Records ManagementJeff Steele, LDO, CPOT, ABOC

Spokane Community College

Objectives State the basic rules for protection and

retrieval of records Know steps required in transferring records Describe various filing techniques

Overview A filing system is only as good as the

accessibility of everything within the files! Records management, aka filing, includes

classifying and arranging records so they will be protected and can be retrieved quickly and easily

Records Protection The loss of records through fire, flood or other catastrophe could cripple

a practice It is important to protect records at all times:1. Original records always remain in the practice2. When not in active use, all records are to be in their proper place in the

filing system3. Return all records at the end of the day4. Before closing the file cabinet, pack records tightly together (slows fire

damage as air cannot circulate)5. Keep all filing cabinets closed and locked6. Make computerized records and back them up on a daily basis.7. Backup copies of records should be stored away from the office!

Records Retrieval Each misplaced record contains an unnecessary

crisis! (and is an expensive waste of time). Misfiling is the most common cause:

1. Having a record “almost” in the right spot isn’t good enough!

2. Recognize that filing is an important responsibility and never be careless

3. Before re-filing, presort the records4. Take the time to get it right the first time5. Be organized and use adequate filing aids to keep

the system in top condition

Practice Records Divided into two major groups:

1. Business records

2. Patient records

Business Records Includes all of the information needed to manage the practice and meet

govt. recordkeeping requirements: All financial data related to patient accts, including insurance claims

information Patient registration forms Bills to be paid Expense records and receipts, including bank statements and cancelled

checks Business correspondence and personnel records Records of practice income Annual practice summaries and financial statements Tax records Professional registrations, licenses and insurance policies

Patient Records AKA the patient’s “chart”: Medical history Progress notes Laboratory/test results Correspondence related to the patient’s care Copies of prescriptions

Computerized Records Management The most common application of

computerized records management is in accounts receivable bookkeeping.

Patient is often linked to an account number, usually by last name

Many offices are moving toward a completely paperless system!

Legal Documents Patient records are considered legal

documents which must be preserved Each patient’s chart must be maintained in

good order so that all parts are clear and well organized

Financial records, such as insurance claims, are generally considered part of the business record (although copies may be stored in the patient’s chart)

Confidentiality Patient records confidentiality must be

protected HIPAA dictates that patient’s records and

personal information not be placed in a matter where it may be seen by another patient or unauthorized persons

Ownership of Records Q: “Who own the patient’s chart?” One way of looking at this is that the physician owns

the actual chart and the patient owns the information contained within the chart

Under law, the patient should be allowed access to their personal records

Patient’s consent needed for all other transfers of information

Transferring of Patient’s Records The doctor may refuse to allow the original chart to

leave the office, except under direct court order Photocopies may be sent in place of the original (a

note is placed in the original chart with the date and where the copies went to)

A doctor may alternatively chose to make a summary of the chart:

A small fee may be charged to cover clerical expenses

Doctor/office cannot refuse to release records due to non-payment

Types of Filing Systems There are numerous filing systems used to

store records: Subject filing: all files are labeled according

to the subject of their contents, then filed alphabetically

Chronological Filing Organizes information according to time

spans such as months and days Frequently used for the recall system (March,

April, May, etc.)

Alphabetical Filing Most common for patient’s charts Categorized by last name, and often color-

coded for first names

Numerical Filing Each chart or document is assigned a number

(often crossed reference by computerized systems)

Generally only used for filing patient’s charts when a practice has more than 20,000 active patient charts or when directly linked to a computerized system

Filing Aids and Equipment Vertical files or drawer files Lateral files, or open shelf filing (often color

coded) File envelopes and folders Labels

Records Retention Basic Rule: NEVER discard a patient’s records

without the doctor’s permission! Most offices divide records into two categories: Active files: those that have been to the office in the

last X years (usually three to five) Inactive files: those who have not been to the office

for a long period of time (often stored in a basement or storage)

Storage Files A place to put the inactive files (patient’s who

are deceased or no longer with the practice) Must be protected and kept in an organized

manner Often stored in cardboard boxes w/ lids Box clearly labeled for content

Filing Rules It is vital that everyone involved with

handling files know that basic rules for filing: Unit 1: The surname (last name) Unit 2: The given name (first name) Unit 3: The middle name (or initial) Unit 4: Terms denoting seniority (“Junior”,

“Senior”, and “III” Example: Jones, John D Jr.

Examples: John David Jones, Jr. I II III IV Jones JonesJ. Jones John JonesJohn D. JonesJohn David JonesJohn David Jr.

Hyphenated Names Indexed as one unit:

Example Henry David Smith-Jones Jr.

Smith-Jones, Henry David Jr.

Titles and Degrees Not indexed units- usually added in column 4

in parentheses (for information only)

Example: Dr. Clarence W. Lawson Lawson, Clarence W. (M.D.)