Chapter 41 Medical record management

What is a medical record also known as?
Patient chart
The process of controlling and handling medical records from the time a record is created until it is placed in permanent storage or destroyed.
Medical record management
Medical records are also considered to be…?
Legal documents – In case a patient wants to sue
For at least 2-3 years after transition to an EMR, the old paper chart is made available to the…
Physician for each pt visit
Health information exchanges (HIEs)
Used so that electronic data can be shared among institutions in a given area.
Advantages of using an EMR
• Medical information is legible
• Information is easy to retrieve
• Medical offices can be linked to laboratories, hospitals, and insurance companies. Access to laboratory data and test results is also easy and quick.
• Less time is spent filing
• Less storage space is required
What are three challenges when a medical office changes from a paper medical record to an electronic medical record?
• Orienting new or temporary staff to the EMR system
• Difficulty in adding older records to an EMR system
• Difficulty preventing unauthorized alterations and authenticating digital signatures
• Cost of hardware and employee training
• Incorporating updates to the software and medical codes
What drawers are more commonly used in the medical office?
Lateral drawers
What is the function of adjustable metal shelf dividers that interlock at the back of the shelves?
Prevents the records from slumping or sliding under on another, keeps the records in an upright position.
Pull down front units can be…
Locked
Why are color -coded year labels used?
To identify the last year a pt was seen at the office
Outguides
marked in a place where a file has been removed
Filing system
-facilitates the storage & retrieval of records
-expansion of the records with minimum disruption
Most common way to arrange medical records
-alphabetic
-numeric
What is the alphabetic system considered to be?
a direct system
-pts name is used directly to locate
-fewer than 5000 records
Rules to follow when filing alphabetically (resource guidelines ARMA International)
1. Individual names
2. Prefixes
3. Abbreviations and Nicknames
4. Hyphenation
5. Titles and Seniority Terms
6. Names of Married women
7. Companies and business
8. Identical names
Another name for last name?
Surname
Prefixes are considered part of?
The last name
ex.
Joanne McCarthy- Mccarthy Joanne
If an abbreviation is part of the last name (such as ST.) is is apart of?
The first indexing unit
Ex.
Alex M. St. Croix – Stcroix Alex M.
Hyphenated names are indexed as?
One unit
Ex.
Anne-Marie Smith- Smith Annemarie
Numeric filing systems are normally used…?
to identify the pt and file the paper medical record
Advantages of a numeric system
– It is easier to preserve confidentiality
– In a large practice, it is easier to identify a pt by number when several pts have the same last name.
Terminal digit filing
an indexing system that uses the final group of digits as the first indexing unit.
Consecutive filing systems are commonly used in?
Smaller offices
What are subject filing often used for ?
insurance, bills, research, or other documents related to running the practice rather than the pts records.
All reports, letters, and other materials that come into the office should be reviewed, initialed, and the filed in the pt record by whom?
The physician
What are three measures to prevent misplaced records?
• The MA should work slowly and carefully when filing records.
• It is recommended to use out guides to keep track of the record
• Medical records should be returned to storage after use and not just handled on to others in the medical office
The storage area for paper medical records humidity should be?
48-52%
Records of Medicare and Medicaid pts should be retained for how long?
5 years after the last contact
tax forms should be kept..?
indefinitely
Files that should be kept indefinitely
insurance polices, licenses, and Drug enforcement Administration
Who is responsible for ensuring that the backup system is implemented according to plan
The system manager
Acronym
A word formed from the first letters in a name
color coding reduces
misfiling
one guide line for back up files
more secure at an offsite location
Baseline data is store for how long?
stored & kept for 3 years
Files are moved to
create more space
One advantage of an electronic medical record
less space required
Tickler file is kept
where the MA sits
If the pt has the same same, what is used to identify them?
The pts street address
Indirect method of filing
Numeric
Least common method for back up
DVD
Office policy determines..
classification of inactive files