RECORDS MANAGEMENT

Chapter 5

Chapter 5 2

Records Management• Learning Objectives

• Discuss the importance of maintaining accurate medical records.

• List the steps in filing a document.• Compare alphabetic, numeric, and subject filing

systems.• Describe two advantages and two

disadvantages of the alphabetic filing system.• List five suggestions for locating a missing file.• Discuss the purpose of a retention plan.

Chapter 5 3

Key Terms Accession book Active files AHIMA Alphabetic filing ARMA Closed files Coding Color-coding Cross-reference sheet Cuts

Dead storage Folders Guides Inactive files Indexing Inspecting documents Labels Lateral files Micrographics Mobile-aisle files

Chapter 5 4

Key Terms (cont’d)

Numeric filing Open-shelf files Out guide Patient medical record Records management Releasing Retention Rotary circular file Sorting Storing

Subject filing Tabs Tickler file Vertical files

Chapter 5 5

Records Management

• Systematic control of records from their creation through maintenance to storage or destruction

• Record is recorded information in any form—paper, disk, or tape

• ARMA• Sets standards for filing and retention of records

Chapter 5 6

Medical Records• Patient medical records (charts)

• Clinical data sheets, medical and laboratory reports, correspondence about patient

• Correspondence related to health care• Information on supplies, professional

organizations, medical research

• Practice management records• Insurance policies, financial statements, tax

documents, leases, contracts

Chapter 5 7

Filing Equipment• Open-shelf files• Filing cabinets

• Rotary circular file• Vertical files• Lateral files• Mobile-aisle files

Chapter 5 8

Filing Supplies• Folders

• Tabs and tab cuts

• Labels• Color coding

• Guides• Visual clues

• Out guides• Cross-reference sheets

Chapter 5 9

Filing Steps• Inspecting documents

• Release mark

• Indexing• Mental process of identifying classification

• Coding• Physical process of marking classification

• Sorting• Storing

Chapter 5 10

Follow-Up Procedures• Tickler file

• Small file used to store notes regarding files that need follow-up action

• Chronological order• Electronic tickler files

• Reminder message appears on screen• Colored tabs attached to patient files

• Color indicates type of action required

Chapter 5 11

Filing Systems• Alphabetic filing

• Based on alphabet• Most popular• Direct reference system• Less confidentiality• Limited expansion of filing system• Typographical errors cause misfiles

Chapter 5 12

Filing Systems (cont’d)

• Numeric filing• Straight numeric filing; terminal digit filing• Number assigned from accession book• Increased confidentiality and accuracy• Unlimited expansion• Alphabetic cross-index needed• Transposing numbers causes misfiles; requires

training

• Alphanumeric filing

Chapter 5 13

Filing Systems (cont’d)

• Subject filing• Often used for nonpatient records• Subject categories depend on specific needs • Direct reference system• Easy to expand• Extensive cross-referencing may be needed• Time consuming

Chapter 5 14

Filing Rules

1. Each filing segment is a unit

2. Alphabetize units by comparing letter-by-letter

3. Ignore punctuation marks

4. “Nothing comes before something”5. Numbers are filed before letters;

Arabic numerals before roman numerals

Source: ARMA

Chapter 5 15

Locating Missing Files• Look directly in front of or behind where

item should be filed• Look between files and in bottom of file

drawer• Check for a transposition of letters or

numbers• Check alternate spellings• Check with previous users• Check with other office personnel

Chapter 5 16

File Classification• Active files

• Pertain to current patients

• Inactive files• Pertain to patients who have not been seen in six

months or longer

• Closed files• Pertain to patients who have died, moved, or

terminated relationship

Chapter 5 17

Records Retention• State laws must be observed• No specific federal law regarding retention

time frames• Medicare guidelines for retention• AHIMA 1997

• Develop a schedule that complies with legal, regulatory, and accreditation requirements

• Specify what, how long, and what media

Chapter 5 18

Retention Periods• Patient health records

• Adults - 10 years after last encounter• Minors - age of majority plus statute of

limitations on malpractice

Source: AHIMA

• Master patient index, register of births and deaths, register of surgeries

• Permanently

2005

1997

• Diagnostic images• 5 years

Chapter 5 19

Retention Periods (cont’d)

• Practice management records• Professional liability policies - permanently• Tax records - for three latest years• Receipts for equipment - until completely

depreciated• Personal records and licenses - permanently

Source: AHIMA

Chapter 5 20

Paper vs. Electronic Records

• Micrographics• Microfilm/microfiche

• Electronic files• Hard disks• CD/DVD

• Less storage space• Maintained for same retention period as

paper files

Chapter 5 21

Records Disposal• Dead storage

• Closed records• Records to be kept permanently

• Records destruction; AHIMA guidelines• Paper records may be burned, shredded, or

pulped beyond reconstruction• Electronic files need to be overwritten• Microfilm/microfiche and CD-ROM/DVD should be

pulverized

Chapter 5 22

Quiz

active

Open-shelf files

Indexing

coding

___________ is mentally determining the classification of a file.

Files of patient seen within the last six months are _______files.

The physical act of marking the file classification is __________.

__________________ are the most popular type of filing equipment used in medical offices.

Chapter 5 23

Critical Thinking Which filing system would you choose

for patient records? Why?

Students should choose between alphabetic and numeric filing systems; subject filing would not be appropriate. Reasons for alphabetic would be ease of access, initial familiarity, and ease of locating misfiles. Reasons for numeric would be patient confidentiality and ease of expanding system.