Y khoa, dược - Managing the office medical records

10Managing the Office Medical Records10-2Learning Outcomes10.1 Describe the equipment and supplies needed for filing medical records.10.2 List and describe the various types of filingsystems.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.10-3Learning 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.10-4IntroductionManagement of patient recordsVital to patient care and smooth operation of medical officePaper-based medical recordsElectronic Health Record (EHR) or Electronic Medical Record (EMR)10-5Importance of Records ManagementThe medical records are the most valuable information in the medical office.A records management system refers to the way patient records areCreatedFiledMaintained10-6Apply Your KnowledgeWhat is a records management system? ANSWER: A records management system is the way patient records are created, filed, and maintained.Super!10-7Filing Equipment Place where the medical records are housedChoice of type is based on space consideration and personal preferenceFiling shelvesFiles are stacked upright on shelves in boxes or heavy-duty envelopesAllow more than one person at a time to retrieve files10-8Filing Equipment (cont.)Filing cabinetsSturdy pieces of office furniture Both vertical and lateral (horizontal)file cabinets are availableCompactable filesKept on rolling shelves that slide along permanent tracks on the floorSeen often in offices with limited space for files10-9Filing Equipment (cont.)Rotary circular files – files are stored in a circular fashion resembling a revolving doorPlastic or cardboard tubs or boxesOrganized like filing cabinet drawersInefficient for a large number of filesFiles can easily be misplaced with this systemHeavy to carry around10-10Filing Equipment (cont.) Labeling filing equipmentLabel outside of drawer represents its contentsEasily retrievable recordsSecurity measuresProtect confidentiality of medical recordsCabinets should lock or be in a lockable roomLimit who has keysA-D10-11ErgonomicsScience of adjusting the elements of the working environment to the human bodyMaintain a healthy and safe posture while workingOverexertion – increases risk of injuryCommon causes of workplace injuryImproper liftingRepetitive motions Being struck by an object Slipping and bending10-12Ergonomics (cont.)TipsPlace a footstool next to the examination tableTake a course in proper liftingEnsure good lightingWear proper shoesSelect storage and shelving that will aid in reducing muscular strain10-13Filing Equipment (cont.)Equipment safetyPost safety guidelines Ensure that everyone follows rules to prevent injuryPurchasing filing equipmentFirst determine space availabilityThen determine number of files to store10-14Apply Your Knowledge1. When restocking the examination rooms in your workplace, you are constantly having to obtain frequently used items from the lowest shelves in the supply room. At the end of the day, you notice that your lower back is achy. What can you do about this situation? ANSWER: Rearrange the supply room so that the more frequently used items are on waist-level shelves to eliminate the need to bend down. 10-15Apply Your Knowledge2. A busy medical office is considering changing  the current filing equipment. Which equipment  would you recommend to this non-computerized office that will allow more people to retrieve files  at the same time?ANSWER: Filing shelves would be a great system if adequate space is available.Good Answers!10-16Filing Supplies Referred to as manila folders Available in 8 ½ by 11 inches and 8 ½ by 14  inchesTabs - extensions at the top or side of the folder and used to identify the contentsSmith, A.Adams, G.File foldersTab10-17Filing Supplies (cont.)LabelsIdentify contentsPrint clearly or use computer- generated labelsCover with tape to prevent smearingFile jacketsResemble file folders but have plastic or metal hooks on both sides for hanging them inside filing drawersFiles are placed inside these jackets10-18Filing Supplies (cont.)File guidesHeavy cardboard or plastic inserts that identify groups of filesOut guides – used as placeholders for removed filesFile sorters – large envelope-style folders with tabs that store files temporarily 10-19Filing Supplies (cont.)BindersSome offices use three-ring binders to keep patient records Tabs are used to separate individual chartsRequire more storageEffective for management of active patient recordsPurchasing filing supplies is a common responsibility of medical assistants10-20Apply 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:AGREAT!10-21Filing SystemsAll use a sequential orderFollow system exactly to avoid losing or misplacing recordsAvoid changing system 10-22Alphabetic Filing SystemMost common systemFiles are arranged in alphabetical orderFollow indexing guidelinesEach individual must have a separate file10-23Alphabetic Filing System (cont.) Indexing rules – guidelines for sequencing filesEach part of name is a unit Last nameFirst nameMiddle name / initialTitles (Jr., Sr. ,Rev., Dr., etc.) are the fourth indexing unit 10-24Numeric Filing SystemsOrganizes files by numbers instead of namesPatients are assigned sequential numbersThis system is often used with highly confidential informationA master list of patient names and numbers must be kept10-25Numeric Filing Systems (cont.)Terminal digit filingTreat the last 2, 3, or 4 digits in a number as a single unitFor example, the numbers 024 represent the last three digits of a longer numberThe numbers 024 are then considered ending or terminal digits, so all folders ending in 024 are grouped togetherFiling is done based on last group of numbersMiddle digit filingUses the middle group as primary index for filing10-26Filing System Used to distinguish files within a filing systemCan be used with either alphabetic or numeric filing systemsUsing classification with color codingIdentify how files are to be classifiedSelect a separate color for each classificationPost codes so all are aware of themColor Coding10-27Filing System (cont.) With alphabetic filing systemsEach letter is assigned a colorThe first two letters of the last name are color-coded with colored tabsCan easily tell if files are filed correctlyWith numeric filing systemsNumbers 1 to 9 assigned a distinct colorHelps identify numeric files that are out of place51610143Color Coding10-28Filing Systems (cont.)Tickler filesReminder filesCheck on a regular basisOrganized by month, week of month, or day of weekComputer systems offer tickler files in the form of a calendarReminders set to alert prior to event 10-29Filing Systems (cont.)Supplemental filesSeparate files containing additional informationPrevents cluttering of primary filesStored in a different location than primary fileContents should be distinguished from the primary file contents10-30 Today is December 17th. Which of the information listed below could be added to a “tickler” file?Names of patients that missed appointments two days agoJune medical conference dates just received in the mailNames of patients seen today for their annual check-upApply Your KnowledgeRIGHT!ANSWER:10-31The Filing ProcessMedical assistant responsibilitiesPulling and filing patient recordsFiling documentsFollow practice policies for returning records to the filesImmediately vs. at the end of dayPlace records to be filed in a secure file return area10-32The Filing Process (cont.)Generally the medical assistant files three types of items:New patientrecordfoldersIndividualdocumentsforexistingfoldersPreviouslyfiledpatientrecordfolders10-335 Steps to FilingThe Filing Process (cont.)Place files in order to save time when storingAdd an identifying mark to ensure that the file is put in the correct placeCodingStoringName the file using the office classification systemMake sure document is ready to be filedIndexingSortingPlace the files in the appropriate location for easy retrieval when neededInspecting10-34Limiting Access to FilesLimit the number of people in the medical office who have access to patient recordsOriginal patient records should not leave the medical office (Exceptions noted in Chapter 9)Identifying information is often recorded when files are retrieved10-35Filing GuidelinesTake a close look at the contents of patient records each time you pull or file themKeep files neatDo not overstuff file foldersPapers should not extend beyond edge of folderRemove file from drawer when adding documentsPrevents damage to documents10-36Filing Guidelines (cont.)Do not crowd the file drawerAllow space for retrieving and replacing files easilyIf possible, use both uppercase and lowercase letters to label the foldersUse file guides with a different tab position to aid in finding filesIt is better to provide too many cross-references than too few10-37Filing 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 system10-38Locating Misplaced Files (cont.)Determine where the file was when it was last seen or usedLook for the file while retracing steps from that locationCheck filing cabinet where it belongsCheck neighboring files10-39Locating Misplaced Files (cont.)Check underneath files in drawer or on shelfCheck items to be filedCheck with other staff membersCheck other file locations Similar indexesUnder patient’s first nameMisfiled chart colorAsk if someone inadvertently picked up the file with other materials10-40Locating Misplaced Files (cont.)Have another person complete the steps to double-check your searchStraighten the office, carefully checking all piles of informationCheck charts that have been pulled for the next day appointmentsCheck physician’s desk10-41Locating Misplaced Files (cont.)File may be considered lost if not found within 24 to 48 hoursLost files can have potentially devastating consequencesRecreate a new file Physicians and staff record recollections of information in the fileDuplicate documents from labs, insurance companies, etc.10-42Active vs. Inactive FilesActive files are files that you use frequentlyInactive files are files that you use infrequentlyClosed files – files of patients that no longer consult the officeThe physician determines when a file is deemed inactive or closed10-43Apply 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!10-44Inactive and Closed File StorageBasicStorageOptionsComputer StorageMicrofilm Paper Storage 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. Patient records can be scanned and saved on computer tapes, recordable CDs or DVDs, flash drives, or external hard drives.Microfilm, microfiche, and film cartridges offer a paperless way of storing records.10-45File Storage FacilitiesSome offices have extra storage space on-siteSmaller offices require the use of off-site storageUse a facility that takes precautions against fires and floodsMaintain a list of all files stored at off-site locations10-46File Storage SafetyInactive and closed files must remain safe and secureEvaluate storage sites carefullyPreferably place files in fireproof and waterproof containersThe storage site should be safe fromFire and floodsVandalism and theftExtremes of temperature 10-47Retaining Files in the OfficeRetention schedule Specifies how long patient records are to be kept once they become inactive or closedDetails when files should be moved to storage and when they can be destroyedGenerally determined by the physician10-48Retaining Files in the Office (cont.)Certain records have legal criteria for the length of time they must be maintained in the office, such asImmunizationsEmployee health recordsMedical office financial recordsCriteria fromIRS – financial recordsAMA, American Hospital AssociationHIPAA lawFederal and state laws10-49Retaining Files in the Office (cont.)Destruction of recordsMaintain ConfidentialityShredRetain list of documents destroyed10-50An 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? Apply Your KnowledgeANSWER: 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!10-51In Summary10.1 Equipment and supplies needed for filing medical records are Filing shelves and cabinets, rotary circular files, plastic index boxesLabeling equipment Hanging file folders and filing supplies such as folders and binders10.2 There are various types of filing systems, including alphabetic, numeric and color coding. 10-52In 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.10-53In 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 fileIndex or name a fileCode a fileSortStore documents neatly within a proper sequence.10-54In Summary (cont.)10.7 Steps to assist in locating a misplaced file:Determine the last time you saw the file and retrace stepsLook in the filing cabinet where the file belongsCheck underneath the files in the drawer or shelfCheck the pile of items to be filedConsider whether it might be cross-referenced Check with other staff members10-55In Summary (cont.)10.7 More steps to assist in locating a misplaced file:Check under the person’s first nameStand back from the file cabinet Check to see if someone else has taken it outAsk other staff members to do the previous steps that you have done.10-56In 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 recordsEmployee health records – retained for three yearsImmunization records should be on file permanently Financial records must be kept up to 10 years. 10-57We must try to continue to hear patient voices above the din of the machinery. ~ Catherine LopezFrom A Daybook for Nurses End of Chapter 10