Lesson 6 Assignment

After reviewing the PowerPoint presentations for this lesson, "Paper Records" and "Records Management," complete these questions. Unless otherwise specified, use complete and correct sentences to adequately answer the following questions about medical records. Cite and list any references used for your answers.

1. Make a table and, in your own words, name five things paper and electronic health records have in common and five ways in which they differ.

2. What supplies are needed to make and maintain paper medical records?

3. A problem with a paper record file is that it physically can be misplaced or lost. It is important that missing files be located as soon as the situation is discovered. When a patient's paper medical file is missing, what steps can be used in the process to locate it?

4. Medical records have a lifecycle; they are created, used, maintained, and then destroyed according to defined regulatory and organizational policies when no longer needed. The methods to destroy paper and electronic medical records are specific to media type. List two ways that paper medical records are destroyed and two ways that electronic records can be destroyed.

MEDICAL RECORDS MEDICAL RECORD - Collection of data recorded when a patient seeks medical treatment. PURPOSES OF MEDICAL RECORDS: 1) Required by licensing authorities and provide a format for tracking, documenting, and maintaining a patient's communication data, both inside and outside a health care facility. 2) Provide documentation of a patient's continuing health care, from birth to death. 3) Provide a foundation for managing a patient's health care. 4) Serve as legal documents in lawsuits. 5) Provide clinical data for education, research, statistical tracking, and assessing the quality of health care. FILE STORAGE: 1. Vertical Files: a. 2-4 drawers. b. Holds 100 records. c. Very heavy and space consuming. 2. Lateral Files: a. Charts easily pulled off of shelves. b. Color-coded system used for visual recognition. 3. Movable Files: a. Electronic/Manual controlled file cabinets. b. Move on tracks in the floor. c. Saves space. · Always file records accurately, neatly and in a timely manner. ____________________________________________________________________________________ FILE FOLDERS: · Can be colored. · Top/side edges can have tabs at spaces intervals for labels to be applied. GUIDES/DIVIDER GUIDES: · Keeps records organized. · Easy to locate. · Separates records into categories. (Ex: Labs, Reports, Progress notes, etc) LABELS: Color coding files · MAIN PURPOSE: To identify what is in the file. (EX: patient name/medical record) · Can be color-coded. · Special Alerts (EX: Allergies, co-pays, year of last visit) 3 SYSTEMS FOR FILING: 1. ALPHABETIC SYSTEM: a. Filed alphabetically by: · (Unit 1) Last Name · (Unit 2) First Name · (Unit 3) Middle Name 2. NUMERIC SYSTEM: a. Used in hospitals and large clinics. b. Number assigned to each record. c. Usually 6 digit number. *Several types of numeric systems: · Straight * Filed by assigned number sequentially. * Numbers begin at 01 and continue upward. · Terminal-Digit Filing: · Based on last 2 digits of record number. · Evenly distributes files within filing system. · Eliminates need for frequent re-shifting of files. · Starts with 00 and ends with 99. · (Tertiary) 1st two digits is the file number. · (Secondary) Middle 2 digits are the shelf number. · (Primary) Last 2 digits are the unit number · Middle-Digit Filing: · 6 digit number. · The middle 2 digits are the file number. · The first 2 digits are the shelf number. · The last 2 digits are the unit number. · Unit-Number Filing: · Typically used by hospitals. · Number is assigned to patient’s first visit. · All records need to be kept at same location. · Serial-Number Filing: · Patient receives a different medical record number each hospital visit. · Multiple records stored at different locations. CROSS REFERENCING: · RECOMMENDED cause of confusion of use of surnames. - Women who uses married name and also goes by maiden name sometimes. EX) Mrs. Amy Myslinski also uses her maiden name Amy Ziarko – so an insert would go into Amy Myslinski’s file that states “see Ziarko, Amy for Mrs. Amy Myslinski file) LOCATING MISSING FILES: · Always conduct a THOROUGH search! · ABSOLUTELY NECESSARY TO FIND RECORD! TIPS FOR FINDING RECORD: · Look at files close to where the record should be. It could be inside another chart. · If patient was recently seen or going to be seen, check area where chart would be located for recent/future visits. · Scan racks for folders out of sequence. · Check common areas. · Check with transcriptionist, receptionist, billing department. · Ask all staff members, physicians, desktops, etc. TICKLER FILES: · Reminds you of actions that will take place in the future. STORING OF MEDICAL RECORDS: ** Medical records may be kept on paper, electronic software, microfilm, or computer tapes or disk. ____________________________________________________________________________________ RETENTION AND STORAGE: 1. Active - Currently being seen. (within the past 3 years) 2. Inactive – No activity within the past 3 years. * May return if problem arises. * Patient has not received notification of termination with particular physician. 3. Closed - Died, moved, terminated relationship with physician, or transferred to another physician. Records should be kept until the applicable statute of limitations period has elapsed which ranges usually from 2-7 years after the last day of treatment. OR 10 years after the age of the majority (which is 18 years old). (EX: If a patient is 8 years old and was only seen the one time in a facility the record would be held till the patient turned 18 plus 10 more years.) · AHIMA and AMA recommend holding records for 10 years. __________________________________________________________________________________ MEDI CAL RECORDS MEDICAL RECORD - Collection of data recorded when a patient seeks medical treatment. PURPOSES OF MEDICAL RECORDS : 1) Required by licensing authorities and provide a format for tracking, documenting, and maintaining a patient's communication data, both inside and outside a health care facility. 2) Provide documentation of a patient's continuing health care, from birth to death. 3) Provide a foundation for managing a patient's health care. 4) Serve as legal documents in lawsuits. 5) Provide clinical data for education, research, statistical tracking, and assessing the quality of health care. FILE STORAGE: 1. Vertical Files: a. 2 - 4 drawers. b. Holds 100 records. c. Very heavy and space consuming. 2. Lateral Files: a. Charts easily pulled off of shelves. b. Color - coded system used for visual recognition. 3. Movable Files: a. Electronic/Manual controlled file cabinets. b. Move on tracks in the floor. c. Saves space. · Always file records accurately, neatly and in a timely manner. ____________________________________________________________________________________ FILE FOLDERS: · Can be colored. · Top/side edges can have tabs at spaces intervals for labels to be applied. GUIDES/DIVIDER GUIDES: · Keeps records organized. · Easy to locate. · Separates records into categories. (Ex: Labs, Reports, Progress notes, etc) MEDICAL RECORDS MEDICAL RECORD - Collection of data recorded when a patient seeks medical treatment. PURPOSES OF MEDICAL RECORDS: 1) Required by licensing authorities and provide a format for tracking, documenting, and maintaining a patient's communication data, both inside and outside a health care facility. 2) Provide documentation of a patient's continuing health care, from birth to death. 3) Provide a foundation for managing a patient's health care. 4) Serve as legal documents in lawsuits. 5) Provide clinical data for education, research, statistical tracking, and assessing the quality of health care. FILE STORAGE: 1. Vertical Files: a. 2-4 drawers. b. Holds 100 records. c. Very heavy and space consuming. 2. Lateral Files: a. Charts easily pulled off of shelves. b. Color-coded system used for visual recognition. 3. Movable Files: a. Electronic/Manual controlled file cabinets. b. Move on tracks in the floor. c. Saves space.  Always file records accurately, neatly and in a timely manner. ____________________________________________________________________________________ FILE FOLDERS:  Can be colored.  Top/side edges can have tabs at spaces intervals for labels to be applied. GUIDES/DIVIDER GUIDES:  Keeps records organized.  Easy to locate.  Separates records into categories. (Ex: Labs, Reports, Progress notes, etc) Paper Medical Records Management Paper Medical Records Management The Lifecycle of A Medical Record CREATION UTILIZATION MAINTENANCE DESTRUCTION FOLDERS: Filling Equipment and Supplies Folders Expandable Guides: organization Section tabs Outguides: Used a place holders that indicate that a file has been removed. Helps with refiling, too. Tabs Colors Index tabs Labels, preprinted STORAGE: Filing Storage Equipment Vertical filing cabinet Lateral filing cabinet Open shelf filing cabinet The more records, the more storage space that is needed. Storage may be at onsite or offsite locations. Alphabetic: Filing in alphabetical order according to the patient’s last name seems like a straight forward method since the alphabet is well known and has a standard order. But, there are rules to be followed. Terminal Digit Filing (TDF): TDF is also commonly used for medical record management of paper files. It has some advantages for space allocation and ease of locating files and refiling. When patients are assigned a permanent ID or “Unit” number for your organization, all records can be filed under this number using the last number section. Filing Methods A direct filing system Go directly to the file folder that is placed according to alphabetical order Most common filing system ARMA International publishes standards rules for records management to index and code paper records Terms: Unit—each part of a name (personal or business) Surname—person’s last name Indexing—determining the order of units in a name Filing--a method of storing and retrieving paper documents Rules Alphabetize unit by unit Uppercase and lowercase letters are considered the same Alphabetic Filing System A-B-C Rule 1: Individual Names/Business Names Individual names Indexed by surname (last name), first name, and middle name or initial Business names Indexed in the order written Exception: Business names which begin with “The” “The”