Chapter 43
Two advantages of a numeric filing system for paper medical records?
- it is easier to preserve confidentiality - in large practice, it's easier to identify a patient by number when several patients have the same last name
What happens to the old paper medical record after transition to an electronic health record system?
After the transition to an EMR, the old paper record may be destroyed if the entire record has been scanned
How are reports and letters filed into existing medical records?
All reports or note to be filed should be initialed by the physician, and any required action should be initialed by the physician and any required action should be completed . Reports should be sorted before filing according to name or medical record number. Once the record has been located the report is filed at the front of the appropriate section filed into the patient record.
How long should the records of adult patients be retained? Why?
All tax records should be kept for 7 years
What is the process for removing a record from the file?
An out guide is placed.
How is an outguide used when filing medical records?
Are placed in the file to mark the place where a folder has been removed.
How should computerized records be stored?
EMRe should be backed up regularly and securely
How long should the medical records of minors be retained? Why?
For a minor, time period should be considered to begin at the age of majority. Records of medicare and medicaid patients should be retained for at least 5 years after last contact.
Identify two ways that documents might be arranged within a subject category
They can be arranged alphabetically or by date
How are medical records selected to be moved to the location of inactive records?
When it hasn't been touched for 3 years.
What equipment and supplies are used for creation and storage of paper medical records?
file cabinets, shelf dividers
Before returning medical records to the files, what are the three things the medical Assistant should do to condition the records?
1) all clips pins or other extraneous material should be removed 2) any tears/broken punch holes should be repaired with tape 3) any sticky notes or other loose papers should be either removed or files in the record in the correct location
How is the medical record of a married woman filed if an alphabetic filing system is used?
A married woman may take her husbands surname , but she retains her own first and middle name.
What is the advantage of using color-coded labels on medical record file folders?
It identifies the last year a patient was seen at the office. This allows the records of patients who have not been seen for some time to be removed from the active files and placed in inactive storage
How are names with prefixes filed if an alphabetic filing system is used?
It is considered as part of the last name.
Describe the form and function of a tickler file
It is used to tickle the memory by serving as a reminder that a specific action must be taken on a specific date, is a type of chronologic system.
What is the most common method used to organize a new paper medical record for a patient?
Most medical offices use source- oriented format to organize their medical records, the alphabetic filing system to arrange records and shelf filing units to store the medical records.
Seven common categories for chart dividers
Progress notes History/Physical Lab reports Diagnostic testing Hospital reports Immunizations Correspondence
Compare and contrast a terminal digit filing system with a consecutive filing system.
Terminal digit fs a common numeric filing system used in a large medical offices and hospitals uses a six digit number with a hyphen between each group of 2 digits consecutive from lowest to highest.
How is an electronic medical record updated?
The EMR is usually updated stat by MAs physicians or other staff members who interact with patients. The physician may use voice recognition software to generate reports
What are three measures to prevent misplaced records?
The medical assistant should work slowly and carefully when filing records. Recommended to use out guide to keep track of the records. Medical record should be returned to storage after use and not just handed to others in the medical office.
Discuss the ownership of a paper medical record
The medical record belongs to the physician and the facility but the information belongs to the patient.
direct filing system
a filing system in which materials can be located without consulting an intermediary source of reference
How are hyphenated names filed if an alphabetic filing system is used?
are indexed as one unit , whether its a first name last name
What are four types of documents that might be filed using a subject filing system?
preprinted forms, invoices, purchase orders, service orders.
What conditions should be present in the storage area for active or inactive medical records?
should be well and in climate control. It is important to keep relative humidity ata 48% to 52% to prevent de-coloration of record.
indirect filing system
uses an alphabetic cross references to find a given file