Chapter 10 - Managing the office medical records. In this chapter you will learn: Describe the equipment and supplies needed for filing medical records, list and describe the various types of filing systems, discuss the benefits of each type of system, discuss the advantages of color coding the files, explain how to set up and use a tickler file,...
PowerPoint® to accompany Medical Assisting Chapter 10 Second Edition Ramutkowski • Booth • Pugh • Thompson • Whicker Copyright © The McGraw-Hill Companies, Inc Permission required for reproduction or display Managing the Office Medical Records Objectives 101 Describe the equipment and supplies needed for filing medical records 102 List and describe the various types of filing systems 103 Discuss the benefits of each type of system 104 Discuss the advantages of color coding the files 105 Explain how to set up and use a tickler file Managing the Office Medical Records Objectives (cont.) 106 Describe each of the five steps in the filing process 107 Explain the steps to take in trying to locate a misplaced file 108 List and describe the basic file storage options and the advantages of each 109 Identify criteria for determining whether files should be retained, stored, or discarded 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 A wellorganized, easytouse system saves time and protects vital medical data Filing Equipment Filing Shelves Files are stacked upright on shelves in boxes or heavyduty envelopes Filing Cabinets Sturdy pieces of office furniture Usually made of metal or wood Both vertical and horizontal (lateral) file cabinets are available Filing Equipment (cont.) Compactable Files Kept on rolling shelves that slide along permanent tracks on the floor Seen often in offices with limited space for files Rotary Circular Files Files are stored in a circular fashion resembling a revolving door Also common when space is limited Filing Equipment (cont.) Plastic or Cardboard Tubs or Boxes Organized like filing cabinet drawers Files can easily be misplaced with this system Labeling Filing Equipment The outside of the file drawer should be labeled to represent its contents AD Filing Equipment (cont.) Security Measures Equipment Safety Many filing cabinets have locks, and the keys should be available to limited staff personnel Post safety equipment for each type of filing system Purchasing Filing Equipment First determine the amount of space availability Then determine number of files to be included FilingSupplies FileFolders Tab Referredtoasmanilafolders Availablein8ẵby11inchesand8ẵby14inches Tabsaretaperedrectangularorroundedextensions atthetopofthefolder Tabshaveavarietyofcuts Smith,A Labeling File Folders Adams, G • Tabs on the file folder identify the contents Filing Supplies (cont.) File Jackets File Guides Resemble file folders but have plastic or metal hooks on both sides to anchor it Files are placed inside these jackets Heavy cardboard or plastic inserts that identify groups of files Out Guides A marker made of stiff material that is used as a placeholder for removed files 10 The Filing Process (cont.) Place the files in the appropriate location, so they can easily be retrieved when needed Get the accumulated files in order. This will save time when storing the folders Place an identifying mark to ensure that the file is put in the correct place Name the file using the office classification system. Make sure document is ready to be filed Inspecting Storing Sorting Coding Indexing 20 Limiting Access to Files Under no circumstances should original patient records leave the medical office. Identifying information is often recorded when files are retrieved Limited persons in the medical office have access to patient records 21 Filing Guidelines Take a close look at the contents of patient records each time you pull them Keep files neat Do not overstuff file folders Take time to properly place documents into the folders to prevent damage Do not crowd the file drawer If possible use both upper and lower case 22 letters to label the folders Filing Guidelines (cont.) Use file guides with a different tab position to aid with finding files It is better to provide too many crossreferences than too few File regularly Do not store anything other than files in the file storage area Train all staff that will be able to retrieve files on the system in place Periodically evaluate your office system to see if it still works 23 Locating Misplaced Files Do a complete search of the office to try and locate the file. If the file is not recovered within 24 to 48 hours, it may be considered lost Lost files can have potentially devastating consequences 24 Active vs. Inactive Files Active Files Inactive Files Files that you use frequently Files that you use infrequently Closed Files Files of patients that no longer consult the office The physician determines when a file is deemed inactive or closed 25 Apply Your Knowledge The medical assistant is training a new employee that 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 this question 26 Apply Your Knowledge Answer Step 1 Step 2 Step 3 Step 4 Step 5 Inspecting Indexing Coding Sorting Storing The primary reason records should first be inspected is to ensure that all documents are present that belong in the chart 27 Storing Files Paper Storage Microfilm Computer Storage Basic Storage Options • Files remain in their original format Microfilm, microfiche and cartridges offer a paperless way Patient records can be scanned and saved on a disk, tape or • Good to place in boxes with lids to afford even stacking of storing records computer hard drive • If the paper becomes brittle, transfer documents to another 28 storage medium. Storage Facilities Some offices have extra closet or storage space on site Smaller offices require the use of offsite storage Use a facility that takes precautions against fires and floods Maintain a list of all files at each storage location 29 Storage Safety Even inactive and closed files must remain safe and secure Place files in fireproof and waterproof devices. Cardboard is not an option The storage site should be safe from: Fire & Floods Vandalism & Theft Extremes of temperature 30 Retaining Files in the Office A retention schedule decides how long different types of patient records are to be kept in the office once they become inactive or closed Certain records have legal criteria for the length they must be maintained in the office such as: Immunizations Employee health records Medical Office Financial Records Legal consultants and the AMA also advise physicians on the length of time patient records should be kept. The best rule of thumb is to seek legal advice before destroying any records 31 Apply Your Knowledge A former employee from two years ago telephones and requests that copies of her annual physical examination forms that she submitted while employed be mailed to her home address. How would you handle this? 32 Apply Your Knowledge Answer A former employee from two years ago telephones and requests that copies of her annual physical examination forms that she submitted while employed be mailed to her home address. How would you handle this? 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 33 Managing the Office Medical Records 34 ...Managing the Office Medical Records Objectives 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 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 Managing the Office Medical Records Objectives (cont.) 10 6 Describe each of the five steps in the filing ... 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