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After studying this chapter you will be able to: Identify the common equipment used to file and store paper medical records, outline the security and safety measures that should be employed when working with paper medical records, list the common filing supplies used in the medical office,…
CHAPTER 15 Managing Medical Records 15-2 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 15-3 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 15-4 Introduction • Records management system – Vital to patient care and office operation – Must be easily retrievable 15-5 Filing Equipment • Filing shelves • Filing Cabinets – Vertical files – Horizontal or lateral files • Compactable files 15-6 Filing Equipment (cont.) • Rotary Circular files • Plastic or cardboard tubs or boxes • Labeling Filing Equipment – Clearly indicate range of files – Write directly on boxes 15-7 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 15-8 Security and Safety Measures • HIPAA privacy and security • Medical record security – Lockable cabinets or room – Limit key access 15-9 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 15-10 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 15-40 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 15-41 Basic Storage Options Paper Storage 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 15-42 Basic Storage Options (cont.) Computer Storage Transfer documents to electronic or digital form Transfer documents from hard drive to storage medium 15-43 Basic Storage Options (cont.) • Other paperless options – Microfilm – Microfiche – Cartridges 15-44 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 15-45 Retaining Files in the Office (cont.) • HIPAA law – required retention periods • State and local requirements • Count from year after document produced 15-46 Retaining Files in the Office (cont.) • Destruction of records – Maintain Confidentiality – Shred – Retain list of documents destroyed 15-47 File Storage Facilities • On-site storage • Off-site storage – Commercial records storage centers – Maintain list of files 15-48 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 15-49 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 15-50 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 15-51 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 15-52 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 15-53 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 15-54 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 .. .15- 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... with paper medical records 15. 3 List the common filing supplies used in the medical office 15- 3 Learning Outcomes (cont.) 15. 4 Contrast the methods used for various filing systems and how color-coding... become top heavy and could tip over 15- 8 Security and Safety Measures • HIPAA privacy and security • Medical record security – Lockable cabinets or room – Limit key access 15- 9 Equipment Safety