Medical assisting Administrative and clinical procedures (5e) Chapter 15 Managing

After studying this chapter you will be able to: Identify the common equipment used to file and store paper medical records, outline the security and safety measures that should be employed when working with paper medical records, list the common filing supplies used in the medical office,…

Managing Medical

Records

Learning Outcomes (cont.)

15.1 Identify the common equipment used to file

and store paper medical records

15.2 Outline the security and safety measures

that should be employed when working with paper medical records

15.3 List the common filing supplies used in the

medical office

Learning Outcomes (cont.)

15.4 Contrast the methods used for various filing systems and how color-coding can assist with the filing systems

15.5 Recall the steps in the filing process

15.6 Compare active, inactive, and closed files

and how to set up a records retention program for the office

– Vital to patient care and

office operation – Must be easily retrievable

Filing Equipment (cont.)

• Rotary Circular files

• Plastic or cardboard tubs

or boxes

• Labeling Filing Equipment

– Clearly indicate range of files

– Write directly on boxes

Apply Your Knowledge

What are the disadvantages of vertical

filing cabinets?

ANSWER: They take up more room than shelves,

only one person can access the files at a time, and

if more than one drawer is pulled out at a time they

become top heavy and could tip over.

Security and Safety Measures

• HIPAA privacy and security

• Medical record security

– Lockable cabinets or room

– Limit key access

Equipment Safety

• Purchasing filing equipment

– Base on space and number of files

– Fire proof and secure

• Post safety guidelines

– Keep drawers closed

– Open one drawer at a time

– Step-ladder safety

Apply Your Knowledge

A busy medical office is currently using filing boxes for patient medical records and wants to change to a

different system What would you recommend to this

non-computerized office that will allow more people to retrieve files at the same time?

ANSWER: Filing shelves would enable more than

one person to access files if adequate space is

available.

Filing Supplies

 Available in letter and legal sizes

 Tabs - extensions used to identify the

Filing Supplies (cont.)

• Labels

• File jackets

• Binders

Filing Supplies (cont.)

• File guides

• Out guides

• File sorters

Apply Your Knowledge

Which of the following would you use to mark the

place when removing a patient record from the

Filing Systems

or misplacing records

Alphabetic Filing System

• Most common system

• Files are arranged in alphabetical order

• Seven indexing rules – keeps

alphabetizing simple and consistent

Alphabetic Filing System (cont.)

• Indexing rules

• Last name

• First name

• Middle name / initial

• Titles (Jr., Sr ,Rev., Dr., etc.) ~ the fourth indexing unit

Chronological Filing

• Based on dates

– Year, month, day

– Used within a patient’s record

– Reverse chronologic order

Numeric Filing

Numeric Filing (cont.)

• Terminal digit filing

– Filing is done based on last group of numbers

– Number is read from right to left

• Middle digit filing

– Uses the middle group as primary index for filing

– Number is read using the middle number first

– Followed by the left-hand number and right-hand

0 0 2 - 25 - 5 6 5

• Using classifications

– Identify how files are to be classified

– Determine method of coding

– Determine color for

each classification – Post codes

Color-coding (cont.)

• With alphabetic filing

– Each letter is assigned a color

– Two or three letters of the

last name are color-coded

Color-coding helps identify charts that are out of order

Color-coding helps identify charts that are out of order

Color-coding (cont.)

• With numeric filing

– Numbers 1 to 9 assigned a distinct color

– Use color-coded “key unit” for each chart

Supplemental Files

• Separate files containing additional information

– Old patient records

– Financial records

• Stored in a different location than primary file

• Contents should be distinguished from the

primary file contents

Tickler Files

• A date-ordered reminder file

• Organized by month, week

of month, or day of week

• Computer systems

– Calendar

– Reminders to alert prior to

event

Match the following:

Apply Your Knowledge

financial records easy to see out of place records reminder system

helps the medical office comply with HIPAA

E F

C B A D

The Filing Process

• Medical assistant responsibilities

• Follow practice policies for returning records to the files

• Place records to be filed in a secure file return area

The Filing Process (cont.)

Generally the medical assistant files three types of

items:

New patient records Documents

Existing patient records

The Filing Process (cont.)

Place the files in the appropriate location for easy

retrieval when needed

Place the files in the appropriate location for easy

retrieval when needed

Place files in order to save time when

storing

Place files in order to save time when

storing

Add an identifying mark to ensure

that the file is put in the correct

place

Add an identifying mark to ensure

that the file is put in the correct

Filing Guidelines

• Check each record when

pulling it

• Keep files neat

• Remove file from drawer

when adding documents

Filing Guidelines (cont.)

• Do not crowd the file drawer

• Use file guides with a

different tab position to aid in

finding files

• It is better to provide too

many cross-references than

too few

Filing Guidelines (cont.)

Locating Misplaced Files

1 Determine where the

file was last seen or used

2 Look for the file

while retracing steps from that location

3 Check filing cabinet

where it belongs

Locating Misplaced Files (cont.)

4 Check underneath files in drawer or on shelf

5 Check items to be filed

6 Check cross-reference or similar indexes

Locating Misplaced Files (cont.)

7 Check with other staff members

8 Check other file locations

9 Stand back and look at the top of the folders

10 Ask another staff member to double-check

your search

Locating Misplaced Files (cont.)

11 Straighten the office, carefully checking

all piles of information

12 Check charts that have been pulled for

the next day appointments

13 Check physician’s desk

Locating Misplaced Files (cont.)

• File may be considered lost if not found within 24

to 48 hours

• Recreate a new file

– Physicians and staff record recollections of

information in the file – Duplicate documents from labs, insurance

companies, etc.

Limiting Medical Record Access

• Computerized offices

– Access code and password

– Limits what files you may see

• Paper records

– Limit who can retrieve and return files

– Requisition slip used to obtain a file

Apply Your Knowledge

The medical assistant is training a new employee who will primarily

be responsible for the medical records The new employee asks

“Can I first sort the charts, then inspect them?” List the 5 steps to

filing in the correct order and provide an explanation to answer her.

ANSWER: The 5 steps to filing

storing.

Active, Inactive, and Closed Files

• Active files – used frequently

• Inactive files – used infrequently

• Closed files

– Patient may have died or moved away

– No longer come to the office

Basic Storage Options

 Files remain in their original format

 Labeled boxes with lids to allow even stacking

 Preserve the original documents.

 If the paper becomes brittle, transfer

documents to another storage medium

Paper Storage

Basic Storage Options (cont.)

 Transfer documents to electronic or

digital form

 Transfer documents from hard drive to

storage medium

Computer Storage

Computer Storage

Basic Storage Options (cont.)

• Other paperless options

– Microfilm

– Microfiche

– Cartridges

Retaining Files in the Office

• Retention schedule

– Specifies length of time records are kept in the office

once they are inactive or closed

– Details when to move files to storage and when they

can be destroyed – Post in file room

Retaining Files in the Office (cont.)

• HIPAA law – required retention periods

• State and local requirements

• Count from year after

document produced

Retaining Files in the Office (cont.)

File Storage Facilities

• On-site storage

• Off-site storage

– Commercial records storage centers

– Maintain list of files

Storage Safety

• Evaluate storage sites carefully

• Place files in fireproof and waterproof containers

• The storage site should be safe from

– Fire and floods

– Vandalism and theft

– Extremes of temperature

A patient who has not been to the office in several years

telephones and requests a copy of his medical record What should you do?

Apply Your Knowledge

ANSWER: First tell him that you need a signed release to

give him a copy of the records Once you have that you

would check to see if his medical record was in the active

files If not you should look on the inactive file list to see if

it had been moved to storage

In Summary

15.1 Filing shelves, filing cabinets, compactable files, and

rotary files are all commonly used to store paper medical records

A very small office might opt to use storage bins for its medical records

15.2 HIPAA requires that filing shelves or cabinets should

be fireproof and locked when the office is closed

Filing systems must be safe for those using them and instructions on their proper use should be posted and

understood by all staff members using them

In Summary (cont.)

15.3 Filing supplies used in the medical office

include tabbed file folders, labels, file jackets, binders, tabs with inserts for labeling, file

guides, out guides, and file sorters

In Summary (cont.)

15.4 Alphabetic filing is the traditional filing

system for medical offices Color-coding can

enhance this process

Numeric systems are used more often because of the confidentiality they provide

These systems use a medical record number,

which are then filed by the terminal digit or

middle digit format Color can be used with

numeric filing also

In Summary (cont.)

15.5 The steps in the filing process include

inspecting, indexing (naming), coding, sorting,

and storing

15.6 Active records are those that are used

frequently Infrequently used records are

known as inactive records

Closed files are those of patients who, for whatever reason, no longer come to the office

We must try to continue to hear patient voices above the din of the machinery.

~ Catherine Lopez

From A Daybook for Nurses

End of Chapter 15