with color coding – Identify how files.. .10- 11 Ergonomics • Science of adjusting the elements of the working environment to the human body • Maintain a healthy and safe posture while working – Overexertion – increases risk of injury – Common causes of workplace injury • Improper lifting • Repetitive motions • Being struck by an object • Slipping and bending © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 12 Ergonomics... two days ago b June medical conference dates just received in the mail c Names of patients seen today for their annual check-up RIGHT! © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 31 The Filing Process • Medical assistant responsibilities – Pulling and filing patient records – Filing documents • Follow practice policies for returning records to the files – Immediately vs at the... rights reserv ed 10- 19 Filing Supplies (cont.) • Binders – Some offices use three-ring binders to keep patient records – Tabs are used to separate individual charts – Require more storage – Effective for management of active patient records • Purchasing filing supplies is a common responsibility of medical assistants © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 20 Apply Your... Com panie s, Inc A ll rights reserv ed 10- 29 Filing Systems (cont.) • Supplemental files – Separate files containing additional information – Prevents cluttering of primary files – Stored in a different location than primary file – Contents should be distinguished from the primary file contents © 2011 T he McGraw -Hill Com panie s, Inc A ll rights reserv ed 10- 30 Apply Your Knowledge Today is December