Chapter 43: Medical Records Management
What are three measures to prevent misplaced records?
-Work slowly and carefully when filing records. -Use outguides to keep track of records. -Return records to storage after use and do not hand them on to others in the medical office. -Discourage physicians and other personnel from hoarding records. -Keep records in orderly piles when they are out of the files. -Remove misfiled records and file correctly whenever a misfiled record is noted. -Be aware of records that are missing and be on the alert to notice them in unusual places.
What is the difference between a direct filing system and an indirect filing system?
A direct filing system allows easy retrieval of the record because it is filed under a category that the subject of the record will know. In an alphabetic system, an appointment is made using the patient's name, and the medical record is filed under the patient's name. An indirect filing system assigns a number or other filing device to each individual. In a numeric system, the filing number must be identified before the record can be located, using a file that cross-indexes the name and the medical record number.
Describe the form and function of a tickler file.
A tickler file consists of a set of folders for each month and a set of folders for the days of the month. Items to be handled in a certain month are filed in the monthly folders. At the beginning of each month, the items are shifted to one of the day folders as a reminder to handle the task on a specific day.
How is an outguide used when filing medical records?
An outguide is placed in the medical record files when a file folder has been removed to identify the individual for whom the record was removed or the current location of the record.
Before returning medical records to the files, what are the three things the medical assistant should do to condition the records?
Before filing a medical record, any paper clips should be removed, tears should be mended, and sticky notes or loose papers should either be removed or filed.
What is the advantage of using color-coded labels on medical record file folders?
Color-coded labels are used to identify medical record file folders that are stored in the same location. Misfiled folders stand out because the colored labels are different from those of neighboring folders. Colored folders may be used for a similar purpose or to identify the medical records of the patients of a specific physician or to categorize similar patients (e.g., pregnant patients in an OB/GYN practice).
What is the process for removing a record from the file?
Each time a record is removed, the individual who takes the record fills out a card identifying the date and destination, places the card in the pocket of an outguide, and places the outguide into the file at the location of the record.
How are hyphenated names filed if an alphabetic filing system is used?
Hyphenated names are indexed as one unit.
How should computerized records be stored?
In a secure location with off-site backup in case of fire or other disaster. The system administrator should be sure that program updates are compatible with previously stored data.
Compare and contrast a terminal digit filing system with a consecutive filing system.
In a terminal digit filing system, the last group of digits becomes the first filing unit. In a consecutive filing system, the first digit is the first filing unit, so files are arranged in consecutive order. A terminal digit filing system keeps all sections of the medical record files active, whereas the most active records in a consecutive filing system are grouped together because they were assigned most recently.
How is an electronic medical record updated?
Information is entered into the electronic medical record at the time of service using either menu boxes or voice recognition software. Reports are either imported directly into the record electronically or scanned from paper documents.
What are four types of documents that might be filed using a subject filing system?
Invoices, purchase orders, service agreements, and forms are often filed using a subject filing system. The subject categories may be arranged alphabetically.
What are two advantages of a numeric filing system for paper medical records?
It provides more privacy for patients because the patient's name does not appear on the outside of the record. In a large practice, it makes it easier to identify the correct record if there are several patients with similar names, because the computer file in which the correct number is located contains other data to help with identification.
Identify two ways that documents might be arranged within a subject category.
Items may be arranged alphabetically or chronologically, or they may be all the same type (e.g., in a folder of forms).
How long should the medical records of minors be retained? Why?
Medical records should be retained for at least as long as the statute of limitations for malpractice after the age of majority, or however long is required by state law. The statute of limitations for malpractice for minors begins to run when they reach the age of majority (usually 18 years). They have the right to initiate a lawsuit on their own behalf, even if the individuals who were responsible for them did not do so previously.
How are medical records selected to be moved to the location of inactive records?
Most offices use a label each year to indicate a patient visit in that year. Records of patients who have not been seen for 2 to 5 years (depending on the size of the storage location) are removed because they have a year label from the year that has been chosen by the medical office to define an inactive record.
What are three factors that influence the decision to choose an alphabetic or chronological filing system for patient records?
Need for privacy, prevention of confusion between names, number of individuals who may be active in a filing area.
What equipment and supplies are used for creation and storage of paper medical records?
Paper medical records are created using manila file folders with alphabetic or numeric labels and optional chart dividers. They are stored either in vertical or lateral file cabinets or on shelving units. Adjustable metal shelf dividers are used for shelving units to keep the records standing upright. There must be a method to lock cabinets or the room containing paper medical records.
What is the first indexing unit if an alphabetic filing system is used?
Patient's last name.
How are names with prefixes filed if an alphabetic filing system is used?
Prefixes to the last name (e.g., van, von, de) are considered part of the last name.
List seven common categories for chart dividers.
Progress notes, history/physical examination, laboratory reports, diagnostic testing, hospital reports, immunizations/medications, and correspondence, but this varies according to medical office requirements.
Discuss the ownership of a paper medical record.
The medical record itself, whether paper or electronic, is owned by the physician or health care facility that created it, but the subject of the record controls the information in the medical record.
What happens to the old paper medical record after transition to an electronic health record (EHR) system?
The old record may be shredded if the entire record has been scanned into the new electronic system. More commonly the old record is stored following guidelines of the institution.
How long should the records of adult patients be retained? Why?
The records of adult patients should be retained as long as is necessary for their medical care, as long as is required by state law, longer than the statute of limitations for malpractice, and at least 5 years for Medicare and Medicaid patients. If a patient initiates a malpractice lawsuit, the medical record is the primary piece of evidence about the care the patient received. It may also be important for continuity of patient care.
What is the second filing unit if the patient's name is Mary Johnson White?
The second filing unit is Mary.
What is the most common method used to organize a new paper medical record for a patient?
The source-oriented format is the most common format to organize a paper-based medical record.
What conditions should be present in the storage area for active or inactive medical records?
The storage area should be well lighted and climate controlled with a relative humidity of 48% to 52%. The records should be protected from dust, insects, and rodents. Main aisles should be at least 5 feet wide, and secondary aisles should be 3 feet wide.
How are reports and letters filed into existing medical records?
They are reviewed and initialed by the patient's physician. Then any tears are repaired and they are sorted and filed into the correct section of the medical record in reverse chronological order.
How is the medical record of a married woman filed if an alphabetic filing system is used?
Under her legal name without consideration of her husband's first name.