Bài giảng Medical Assisting - Chapter 10: Managing the Office Medical Records

Medical Assisting Chapter 10PowerPoint® to accompany Second EditionChapterCopyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.Ramutkowski • Booth • Pugh • Thompson • Whicker1Managing 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.2Managing 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.3Importance of Records ManagementThe 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.4Filing Equipment Filing ShelvesFiles are stacked upright on shelves in boxes or heavy-duty envelopesFiling CabinetsSturdy pieces of office furnitureUsually made of metal or woodBoth vertical and horizontal (lateral) file cabinets are available5Compactable FilesKept on rolling shelves that slide along permanent tracks on the floorSeen often in offices with limited space for filesRotary Circular FilesFiles are stored in a circular fashion resembling a revolving doorAlso common when space is limitedFiling Equipment (cont.)6Filing Equipment Plastic or Cardboard Tubs or BoxesOrganized like filing cabinet drawersFiles can easily be misplaced with this system.Labeling Filing EquipmentThe outside of the file drawer should be labeled to represent its contents.(cont.)A-D7Security MeasuresMany filing cabinets have locks, and the keys should be available to limited staff personnel.Equipment SafetyPost safety equipment for each type of filing system.Purchasing Filing EquipmentFirst determine the amount of space availabilityThen determine number of files to be includedFiling Equipment (cont.)8Filing 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 cutsTab Tabs on the file folder identify the contentsLabeling File FoldersSmith,A.Adams, G.9File JacketsResemble file folders but have plastic or metal hooks on both sides to anchor itFiles are placed inside these jacketsFile GuidesHeavy cardboard or plastic inserts that identify groups of filesOut GuidesA marker made of stiff material that is used as a placeholder for removed filesFiling Supplies (cont.)10File SortersLarge envelope-style folders with tabs that temporarily store filesBindersSome offices use three ring binders to keep patient records Tabs are used to separate individual chartsPurchasing Filing SuppliesA common responsibility for medical assistantsFiling Supplies (cont.)11Apply 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?12Apply Your Knowledge - AnswerA 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.13Filing SystemsAlphabetic1 2 3 NumericFiles are arranged in alphabetical orderFiles are labeled with the patient’s last name first, then first name and middle initialOrganizes files by numbers instead of namesPatients are assigned sequential numbersThis system is often used with highly confidential informationA master list of patient names and numbers must be kept14Filing Systems (cont.)Using Classifications First identify how files are to be classified Select a separate color for each classificationColor coding can be used with both alphabetic and numeric filing systems.ColorCodingUsed to distinguish files within a filing system15Filing Systems (cont.)Tickler FilesA reminder fileShould be placed separately and reviewed oftenComputers now offer tickler filesSupplemental FilesSeparate files containing additional informationPrevents cluttering of primary filesContents should be distinguished from the primary file contents16Today is December 17th , which of the information listed below could be added to a “tickler” file?Names of patients that missed appointments two-days agoJune medical conference dates just received in the mailNames of patients seen today for their annual check-upApply Your Knowledge17Today is December 17th , which of the information listed below could be added to a “tickler” file?Names of patients that missed appointments two-days agoApply Your Knowledge - Answerb. June medical conference dates just received in the mailc. Names of patients seen today for their annual check-up18The Filing ProcessGenerally the medical assistant files three types of items:New PatientRecordFoldersIndividualDocumentsForExistingFoldersPreviouslyFiledPatientRecordFolders195 Steps to FilingThe 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.CodingSortingStoringName the file using the office classification system. IndexingMake sure document is ready to be filed.Inspecting20Limiting Access to FilesUnder 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.21Filing GuidelinesTake 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.22Use 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.)23Locating 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.24Active vs. Inactive FilesActive FilesFiles that you use frequentlyInactive FilesFiles that you use infrequentlyClosed FilesFiles of patients that no longer consult the officeThe physician determines when a file is deemed inactive or closed25Apply 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.26The primary reason records should first be inspected is to ensure that all documents are present that belong in the chart.Apply Your Knowledge- AnswerStep 1Step 2Step 3Step 4Step 5IndexingSortingCodingInspectingStoring27Storing FilesBasicStorageOptionsComputer 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.28Storage FacilitiesSome 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.29Storage SafetyEven 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 & FloodsVandalism & TheftExtremes of temperature 30Retaining Files in the OfficeA 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.31A 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 Knowledge32A 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 - Answer33End of ChapterManaging the Office Medical Records34