Medical Record Management



Medical Record Management



Key Terms













































LEARNING OBJECTIVES PROCEDURES
1. Identify supplies and equipment needed to create and store paper medical records.  
2. List principles of alphabetic and numeric filing.  
3. Compare and contrast advantages and disadvantages of alphabetic and numeric filing systems for paper records.  
4. Describe the process of filing reports and patient records. File patient records: alphabetic.
5. Describe the implications of the paper medical record and the electronic medical record for medical record management. File patient records: numeric.
6. Differentiate between storage of active and inactive records. File reports.
7. Identify methods for retention and disposition of paper medical records.  



Introduction to Medical Records


A medical record (also known as a patient chart) contains the important information related to an individual patient in written or electronic form. It includes the care given to that patient and the progress of the patient’s condition. Medical record management is the process of controlling and handling medical records from the time a record is created until it is placed in permanent storage or destroyed. In addition to recording the care given to patients, both paper-based records and electronic medical records (EMRs) may also be used to review quality of care and for recording statistical information.


It is impossible for a physician or other professional to remember every detail of care, such as the results of a physical examination or doses of particular medications. Many people in the primary care physician’s office have contact with a patient, as well as consulting professionals, laboratories, and hospitals. It is important that each interaction be recorded in the patient’s medical record. This provides an ongoing record of both the patient’s state of health and the service provided by the medical office.


Medical records are also legal documents, if there are questions about the care given. If a patient sues a physician, the court will require documentary evidence, such as a medical record, to be presented in court. The court will take the position that whatever is documented in the record is the care that was given. If something is not documented, officially it never happened. To protect the legal interests of the physician’s office, it is therefore important to keep complete medical records.



Paper-Based Medical Records


Many medical offices still rely on paper-based medical records to document care. A manila file folder is created for each patient, containing all documents related to the care of that patient. These records are maintained in files to be available each time the patient is seen at the office. After the transition to an EMR, the old paper record may be destroyed if the entire record has been scanned. In some offices, most of the paper record is scanned into the new electronic record system, and the old record is placed in storage. In most offices, however, only baseline data and very recent information are entered into the new electronic record, because large charts are time-consuming to scan, and too much information tends to overwhelm the system. For at least 2 to 3 years after the transition to an EMR, the old paper chart is made available to the physician for each patient visit.



Electronic Medical Records


In many medical offices, part or all of the medical record is maintained on computer. This is usually called an electronic health record (EHR) or electronic medical record (EMR).


There is a growing movement to develop health information exchanges (HIEs) so that electronic data can be shared among institutions in a given area. Currently each EMR system uses its own standards and is not necessarily able to share data with other systems. A Nationwide Health Information Network (NHIN) is being developed through the Office of the National Coordinator for Health Information Technology (ONC) to allow for the national exchange of health care information.


When a medical office uses an EMR, information is entered directly into the computer system via a keyboard, mouse, screen display, and/or voice recognition systems. Computer terminals may be located in each examination room or at selected areas within the office. As an alternative, staff may rely on portable devices such as laptops, tablets, or personal digital assistants (PDAs). Entry of information is necessary whenever care is provided or information is obtained from the patient. The EMR is usually linked to the computer appointment system and often to the billing systems.


An electronic medical record offers a number of advantages:



The change from a paper system to an electronic system often seems overwhelming. In addition to the important issues related to data security (and hence patient confidentiality), there are several other challenges to overcome:



Some facilities print a full or partial record for office visits and then enter new information during the visit or immediately after the patient has been seen. Old records may be gradually scanned into the system, but until this process is complete, established patients often have an old paper record in addition to the new electronic record. Even with high-quality scanning systems, handwritten originals may not be legible after scanning.


Despite the problems of change, many hospitals have made or are in the process of making the transition to a paperless system for maintaining patient records. This encourages physicians who are affiliated with those hospitals to do the same. The number of physician offices using electronic records continues to increase. The current challenge is to include implementation of standards to allow for interchange of data among different systems. This will improve patient care by making all health care data for an individual available to any practitioner treating that patient.



Equipment and Supplies


Storage Equipment


Paper medical records may be kept in various types of file cabinets or on open shelves. The choice of equipment depends on the following: the number of people who need to access the medical records, the office layout, and the amount of floor space available. Usually the records are stored with the files side to side. The files may take up part or all of a room. In a rotary system, the medical assistant can move sections of shelving to access other shelves behind. Large offices may even use an automated system, which stores more records and brings the record to the medical assistant.




Shelf Filing Units

Shelf filing units consist of shelves arranged horizontally similar to bookshelves. Shelf units are often used to store medical records because the records can be accessed without having to open and close drawers. Adjustable metal shelf dividers that interlock at the back of the shelves come with the units. Their function is to keep the records in an upright position, thus preventing the records from slumping or sliding under one another.


File folders with side tabs (described later in this chapter) must be used with shelf units to permit the patient’s name to be visible on the shelf. A record is placed on the shelf with the bottom edges of the folder down and the side tabs facing outward. This means that the record is accessed from the side, rather than the top, as with drawer filing cabinets.


Shelf files are preferred because they allow easier access to records, and a number of people can have access to the shelves at the same time. For example, a medical assistant may need to retrieve the medical records of patients to be seen that day, while at the same time another medical assistant may need to look up information for an insurance company or to document a patient telephone call.


Shelf units are available in two styles: open-shelf units or pull-down front units. As the name suggests, open-shelf units are open to the environment and cannot be closed. They must be in a room that can be locked separately from other parts of the office. The pull-down front units have lids that can be pulled over the front of the shelves and locked. This protects the records from environmental factors and allows each part of the file to be locked (Figure 41-1). It must always be possible to lock either the entire medical record room or individual shelving units.


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Figure 41-1 The pull-down front of a shelf storage unit may function as a work space.


Putting It All into Practice


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My name is Ellen McDonald and I am a certified medical assistant. I have been working for a group practice specializing in internal medicine and cardiology for about a year. Although our office uses a computer-based billing and appointment system, our patient medical records are still in paper-based format. We file our records alphabetically. We are changing to an electronic system this year, but we will be using the paper system during the transition. There is always a big stack of reports, correspondence, and other paperwork to be filed. We are not allowed to file any report unless the physician has seen it. In addition, our physicians dictate their progress notes, which are sent electronically to a transcription service. Every day we print the dictation that the transcription service has returned to us electronically, and we stamp them for the physicians to initial after they read them and make any corrections. I am responsible for making sure the files of medical records are kept in good order. In addition to pulling records and putting them away, I sometimes have to look for a misplaced record. If I can’t find a patient’s medical record, I begin to look for it. First I check the stacks of records for patients who will be seen that day or the next day. Sometimes a medical record gets caught on another record, so it is important to check through the stacks thoroughly. Next I check the computer to find out when the patient was last seen. I check on and behind the desks of the physician the patient last saw, as well as the billing desk. I also check through the files looking for a record that has been misfiled. We use color-coded labels, so it is usually easy to see when a record is out of place. These measures are usually enough to find the record, although sometimes it may take as long as a week before the record turns up. One time we looked for a record for 3 weeks before we found it. Whenever I am filing, I am very careful, because I remember how much work it is to find a record that has been misfiled. image



Filing Supplies



File Folders

A file folder is a protective cover used to hold medical record documents in an organized format. Usually file folders are made of manila card stock. Flexible metal fasteners at the top of the inside of the folder hold documents in place. Although the folders expand as the number of documents increase, it is recommended that the folder be broken down into two folders after attaining a width of image inch.


Folders are available with tabs. A tab is a projection of a folder that extends beyond the top or side edge of the folder. Folders for a file cabinet with drawers have tabs on the top, whereas folders for shelf units have tabs at the side of the file folder. In the medical office with shelf filing cabinets, a folder with a full-cut side tab is used. Indentations at intervals along the tab indicate the placement of adhesive labels. This ensures that all the labels on all the medical records are affixed at the same place on the file folders (Figure 41-2).


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Figure 41-2 File folders for shelf units have a full-cut side tab. Color labels are affixed in the same position on each folder.


Folder Labels

Labels are used to identify the medical record and are commercially available in rolls or continuous folded strips. Most offices use pressure-sensitive self-adhesive labels. The labels for an alphabetic system assign colors to letters in either the first third or first half of the alphabet, and the remaining letters are assigned the same colors along with some type of distinguishing mark, such as one or two white stripes. If the office uses a numeric filing system, each digit from zero to nine is assigned a specific color. Color-coded year labels are often used to identify the last year a patient was seen at the office. The current year label is placed on a new record and updated the first time a patient has an office visit each year. This allows the records of patients who have not been seen for some time to be removed from the active files and placed in inactive storage.





Other Supplies

Outguides, shown in Figure 41-4, are placed in the file to mark the place where a folder has been removed. Each guide has a pocket for a card indicating who removed the record and/or items that accumulate while the record is out of its storage area. Another type of outguide is made of heavy cardboard and has lines to write the name of the individual removing the record.


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Figure 41-4 Outguides.

A sorter is a device that facilitates placing documents in alphabetic or numeric order. It has pockets or dividers for each letter or number.



What Would You Do? What would You Not Do?




Filing Systems


The way in which records are arranged is referred to as a filing system. The primary purpose of a filing system is to facilitate the storage and retrieval of records; a secondary function is to allow for expansion of the records with a minimum of disruption. The two systems most commonly used to arrange medical records are alphabetic and numeric. Other types of records (such as financial records or office correspondence) can be arranged in chronologic order, by subject, or by geographic location.



Alphabetic Filing


The alphabetic system is considered a direct system, which means that the patient’s name is used directly to locate the medical record. It is commonly used in medical offices with fewer than 5000 records. Alphabetic filing uses parts of the legal name as indexing units. Indexing units are pieces of information used to identify the correct filing location. The records are arranged alphabetically based on the first unit.


All names that have exactly the same first unit are then arranged by the second unit, the third unit, and so on. If the name is unusual, if the patient uses more than one name, or if it is unclear which name is the last name, the record may be cross-indexed. To cross-index means to file under one unit and to file a guide or card referring to the primary filing location under another unit.


It is important to follow rules when filing alphabetically. One resource for guidelines is ARMA International, an association for records and information management personnel. The medical assistant must always clarify the procedures followed by any given medical office (Procedure 41-1).



image Procedure 41-1   Filing Patient Records


Alphabetic



Outcome


File patient records correctly using an alphabetic filing system.



Equipment/Supplies





1. Procedural Step. Gather the records that are ready to be filed and remove any elastic bands or paper clips.


    Principle. Paper clips, elastic bands, and so on prevent the record from sliding easily into and out of the file.


2. Procedural Step. Check the records to be sure that no loose sheets of paper are present. If loose sheets are found, insert them in the record.


3. Procedural Step. Sort the records alphabetically by last name, using the alphabetic sorter if available.


4. Procedural Step. Find the correct location in the file for the first record, pull the outguide halfway out, slide the record in front of the outguide in the correct location in the file, and finish removing the outguide. If your office does not use outguides, use your hand to make a space between the record before and the record after the one you are filing.


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Slide the record in front of the outguide.

5. Procedural Step. If there is an index card in the outguide showing who had the record from the outguide, remove it. Place the outguide with other unused outguides. Some offices keep index cards for the physicians in separate boxes so that new cards do not need to be written; some offices cross out the name and reuse the index cards; some offices use slips of paper that are discarded after each use.


6. Procedural Step. File each record in the same way until all records have been filed.



Rule 1: Individual Names

In a patient’s name, the surname (last name) is the first indexing unit, the given name (first name) is the second unit, and the middle name or middle initial is the third unit. A name with only two units is filed before a name with three units. (“Nothing” always comes before “something”.) A unit with only an initial is filed before a unit with a full name beginning with that initial. Business names are indexed in the order of the names in the business (excluding a, an, and the). Examples are as follows:


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Apr 16, 2017 | Posted by in NURSING | Comments Off on Medical Record Management

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