chap 8

backing up

should be done periodically and at the end of the day

filing equipment

Filing equipment consists of the storage units used to keep files. Size (floor space used), accessibility (ease of use), durability, security, and appearance are all considered when selecting filing equipment.

purged

Procedure used in filing to remove outdated files or items from files, folders, or computer disks

download

Process of transferring data (file or program) from a central computer to a remote computer

password

Secret word, phrase, code, or symbol input for security purposes to identify the authorized computer user who wishes to gain access to the computer system

File labels

Sticker used in filing that attaches to the file folder tab or other part of a folder; it may carry a caption or color code

Rule 4: Abbreviated Names and Nicknames

indexed as they are written

paper-based filing system

systems have been around for years, and although electronic medical records are becoming the norm, most offices have some sort of paper files, so it is important to understand how a paper-based filing system is organized.

Document Disposal

Any document that identifies a patient by name should be considered confidential and disposed of in a way that ensures privacy. When obtaining a written agreement with an outside company, ensure that all documents containing PHI will be handled securely.

calendars, appointment books etc

Calendars, appointment books, and telephone logs should also be filed and stored. Cases involving radiologic injury, such as leukemia, may be considered under the statute after the injury is discovered, and this can occur 20 to 30 years after radiation exposure. Before purging records, the medical assistant should refer to the office records retention schedule. Refer to Table 8-1 for suggested guidelines. The physician should have the final say on the length of time that files should be kept active, depending on the type of medical specialty

electronic files

Collection of related data stored under a single title in a computerized system.

active and inactive patient files

In a typical medical office, patient files are purged and moved from active to inactive status every 3 to 5 years. However, the assistant should review all files at least once a year to remove useless data, making it easier to find things and reducing bulk. This task may be worked into the regular filing routine

surgeon charts

Typically, the charts of a surgeon would be kept in the active file for a shorter period of time than those of a pediatrician or family practitioner, whose patient care is more likely to continue over years. Physicians located near military bases or resort areas see many transient patients, whose records would be purged frequently

Rule 6: Married Women

Typically, the surname is the only part of her husband's name a woman assumes when she marries. Her legal name, however, could be anyone of the following: (1) her own first and middle names together with her husband's surname, (2) her own first name and maiden surname together with her husband's surname, or (3) her first (given) name and her own (maiden) surname The title "Mrs." is not typically used on file folder labels anymore but may be considered part of the third unit and placed in parentheses; adding the husband's first and middle names or initials is optional, typed to the side or below the woman's legal name.

HIPPAS security rule

addresses physical safeguards, such as facility access and control along with workstation device and security. Technical safeguards are also addressed, such as audit controls, integrity controls, and transmission security. A covered entity, such as a medical practice must adopt reasonable and appropriate policies and procedures to comply with the provisions of the Security Rule.

name captions

are typed in correct indexing arrangement (last name first) either in all capital letters or in a combination of uppercase and lowercase letters, as shown in Figure 8-15. The patient's name should start two or three spaces from the left edge of the label on the second line space from the top edge, and placement should be consistent on all labels. When children's names are different than their parents', the parents' name (guarantor—individual responsible for the bill) should be cross-referenced on the chart, as this will help locate the account for billing. Refer to Procedure 8-5 for instructions on labeling and color-coding patient charts.

given name

first name

filing by consecutive numerical sequence

result in more even distribution of active and inactive records. The middle-digit numbering sequence arranges records by six-digit numbers. The terminal-digit and triple-digit systems use numbers to designate shelves or drawers to find charts, and all digits are color-coded. Hospital record numbers, x-ray numbers, and telephone numbers are often used as a basis for arranging records by the last digits

out folder

serves the same purpose as an outguide except that it provides a place to store incoming items (e.g., laboratory reports) until the regular folder is returned. Charge-out information may be written on the front of the folder, which is often printed with ruled lines

Two identifiers

such as the patient's name, medical record number, or date of birth.

proof materials

such as x-rays, laboratory reports, and pathology specimens, should be kept indefinitely. If a patient is a minor, records should be retained until the patient reaches the age of majority, that is, 18 to 21 years, plus the time allowed in that state for a lawsuit to be instituted for injuries the patient sustained as a minor. In most states, that period is 1 to 4 years beyond the age of majority. Everything pertaining to a patient who has had a negative attitude toward his or her care should be retained

full-suspension drawer files

traditional upright steel cabinets with three to five drawers is still popular for the storage of business records

choosing a filing system

(1) number of active records, (2) number of inactive records, (3) frequency of record retrieval, (4) amount of filing and/or equipment space, (5) convenience of file or computer terminal locations, (6) cost of the system, and (7) overall size of the medical practice to be compliant with electronic health record (EHR) mandates.

record retention schedule

A document that details what data will be retained, the retention period, and the manner in which the data will be stored.

files for deletion

A file that has been superseded by another file. A backup or temporary file created by an application program. An older version of a software program if the newer version is on the hard drive. An infrequently used file that should have been transferred to another media. Whatever the method, it is essential that all information be completely eradicated.

florescent sticker

A fluorescent sticker placed on the front of the chart alerts the physician to a patient's drug allergies. Dots indicating type of insurance coverage assists the physician when prescribing medication according to specific insurance formularies and when sending patients to in-network facilities. It also speeds the completion of insurance claims (Figure 8-13). For example, all Medicare folders are put in one pile and completed at one time. For heavy usage, file labels can be covered with Mylar overlays.

recent service

A small wraparound self-stick label printed with the last digit of each year can be attached to the edge of the folder to indicate the most recent year of service. This can be covered with a new sticker each year after the patient has seen the physician. Folders with old dates that need to be purged from the active files can be seen easily.

Subject filing

Alphabetical arrangement of records filed by topic or grouped under a main theme

Most medical office computer systems include some type of electronic tickler file. Some options include:

Built-in reminders that can be selected and set automatically for such things as patients' monthly blood pressure checks or annual physical exams. Drop-down calendars that allow reminder notes to be placed in certain dates, then pop up and appear on that date as a reminder. Links to the patient's progress notes, where reminders can be recorded and later present as a reminder.

databases

Collection of data (information) stored electronically.

commercial filing system

Customized guides and folders manufactured for professional office use

scores

Creases along the lower front flap of a file folder that unfold to allow the folder to expand

Hippa divider

HIPAA divider sets are used in patient files to quickly identify records with protected health information (PHI); fluorescent labels are placed on the cover of the folder to alert office staff of PH

back up

Duplicate data file; equipment designed to complete or redo an operation if primary equipment fails

Encryption

Encoding of computer data for security purposes, making data appear like gibberish to unauthorized computer users.

virus

Hidden program that enters a computer by means of an outside source, such as software, CD, or online services; can be harmless (flashing an on-screen message) or harmful (replicating itself throughout CD and memory, using up or wiping out data or memory and eventually causing the system to crash.

diagnostic file

Information based on the characteristics of a disease or illness learned from patient case histories and filed for reference.The main heading in this type of subject file might be the name of the disease. Then after the main heading, patient cards can be alphabetized with name, diagnosis, treatment, prognosis, and additional information outlined.

filing supplies and their uses

It is important to find a reliable office supply company with a knowledgeable salesperson who can provide up-to-date information and supplies at reasonable costs. Companies that specialize in medical supplies will have items specific to a medical practice's needs and will incorporate new items when government mandates become law (e.g., HIPAA-regulated consent forms, latest CMS-1500 claim form). Following are general supply items found in a medical practice.

Outguide

Manila sheet or folder inserted when a file is taken from a file drawer or cabinet to signal that it has been removed from the file; a substitution card.

Filing guidelines

Names are divided into sections called units (last name, first name, middle name). The alphabetical process starts by comparing the last name—first unit—letter by letter. If only a last name is known, this single unit is filed before a last name with a first initial. A last name with only an initial is filed before a last name with a first name beginning with the same initial; this rule is often stated as "file nothing before something."

correspondence

Miscellaneous communication dealing with matters other than patient treatment may be filed under

misplaced or lost records

Misplaced or lost records can disrupt the routine of the day, creating delays and problems for the entire staff. When a record cannot be found, the assistant conducts an organized search. Refer to Procedure 8-7 for step-by-step instructions on locating a patient's lost record

caption

Name or number used in a filing system under which records are filed

Rule 1: Individual Names

Names of patients are assigned indexing units and alphabetized by comparing the first unit in each name, letter by letter, in this order: surname (last name), first indexing unit; given name (first name), second indexing unit; and middle name (if any), third indexing unit (see Example 8-6). Second units are considered only when the first units are the same, third units are considered only when the first and second units are the same, and so on. Any additional names are filed as successive units. If only initials are listed, for example, E. J. Hoover, the first initial is considered a complete unit and filed before names with additional letters

electronic confidentiality guidelines

Never leave any storage media (e.g., flash drive, DVD) unguarded on desks or anywhere else in sight. Always log off of the computer terminal before you leave your workstation. Never write down log-on sequences, passwords, or any other codes that regulate personal access to a system; change your password periodically. If you must write down your password, hide the paper and scramble what is written (Example 8-1). Never download (transfer data) public domain software, files from electronic bulletin boards, or other communications systems, because a virus can get into the office system. Never bring in portable storage devices (e.g., DVDs) from outside your office. Always back up files regularly to save data that might get lost through a breach of security. Respect other employees' computer files the same way you do those kept in a desk file drawer. If you use another employee's computer, do not move or alter files or change the screen format.

ARMA International

Nonprofit records management association organized to promote research and provide standardized filing guidelines. 1996

online record storage

Online personal health record (PHR) services are emerging where patients can import records from various health providers to be stored online and create their own personal health profile. Some online sites offer free access and storage of electronic medical records which are used by large employers; others are targeted to health care providers

document imaging

Paper-based medical and financial records can be converted into electronic documents using document-managing software. Records are scanned into the computer system, digitized, and stored on the hard drive or transferred to one of the previously mentioned media for storage. Archived electronic documents may then be retrieved using electronic search capabilities, saving time and space. Advanced programs have the capability of sorting similar documents and organizing them by date, check number, and so forth. The type of scanning equipment would determine how fast this process could be done, but the money saved on medical record storage might be worth the effort and expense. Prior to the use of computers, images were taken of documents and reduced on film using micrograph technology by hospitals, clinics, and insurance companies. Microfiche technology, or a microfilming photographic process was often used and older medical records may still be found which have been stored on this type of media.

indexing units

Parts of a patient's name that has been separated into components (units) to be considered when filing

downtime

Period during which a computer is malfunctioning or not operating correctly

File guides

Pressboard sheet or metal divider used in a filing system to guide the eye to a section of a file and to provide support for records.Typically, one divider is used for 25 folders, allowing 4 to 6 inches of empty space for working. In a lateral filing system, alpha-guide labels can be placed in the extreme left position or staggered throughout the files. As the number of folders increases, two-letter (color-coded) secondary guides may be added to serve as additional signposts

destroying documents

Some large medical facilities may contract with outside vendors to destroy medical documents while others may use small paper shredders that attach to waste baskets and shred two to five sheets at a time or stand-alone machines that shred up to 27 sheets simultaneously.

HIPPA and CMS retention requirements

The HIPAA Administration Simplification Rule requires "a covered entity, such as a physician billing Medicare, to retain required documentation for 6 years from the date of its creation or the date when it last was in effect, whichever is later." The Center for Medicare and Medicaid services requires Medicare managed care program providers to retain records for 10 years.

deleting confidential files

The HIPAA Privacy Rule requires appropriate administrative, technical, and physical safeguards to protect the privacy of health information through the disposal process. Deleting confidential files may not be sufficient to prevent unauthorized disclosure of information. The impression that the information, once deleted, has been removed from the system and is inaccessible to others may not always be true. Measures to prevent unauthorized disclosure of information are as follows: Encrypt confidential files. Use utility software to specifically overwrite files that have been deleted. Physically destroy disks that are being discarded. Monitor the printer while printing, and destroy "bad" copies of confidential printouts. Carefully control, or do not permit, utility software designed to read and restore deleted files.

electronic storage

The advantage of computerized medical records is that they can be downloaded from the computer to other media (e.g., flash drive, external hard drive, DVD) for storage. The transfer of such records is accomplished quickly and the media can be stored in a fireproof safe or off-site for safe keeping.

Authorization to release information

The medical assistant should retain requests made by patients to transfer or release medical information to other parties (e.g., other physicians, insurance companies). These documents become part of the permanent medical record

Rule 7: Hospitals, Medical facilities, and businesses

The names of hospitals, pharmacies, and other business facilities are indexed in the same order as written on the letterhead unless the firm name includes the complete name of a person, in which case the surname would be followed by the given name or initials. Some offices follow an optional rule that does not transpose the full name in a business. Thus, in Example 8-12, Wm. Ingram's Pharmacy would be the last name in the group.Numbers are indexed as though written out and are filed as one unit. Compass directional terms are usually considered separate units. Prepositions, conjunctions, and articles are not units except when "a," "an," "and," "the" are the first words, in which case they become the last filing unit

alphabetical filing system

The simplest and most popular filing method is by alphabetical name sequence, because it is easy to understand and does not require a cross-reference index. Also, if an alphabetical entry is especially confusing, the telephone book, which is a classic example of alphabetical name filing, provides an excellent reference.

full suspension drawers

The traditional upright steel cabinet with three to five drawers is still popular for the storage of business records in a medical office (e.g., payroll records, insurance explanation of benefit documents). leave 3-4 inches in drawers

Rule 5: Titles and Degrees

Titles, degrees, and seniority terms following the name are not units and are disregarded in the indexing unless they are needed to distinguish identical names. Alphabetic suffixes (e.g., Jr. or Sr.) are filed before Roman numerals (I, II, III). Both alphabetic abbreviations, such as "Jr.," and numerical suffixes, such as "II" and "III," are filed before alphabetical suffixes such as "Prof.," "Dr.," or "PhD."A man with a name identical to his father's is called "Jr." as long as his father is alive; when his father is dead, he may drop the "Jr." A male is a "III" when his father is a "Jr." A male named after his grandfather, uncle, or cousin is a "II." These terms may be enclosed in parentheses and placed at the end of the name on file labels.

financial and legal reports

Vital papers such as financial reports and legal documents are considered permanent records and are kept indefinitely in a secure file (see Table 8-1). A loose-leaf notebook can hold a record of the physician's personal inventory; changes and additions may be made simply by adding and deleting pages.

Rule 2: Prefixes

called surname particles, are filed like other surnames as one indexing unit, whether the prefix is followed by a space or not

business papers

other than those dealing with patients are usually stored in a separate cabinet or desk drawer and filed in alphabetical order by subject.

maintaining email files

the medical office may get electronic mail from vendors, patients, government agencies, and other outside sources. Email files need to be managed the same way paper files are managed so that information can be easily retrieved. It is important to sort email regularly so that you can determine what is important, label it, and file it so that it is easily found.

green team

A green team should be selected from concerned employees who would be willing to evaluate all aspects of the office then suggest improvements. Water conservation, energy efficiency, and purchasing environmentally preferable products are common areas to review. On the top of the list would be an office-recycling center placed in a prominent location. A three-level recycling system would target disposal of regular waste, paper waste, and biohazard waste. The adoption of green policies should focus on changing the behavior and attitudes of all workers so that compliance is achieved.

paper shredder

A paper shredder should always be used to ensure confidentiality of medical records that are being discarded.

Electronic Health Record (EHR)

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization

alphabetical filing

Arrangement of names in alphabetical sequence according to filing unit

numerical filing

Arrangement of records in number sequence.unit numbering system, is used primarily to handle rapidly growing files in hospitals, clinics, and large medical practices. It is termed an "indirect" system because an auxiliary cross-reference index is used to determine a patient's assigned number before locating the file.

stapled and shingled documents

Because paper clips slip off or attach to neighboring papers, stapling continuation sheets or related items diagonally in the upper left corner is preferable. A telephone message or small laboratory test report may be stapled, taped, or glued to a standard-size sheet of paper so that it will not be misplaced or overlooked. It may also be shingled as described in Chapter 6 (Figure 6-6). This method is not preferred, because data are covered and it is time consuming to take documents apart before photocopying a medical record.When it is time to dispose of the contents of a folder, the assistant should remove labels and save the folder for reuse by placing a new label directly on top of the old one or by replacing a removable label. Old folders may be used for inactive storage because they will not be reviewed often.

lateral files

Cabinet in which records are stored perpendicular to the opening of the file; also called vertical file

opne shelf file

Cabinets with horizontal shelves for record storage. 36 inch shelves can hold 1000 records

tickler file

Chronological file system that calls attention to future dates of appointments or business matters; a follow-up file that "tickles" the memory

maintaining computerized reports

Computer files can grow tremendously and then become unmanageable when the medical assistant tries to find a letter or report, especially when the patient is not registered with the office and reports or medical records are received in preparation for a scheduled visit. Computerized file management systems are available to assist in arranging electronic files. Using such a system not only helps with quick retrieval but also saves space on the computer hard drive.

creating electronic documents

Computerized medical practices use a scanning machine to scan and index documents that are collected via the paper route, such as patient registration forms, history forms, authorization documents, and insurance cards. The information is digitized, sorted, and filed according to the design of the software program or the medical practices' preference. Original documents may be shredded, so little office space is needed for storage.

Alphabetical color coding

Depending on the size of the practice, tabs are selected for the first, second, and sometimes third letters in the patient's last name and secured to the edge of the file folder for easy reference. Any misfiled record would break the color pattern and stand out, for example, when filing the name "Franklin," the letter F could be red and the R would be color-coded green. You would quickly locate the "FR" section in the file cabinet and file the chart using the remaining letters of the patient's surname alphabetically.

binder file folder

Document container with clamps for securing data.Information is placed in folders with correspondence headings visible and with most recently dated papers at the front (Figure 8-10). Special medical reports may be filed according to type of report; that is, all ECG results together, all urinalysis reports together, and so forth. It is best for a medical assistant to set aside a specific time each day to transfer and file patient data

file folders

Letter-size file folders (8.5" by 11") are designed to hold information to be stored in open-shelf cabinets or file drawers. Ordinary kraft or manila folders in 11-point stock are suitable for average medical practices. The choice of weight ranges from 8-point, which is very light, to 24-point, which is extra heavy, and will depend on the extent of handling. If folders are to be handled often, sturdier file folders should be purchased because redoing folders is not only time consuming but also expensive.

Tickler Card File

Method of reminding office staff of important dates and pending deadlines.

miscellaneous colored labels

Other kinds of labels are also useful, such as those indicating restrictions for private health information

charge-out system

Procedure in a filing system provided to account for items removed from the files.One person should supervise the system and all members of the staff who remove records, charts, or folders should be admonished to return them promptly. A team effort should be made to avoid misplacement. Patients have the right to expect that their medical records will be safeguarded from unauthorized use or disclosure and that the filing system adopted by the office will ensure accurate retrieval.

file tabs

Projection above the body of a folder or guide; used for labeling.

methods of disposing PHI

Record over original tape to Dated electronic documents hamper retrieval, increase supply costs, and use up valuable storage space, so whenever computers are used, data need to be purged frequently. One way to assist purging of electronically stored files is to print a list of document types and indicate the retention time (e.g., 3 days, 6 months, 1 year).

purging computer files

Records are increasingly being stored electronically, that is, on computer hard drives, flash drives, microfilm, optical disks, and various types of backup media. Disposal methods may include degaussing (wiping out information using a magnet) and zeroization (which involves writing binary code zeros over the data). Refer to Table 8-2 for methods of recycling and destroying various types of media

Rule 3: Hyphenated Names

any hyphenated patient name is considered to be one indexing unit; if a business, the two words in a hyphenated name are indexed as separate units. For example, when a husband and wife combine their surnames with a hyphen, ignore the hyphen and file the two names as one unit. Surnames on folder labels may be typed without a hyphen, a space, or any punctuation marks.

cut

Term used in filing to describe the size of the tab on the back of a file folder; usually expressed as a fraction, for example, one-half cut

Record Retentionn and storage

There are both federal and state laws that pertain to the requirements for keeping records; however, in some cases a law cannot be found for the retention of a particular type of record. All records should be retained for at least the number of years included in the statute of limitations and if federal laws and state laws do not agree, always keep the record for the longer period stated. Most states have statutes requiring medical or hospital records to be kept anywhere from 7 to 25 years. Because records chiefly contain information on patient care, the records may be of value to patients in later years or even to their offspring. It is, therefore, the policy of most physicians to retain paper medical records indefinitely.

Misfiling

Type patient names legibly using a standardized form. Changes in the typed format of headings can be misread. Include adequate guides for the number of files stored. Too many or too few guides make filing difficult. Leave 3 to 4 inches of extra working space per shelf or drawer. Overcrowding causes misfiling, damages records, and makes filing difficult. Rid file folders of unnecessary items. Overloaded folders cause papers to push up and conceal file tabs. Staple papers when necessary. Avoid paper clips because they can cling to other papers in the file. File carefully. Hurrying causes carelessness and folders get filed in the wrong place. Select proper titles for subject files and keep headings simple. Failing to properly designate the subject or name results in lost files.

Rule 8: Addresses when names are identical

When patients have identical names, alert each patient to that fact and suggest that both remind the staff at each office visit to prevent confusion about records. If two names are identical and the physician or hospital sees patients from more than one city or state, the address may be used to make the filing decision. Index by name first, then state, city, street, and finally by number from the lowest to the highest number (see Example 8-13). Geographic names such as Las Vegas are treated as two separate indexing units.

color coding of files

When several physicians are associated but maintain separate practices, patient folders may be color-coded to distinguish each physician's patients (Figure 8-11). An inexpensive way to convert ordinary manila folders to color is to purchase colored tape, colored dots, or preglued colored tabs to affix directly to the folder tabs.

chronological files

a chronological filing system, numbers are used based on dates. Files, or sections within a file, are listed by year, month, and day with the most recent files in the front of the file drawer or the most recent documents in the front of the folder. In a physician's office, chronological filing is one method used to file documents within a chart so that the latest visit, laboratory test, x-ray, hospitalization, and so forth are at the beginning of each section of the file

short notice reminder file

a file is divided into time categories appropriate to the practice, such as urgent, anytime, a.m., and p.m. When making appointments, patients are asked if they are interested in coming on short notice or anytime there is an opening. This information is placed on a card and filed in the appropriate category

once a week

have the computer compare the original records with the backup. This verification can take 20% to 30% longer than an ordinary backup, but if a comparison is not made, there is no way to ensure information has been backed up properly. Another good practice is to select one backup per month to keep indefinitely.