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Medical Assisting Chapter 10

PowerPoint® to accompany

Second Edition

Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

Ramutkowski • Booth • Pugh • Thompson • Whicker

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Managing the Office Medical RecordsObjectives10-1 Describe the equipment and supplies needed

for filing medical records.10-2 List and describe the various types of filing

systems.10-3 Discuss the benefits of each type of system.10-4 Discuss the advantages of color coding the

files.10-5 Explain how to set up and use a tickler file.

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Managing the Office Medical RecordsObjectives (cont.)

10-6 Describe each of the five steps in the filing process.

10-7 Explain the steps to take in trying to locate a misplaced file.

10-8 List and describe the basic file storage options and the advantages of each.

10-9 Identify criteria for determining whether files should be retained, stored, or discarded.

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Importance of Records Management The medical records are the most valuable

information in the medical office. A records management system refers to the

way patient records are: Created. Filed. Maintained.

A well-organized, easy-to-use system saves time and protects vital medical data.

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Filing Equipment Filing Shelves

Files are stacked upright on shelves in boxes or heavy-duty envelopes

Filing Cabinets Sturdy pieces of office furniture Usually made of metal or wood Both vertical and horizontal (lateral) file cabinets

are available

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Compactable Files Kept on rolling shelves that slide along

permanent tracks on the floor Seen often in offices with limited space

for files Rotary Circular Files

Files are stored in a circular fashion resembling a revolving door

Also common when space is limited

Filing Equipment (cont.)

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Filing Equipment Plastic or Cardboard Tubs or Boxes

Organized like filing cabinet drawers Files can easily be misplaced with this

system. Labeling Filing Equipment

The outside of the file drawer should be labeled to represent its contents.

(cont.)

A-D

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Security Measures Many filing cabinets have locks, and the keys

should be available to limited staff personnel. Equipment Safety

Post safety equipment for each type of filing system.

Purchasing Filing Equipment First determine the amount of space availability Then determine number of files to be included

Filing Equipment (cont.)

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Filing SuppliesFile Folders

• Referred to as manila folders• Available in 8 ½ by 11 inches and 8 ½ by 14 inches• Tabs are tapered rectangular or rounded extensions at the top of the folder• Tabs have a variety of cuts

Tab

• Tabs on the file folder identify the contents

Labeling File Folders Smith,A. Adams, G.

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File Jackets Resemble file folders but have plastic or

metal hooks on both sides to anchor it Files are placed inside these jackets

File Guides Heavy cardboard or plastic inserts that

identify groups of files Out Guides

A marker made of stiff material that is used as a placeholder for removed files

Filing Supplies (cont.)

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File Sorters Large envelope-style folders with tabs

that temporarily store files Binders

Some offices use three ring binders to keep patient records

Tabs are used to separate individual charts

Purchasing Filing Supplies A common responsibility for medical

assistants

Filing Supplies (cont.)

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Apply Your KnowledgeA busy medical office is considering changing their current filing equipment. Which equipment would you recommend to this non-computerized office that will afford more persons to retrieve files at the same time?

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Apply Your Knowledge - AnswerAnswerA busy medical office is considering changing their current filing equipment. Which equipment would you recommend to this non-computerized office that will afford more persons to retrieve files at the same time?

Filing shelves would be a great system if adequate space is available.

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Filing Systems

•Files are arranged in alphabetical order•Files are labeled with the patient’s last name first, then first name and middle initial

•Organizes files by numbers instead of names•Patients are assigned sequential numbers•This system is often used with highly confidential information•A master list of patient names and numbers must be kept

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Filing Systems (cont.)

Using Classifications

• First identify how files are to be classified• Select a separate color for each classification

Color coding can be used with both alphabetic and numeric filing systems.

ColorCoding

Used to distinguish files within a filing system

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Filing Systems (cont.)

Tickler Files A reminder file Should be placed separately and reviewed often Computers now offer tickler files

Supplemental Files Separate files containing additional information Prevents cluttering of primary files Contents should be distinguished from the primary

file contents

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Today is December 17th , which of the information listed below could be added to a “tickler” file?

a. Names of patients that missed appointments two-days ago

b. June medical conference dates just received in the mailc. Names of patients seen today for their annual check-up

Apply Your Knowledge

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Today is December 17th , which of the information listed below could be added to a “tickler” file?

a. Names of patients that missed appointments two-days ago

Apply Your Knowledge - AnswerAnswer

b. June medical conference dates just received in the mail

c. Names of patients seen today for their annual check-up

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The Filing ProcessGenerally the medical assistant files three types of items:

New PatientRecordFolders

IndividualDocuments

ForExistingFolders

PreviouslyFiled

PatientRecordFolders

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The Filing Process (cont.)

Get the accumulated files in order. This will save time when storing the folders.

Place the files in the appropriate location, so they can easily be retrieved when needed.

Place an identifying mark to ensure that the file is put in the correct place.

Coding

Sorting

Storing

Name the file using the office classification system.

IndexingMake sure document is ready to be filed.

Inspecting

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Limiting Access to Files Under no circumstances should original

patient records leave the medical office. Identifying information is often recorded

when files are retrieved. Limited persons in the medical office

have access to patient records.

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Filing Guidelines Take a close look at the contents of patient

records each time you pull them. Keep files neat. Do not overstuff file folders. Take time to properly place documents into

the folders to prevent damage. Do not crowd the file drawer. If possible use both upper and lower case

letters to label the folders.

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Use file guides with a different tab position to aid with finding files.

It is better to provide too many cross-references than too few.

File regularly. Do not store anything other than files in the file

storage area. Train all staff that will be able to retrieve files on the

system in place. Periodically evaluate your office system to see if it

still works.

Filing Guidelines (cont.)

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Locating Misplaced FilesDo a complete search of the office to try and locate the file. If the file is not recovered within 24 to 48 hours, it may be considered lost.

Lost files can have potentially devastating consequences.

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Active vs. Inactive Files Active Files

Files that you use frequently Inactive Files

Files that you use infrequently Closed Files

Files of patients that no longer consult the office The physician determines when a file is deemed

inactive or closed

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Apply Your KnowledgeThe medical assistant is training a new employee that 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 this question.

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The primary reason records should first be inspected is to ensure that all documents are present that belong in the chart.

Apply Your Knowledge- AnswerAnswer

Step 1

Step 2

Step 3

Step 4

Step 5

Indexing

Sorting

Coding

Inspecting

Storing

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Storing Files

BasicStorageOptions

Computer StorageMicrofilm Paper Storage

• Files remain in their original format• Good to place in boxes with lids to afford even stacking• If the paper becomes brittle, transfer documents to another storage medium.

Patient records can be scanned and saved on a disk, tape or computer hard drive.

Microfilm, microfiche and cartridges offer a paperless way of storing records.

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Storage Facilities Some offices have extra closet or storage

space on site. Smaller offices require the use of off-site

storage. Use a facility that takes precautions against

fires and floods. Maintain a list of all files at each storage

location.

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Storage Safety Even inactive and closed files must remain

safe and secure. Place files in fireproof and waterproof

devices. Cardboard is not an option. The storage site should be safe from:

Fire & Floods Vandalism & Theft Extremes of temperature

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Retaining Files in the Office A retention schedule decides how long different types of

patient records are to be kept in the office once they become inactive or closed.

Certain records have legal criteria for the length they must be maintained in the office such as: Immunizations. Employee health records. Medical Office Financial Records.

Legal consultants and the AMA also advise physicians on the length of time patient records should be kept. The best rule of thumb is to seek legal advice before destroying any records.

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A former employee from two years ago telephones and requests that copies of her annual physical examination forms that she submitted while employed be mailed to her home address. How would you handle this?

Apply Your Knowledge

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A former employee from two years ago telephones and requests that copies of her annual physical examination forms that she submitted while employed be mailed to her home address. How would you handle this?

You should get this request in writing and then proceed to locate the records. The Labor Standards Act specifies that employee health records must be kept for three years, so they should be on hand at the office.

Apply Your Knowledge - AnswerAnswer

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Managing the Office Medical Records