Essentials of Health Information of Management (Principles & Practices: Chapter 7

Name the disadvantages of the unit numbering system

- compute software must be purchased to manage unit numbering system - folders can become thick and cumbersome - multiple folders may be needed to house all records for one patient (and they should be labelled as Vol.1 of 2, and so on)

Name the advantages of the serial unit numbering system

- computer software is not needed to track assignment of patient numbers - patient is assigned new number for subsequent visits, and previous records are brought forward to the new number - patient records are filed in one location in the filing system - patient records can be easily retrieved and refiled

Name the disadvantages of the serial numbering system

- patient records are filed in different locations in the filing system - multiple locations must be accessed to retrieve patient records

Name the advantages of the unit numbering system

- patient records are filed in one location in the filing system -patient is assigned same number for each subsequent admission - patient records can be easily retrieved and refiled - system is cost effective because just one file folder per patient is needed

Name the disadvantages of the serial unit numbering system

- previous folders must remain in file system with a note providing new patient number information -folders can become thick and cumbersome, and multiple folders may be needed to house all records for one patient

When selecting file folders, the following should be considered:

-Color coding -Fastener position -Preprinted information -Scoring and reinforcement

Name the disadvantages of the decentralized filing system

-Confusion can occur regarding where patient information can be found. -"Fragmented" documentation can result because information related to patient care is filed in multiple locations. -Providers may not know how to properly maintain patient records. -Lack of uniformity or consistency exists in record keeping and storage results.

Facilities must also establish policies and procedures to address portable computer security (laptops, cell phones, tablets, and so on). Health care facilities must establish appropriate controls to address this issue by:

-Establishing policies and procedures that address portable technology -Educating and training users of portable technology about facility policies and the potential for theft and loss of patient information -Using appropriate encryption and password security -Purging information from portable computers when the computer is assigned to a new user

Facilities establish policies to:

-Identify authorized personnel who may requisition a record from the file area -Indicate how long the record may be removed -Establish a procedure for the transfer of a record from one patient care area to another

Name the advantages of the alphabetic filing system

-It is easy to learn. -Staff members can be quickly trained. -It does not require a master patient index. Record retrieval can be performed quickly.

Name the advantages of terminal-digit filing

-It provides a high degree of record security as compared with other filing systems because unauthorized persons cannot easily locate files. -Files expand evenly as new records are added because records are distributed throughout the 100 primary sections. -More than one file clerk can easily work in the file area because clerks can be assigned to specific primary sections; the work is evenly distributed, eliminating congestion. -Even distribution of records simplifies planning for file equipment. -Large gaps in files will not occur, and records will be shifted infrequently. -Misfiles are reduced because clerks are concerned with just two digits at a time when filing. -Transposition of digits occurs less frequently, also resulting in decreased misfiles. Inactive records can be easily retrieved as new records are added to each section.

Name the advantages of the straight numeric filing

-Office staff can be easily and quickly trained. -Patient records are more secure because unauthorized personnel cannot retrieve a record according to name (a patient number must be known). -Retrieval of consecutive records for research or purging (for inactive storage) can easily be done. -Files can be easily expanded to add additional file space at the end of files.

Name the disadvantages of straight numeric filing

-Office staff must consider all digits of the number when filing, resulting in transposition of digits and misfiled records. -Misfiles increase as the number of digits increases (the more digits, the greater the chance of error). -Work flow problems arise because activity in the file area focuses on that section with the highest consecutive numbers (e.g., most recent patient records will be filed in that section). -Work space is restricted when more than one staff member files records because they usually must file in the same section.

Outguides are also made of heavy stock (e.g., cardboard), which allow the following information to be entered:

-Patient name -Patient number -Date of removal -Current location of record -Requestor's name or signature

Name the disadvantages of the alphabetic filing system

-Patient names must be spelled correctly or the entire system will fail. -Misspelled patient names result in misfiling of records. -Files do not expand at an even rate, causing reorganization of shelves. Typically about half of the filing space will store files that start with the letters B, C, H, M, S, and W.

Two types of requisitions typically occur:

-Planned -Non-routine (or emergency)

Name the advantages of the decentralized filing system

-Records are located near providers that create and use them. -No "extra" space is needed in the health information department to store files. -Providers control filing and retrieval of patient information.

Name the disadvantages of the centralized filing system

-Records may be too remote from staff for adequate patient care. -It can result in increased personal filing systems (e.g., emergency department stores copy of records to facilitate rapid retrieval). -It requires additional staff to handle filing and retrieval of records. -It requires investment in more efficient filing equipment and/or automation.

Name the advantages of the centralized filing system

-Responsibility for record keeping is easily identified. -Effective use of equipment, supplies, space, and personnel is made. -All information about a patient is organized in one location. -Consistent services are provided to all users. There is improved security.

Name the disadvantages of terminal-digit filing

-Training time for staff is lengthier as compared with other filling methods, although clerks usually master terminal-digit filing in one day or less. -Initially, more space and equipment will be needed to organize the file area. The file area must be well organized from the beginning to include room for even expansion of files.

To prevent reports from becoming separated from the record, all pages are secured to the file folder with the following:

-adhesive strip - embedded - heat-bonded - DocuClip fastener

primary memory

A computer's built-in microchip that stores data and information.

primary storage

A computer's built-in microchip that stores data and information.

Automated chart tracking systems

A method that allows providers to request records using a computer; the health information department clerk references a computer screen to process all requests.

Secondary storage

Auxiliary, external, or permanent storage on devices or servers.

Facsimile (or fax) machines

Computer devices that transmit a document's image via telephone lines.

natural or man-made disaster record destruction corroboration process

Confirms allegations that patient records were destroyed during a natural or man-made disaster.

Conveyor belt

Device similar to a pneumatic tube, except it uses a belt instead of a tube, and records are clipped to the belt for transport from one area to another.

Computers

Devices that allow for rapid circulation of patient information. Access to all patient information contained in the automated record is possible for authorized users via a computer terminal, an intranet, and/or the Internet

visible file

File system that allows user to easily view contents of a file drawer. (Manual master patient index cards for hospital inpatients are often housed in a visible file until discharge, after which they are filed in the permanent master patient index file system.)

power filing machines

Filing equipment that is designed to utilize ceiling height rather than floor space. Clerks quickly access records without bending, lifting, or stretching. End-tab folders are housed in power filing machine systems.

movable (compressible file)

Movable files include both manual and power types. Manual movable files are mounted on tracks that are secured to the floor and are moved by using a handle or crank. Power movable files are motorized systems that move when the file clerk presses a button. End-tab folders are housed in movable file systems.

non-routine (or emergency) requisition

Occurs when a patient record is needed for an unscheduled service, such as an emergency room visit; also called emergency requisition.

Name the disadvantage of middle-digit filing

Patient numbers should be limited to six digits to easily divide the number into primary, secondary, and tertiary digits.

secondary devices

Physical equipment that stores data and programs.

outguide

Replaces the record in the file area to indicate it has been removed and to identify its current location.

planned requisition

Request of a patient record for a scheduled service.

vertical file

Resembles a file cabinet in which records are stored in a drawer. (Medical records used to be stored entirely in four-drawer file cabinets that were double-stacked. Clerks accessed records in the topmost drawers using movable ladders.) Top-tab folders are housed in drawer file systems.

periodic audit of file area

Review of charged-out records to ensure that all records removed from the file area are returned in a timely fashion.

open-shelf file

Six- to eight-shelf unit, which resembles a bookshelf, provides twice as much filing space as a standard drawer file cabinet, and requires less than 10 percent additional floor space.

Dumbwaiter

Small elevator that transports records from one floor to another.

file folders

Store paper-based records; are color-coded, durable, come in a variety of sizes and weights, and can be customized by vendors.

binders

Store records for hospital patients who are currently receiving care.

jackets(envelopes)

Store x-rays and other oversized materials; open at the top and closed on three sides; also called envelopes.

requisition forms

Submitted to the health information department to retrieve the record and track its return.

Mirrored processing

The simultaneous entry and storage of data into a primary and secondary server.

Pneumatic tube

Transports a single record in a tube through a tunnel.

lateral file

Two-to eight-shelf unit with retractable doors (and lock system if desired). (Bibbero Systems, Inc., offers Stak-n-Lock™ modular shelf filing by Datum, which allows a department to expand the filing system as filing needs increase.) Top-tab folders are housed in lateral file systems.

Name the numbering system: Mary Adams and her three children receive care from Brookside Clinic, where the health information department retrieves one record that contains patient information on Mary and her three children.

Unit- family numbering

Name the numbering system: Perry Parks receives care at the local hospital and is assigned a patient number based on the letters of his name and his date of birth because he does not have a social security number.

Unit- social security numbering

numeric filing

a methodology that uses a number to file patient records. Patients are assigned a health record number, and the records are organized according to that number.

pseudonumber

a number that is assigned to a patient that does not have an SSN

social security numbering

a patient's social security number (SSN) is assigned as their patient number

middle-digit filing

a variation of terminal-digit filing, assigns the middle digits as primary, digits on the left as secondary, and digits on the right as tertiary.

All pages of the patient record should be secured to the file folder with a fastener. Identify the four types

adhesive strip, embedded, heat bonded, DocuClip fastener

Name the two systems that are used to file patient records

alphabetic and numeric

Some facilities use a computer tracking system to monitor record circulation and have folders preprinted with ________ which looks like a UPC scanning code.

bar coding

To control the movement of records into and out of the file area and to account for the location of each record, health information departments establish_______systems.

charge- out systems

Controls the movement of records in and out of the file area and accounts for the location of each record removed.

charge-out system

A system capable of generating a report that lists all patient records not returned to the department is a computerized ______ system.

charge-out systems

A common policy and procedure established by HIM departments to address patient record maintenance and management issues is that only staff ________to use the file system are permitted to file and retrieve records.

chart tracking systems

Transports records from one location in the facility to another (as well as to locations outside of the facility).

circulation

It is the assignment of color to primary (and, in some cases, secondary) patient numbers or letters used for filing patient records.

color coding

What is the term for the assignment of color to primary patient numbers or letters used to file patient records?

color coding

Name one advantage of the serial numbering system

computer software is not needed to track assignment of patient numbers

chart tracking system

controls the release and return of patient records and uses record requisition forms to retrieve and track requests for patient records.

family numbering

each household is assigned a unique patient number, and each family member is assigned a two-digit modifier number that serves as a prefix to the patient number

Other than color coding and preprinted information, identify two other items that should be considered when selecting file folders.

fastener position

Established to ensure accurate filing and timely retrieval of patient records, including chart tracking system (manual or computerized), file guides, and periodic audit of file system.

filing controls

The request of a patient record for a scheduled service is called a ________requisition.

form

soundex

is a phonetic indexing system allowing surnames (last names) that sound alike but are spelled differently to be filed together.

terminal-digit filing (reverse numeric filing)

is commonly used in health care facilities that assign six-digit (or longer) patient numbers because the number can be easily subdivided into three parts: primary, secondary, and tertiary digits.

_________Shelving that contains retractable doors and uses top-tab folders.

lateral file

Individual reports that must be filed in the patient record after discharge from the facility.

loosing filing

______Units that are operated with a handle or crank.

movable file

centralized filing system

organizes patient records in one central location under the control of the facility's health information department.

decentralized filing system

organizes patient records throughout the facility in patient care areas under the control of the department that creates and uses them.

To maintain control of the file area, an_______ must be inserted each time a record is removed from the area!

out guide

When a record is removed from the file area, a(n) ________ replaces the record to indicate it has been removed and to identify its current location.

outguide

_______Shelving unit that resembles a bookshelf and uses end-tab folders.

power filing machines

straight numeric filing (consecutive numeric filing)

records are filed in strict chronologic order according to patient number, from lowest to highest.

Identify the term used to measure a folder's weight (durability).

reinforcing

Name the numbering system: Larry Allen registers for outpatient care on March 30 and is assigned patient number 363258. He returns on December 10, and is assigned patient number 456898. Records for both encounters are filed in a folder labeled 456898.

serial

In a _____, each time the patient is registered, a new patient number is assigned by the provider and a new patient record is created.

serial numbering system

Name the three numbering systems

serial, unit, serial-unit

Name the numbering system: William Wood is admitted for surgery on February 2 and assigned patient number 567890. On March 5, he returns for outpatient testing and is assigned patient number 678900. Records for the two encounters are contained in separate folders in two different locations in the file area.

serial- unit

alphabetic filing system

the patient's last name, first name, and middle initial are used to file records (when no numbering system is selected for use by the facility) and master patient index cards (when a numbering system is used by the facility).

Name the numbering system: Annie Smith is brought into the emergency department following a motor vehicle accident and assigned patient number 123456. She is discharged home, and three days later she returns for further evaluation. She is reassigned patient number 123456.

unit

In a _____, the patient is assigned a patient number the first time he or she is registered, and the patient is reassigned that same number for all subsequent admissions and encounters.

unit numbering system

______Shelving that resembles a file cabinet.

vertical file