Chapter 13 Managing Medical Records

Which of the following are examples of color-coding using classifications?

-All patients with Medicare have folders with a blue sticker. -All new patients have red folders.

Which of the following are guidelines for filing correctly?

-Become familiar with the typical contents and order of a patient record folder. -Keep files neat and without too many papers in each folder.

Which of the following may be used in color-coding?

-Colored labels -Colored file folders

Which of the following are guidelines for filing efficiently?

-Do not store office equipment where files belong. -Do not crowd the file drawer.

Which of the following are the most commonly used options for filing equipment?

-Filing shelves -Filing cabinets

Identify steps that can be taken during file storage to make your job easier.

-If a file contains too many documents, separate it into two folders. -Replace folders that are damaged or torn.

Which of the following are ways to maintain medical record security?

-Lock cabinets at night. -Lock the file room.

Which of the following are contained in a master file?

-Medical record numbers -Patient names

What patient information should be recorded when coding a document?

-Name -Medical record number

Where may a record of who has a file be kept?

-On the out guide -On index cards in a card file -In a notebook

Which of the following are characteristics of sequential order?

-Predictability -Sequence

Identify the tasks involved in the inspecting step of filing.

-Remove paper clips or other fasteners -Staple related papers together.

How may a practice limit access to medical records?

-Require staff members to fill out a requisition slip when obtaining a file. -Maintain a record of who has each file in a notebook.

Identify the characteristics of indexing rules.

-They define a consistent method for the ordering of filed materials. -They are a guideline for sequencing files. -They are used with alphabetic filing systems.

Why is it more desirable to print or type chart labels?

-They have a more professional appearance. -They are easier to read.

Identify the ways that inactive files may be stored.

-Transfer them to another format, such as computer disk or microfilm. -Store them in their original paper state.

Which of the following are guidelines for labeling boxes

-Write directly on top and front of the box. -Use permanent marker.

Rotary circular files can be operated:

-electronically -manually

A retention schedule specifies

-how long to keep different types of patient records after files have become inactive. -when files should be moved to a storage area.

Place the steps for locating misplaced files in order, with the first step on top. Instructions

1. Determine the last time anyone in the practice knew the file's location 2. Go to the last location and retrace the steps of the last person who handled the file, looking for the file along the way 3. Look in the filing cabinet where the file belongs, checking neighboring files 4. Check underneath the files in the drawer or shelf to see if the file slipped out 5. Check the pile of items to be filed or the filer sorter envelope 6. Consider possible cross-reference or similiar indexes and check those headings for the file.

1. Cross-referenced 2. Indexing 3. Indexing rules 4. Out guide 5. Compactible file 6. Unit

1. Filed in two or more places, with each place noted in each file 2. Naming a file 3. Specific rules to follow when filing names alphabetically 4. Marker made of stiff material used as a placeholder when a file has been removed 5. Files that are kept on rolling shelves that slide along tracks in the floor 6. Each part of a person's name or title

Place the steps for making the best use of color-coding in order, with the first step on top. Instructions

1. Identify the classification that are important to the office. 2. Decide what method of coding will be used (folder, labels, or stickers) 3. Choose a different color for each classification. 4.Post the codes in a prominent location in the file room for all staff members to see.

Place the 5 steps involved in filing in order, with the first step on top. Instructions

1. Inspecting and releasing 2. Indexing 3. Coding 4. Sorting 5. Storing`

1. Alphabetic filing system 2. Records management system 3. Retention schedule 4.Sequential order 5. Terminal digit

1. System in which files are arranged in alphabetic order 2. Way patient records are created, filed, and maintained 3. Specifies how long to keep different types of records after they become inactive or closed 4. One after another in a pattern that can be predicted 5. Numeric filing system in which the last unit is the primary index

A legal-size folder measures 8.5 x ______ inches.

14

At what point may a misplaced file be considered lost?

24 to 48 hours

There are ______ steps involved in filing.

5

Files used frequently are called?

Active

What type of office should use compactible files?

An office that has limited space

Which of the following are particularly helpful for practices that see patients repeatedly, resulting in very large medical records?

Binders

Which filing system uses numeric dates as indexing units?

Chronological filing

Which files are kept on rolling shelves that slide along permanent tracks in the floor?

Compactible files

When should you verify if any changes are needed to be made tot he patient's file related to his/her current demographic?

During indexing

When does releasing occur in the steps of filing?

Either before or immediately after conditioning

Which of the following is the most basic filing supply?

File folder

Which of the following refers to the place where records or files are housed and stored?

Filing equipment

In alphabetic filing, if two last names are identical, what is the next indexing unit?

First name

Which of the following resembles a regular file folder but features metal or plastic hooks on both sides at the top?

Hanging file folder

Lateral files are also known as:

Horizontal files

Files used infrequently or not at all are called:

Inactive

Cross-referencing is found to be done in which step in filing?

Indexing

What should a medical assistant do when using a commercial records center?

Keep a separate list of files stored office site

Which of the following are often used on folder tabs to identify the individual folder's contents?

Labels

In alphabetic filing, files are arranged in what order?

Last name first

How are patient files arranged in an alphabetic filing system?

Last name, first name, middle initial

What type of files have wider drawers that are usually split into three or four sections?

Lateral files

What is an important administrative function of the medical assistant?

Management of the medical record

Which system of filing uses the middle group of numbers as the primary index?

Middle digit

In a numeric filing system, in which each patient is assigned a number, how are patient files arranged?

Numeric order

Which of the following is a system for the way patient records are created, filed, and maintained?

Records management system

Which of the following specifies how long to keep different types of patient records in the office after files have become inactive or closed?

Retention schedule

Which type of file is helpful when space is limited?

Rotary circular files

Which piece of equipment copies a document into a document on the computer's hard drive?

Scanner

Which of the following is an advantage of keeping files on shelves?

Several people can retrieve and return files at the same time.

What is a disadvantage to using binders as a way to hold the medical record?

Takes up space

Which of the following is the filing system of choice for numeric filing systems?

Terminal digit

Why should inactive files be stored with the same security as active files?

They contain PHI

Why should file cabinets be locked when not in use?

To maintain medical record security

What is the most common order of units, in a chronological filing system?

Year, month, and day

Which of the following is an advantage of color-coding in an alphabetic filing system?

You can tell at a glance if files are filed correctly.

Files of patients who have died, have moved away, or no longer consult the office are

closed.

The process of marking a document to ensure that it is placed in the proper file is called

coding.

A(n) ______ system is used to distinguish files within a filing system.

color-coding

When there is a need to distinguish between types of files within a paper filing system, a practice may use

color-coding.

A center that houses and manages stored documents is called:

commercial records center

Inspecting and releasing inspecting is sometimes called:

conditioning

The process of getting items ready for filing is known as:

conditioning

Placing a file in two or more places, with each place noted in each file, is called

cross-referencing

With ______, systems are often long and can extend the full length and height of an office wall.

filing shelves

Closed files are usually treated in the same manner as ______ files.

inactive

Specific rules for filing personal names alphabetically are called

indexing rules.

Naming a file is also known as

indexing.

The first step in the filing process, to make sure the item is ready to be filed, is called

inspecting

The use of ______ on filing equipment allows you to go directly to the appropriate place when retrieving a file.

labels

Each ______ is assigned a color in color-coding in an alphabetic filing system.

letter of the alphabet

Master files are most commonly used with the ______ filing system.

numeric

The filing system that assigns a number to each patient name is known as

numeric filing

The contents of hanging file folders are identified with

plastic tabs.

The process a physician stamps or marks an item ready for filing is known as:

releasing

The easiest way to transfer documents directly onto a computer is to use a

scanner.

Files placed one after another in a pattern that can be predicted is known as putting them in

sequential order.

Indexing rules, using units, are designed to keep alphabetizing:

simple and consistent

A system that provides an order to files before they are stored is called

sorting.

Placing documents or files in proper sequence, either numerically or alphabetically, is known as

sorting.

Keeping files in their proper location when not in use is known as

storing.

A tapered, rectangular or rounded extension at the top of a file folder is called a

tab.

Middle digit filing is similar to:

terminal digit filing

A small group of 2 or 3 numbers at the end of a patient number, used as an identifying unit in a filing system, is called a(n)

terminal digit.

The most common type of folder for medical charts has the ______ style of tab.

third cut

Indexing rules define each part of a person's name or title as a(n)

unit.

Chronological filing is a method to file documents _________ a patient's chart.

within