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Efficient Records Management Procedures Boost Patient Service

Learn commercial, alphabetic, subject, indirect, and electronic filing systems. Understand alphabetic filing rules, filing equipment, and supplies for effective record-keeping. Explore charge-out systems, filing patient documents, retrieval, record retention, and document destruction methods.

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Efficient Records Management Procedures Boost Patient Service

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  1. Unit 3 Records Management

  2. Chapter 8 Filing Procedures

  3. Objectives • Review the learning and performance objectives for this chapter • By the end of this chapter, demonstrate the procedures in the textbook and the job skills in the workbook

  4. Heart of the Health Care Professional • Service • Having information at your fingertips and being able to locate documents quickly is a great service to patients.

  5. Commercial Filing Systems • Considerations • Amount of active records • Amount of inactive records • Frequency of record retrieval • Amount of filing space • Convenience of file locations • Cost of the system

  6. Commercial Filing Systems • Alphabetic filing system • Easy to understand • No cross-reference index needed • Alphabetic color-coding • Colored tab for each letter • First three letters of last name • Reduces misfiles

  7. Commercial Filing Systems • Subject filing system • Alphabetic arrangement by topic • In-office reference files • Medical articles • Example 8-1 • File using a subject filing system • Procedure 8-1

  8. Commercial Filing Systems • Indirect filing system • Numeric color-coding • Colored tab for each number • File using a numeric filing system • Procedure 8-2

  9. Commercial Filing Systems • Indirect filing system • Master patient index • Cross-reference • Chronological files • Numbers are used based on dates • Filing documents within a chart

  10. Commercial Filing Systems • Phonetic filing system • Based on phonetic sounds • A, E, I, O, U, W, H, Y – not used • Special training required • Example 8-3

  11. Commercial Filing Systems • Electronic filing system • Bar codes • Swiped like a credit card • Easy tracking • Scanners • Scan outside documents • Store on disc

  12. Commercial Filing Systems • Electronic filing system • Databases • Electronic collections of data • Easily searchable • Electronic security • Confidentiality • Passwords • Access codes

  13. Commercial Filing Systems • Electronic filing system • Maintaining computer files • Label discs with contents • Maintaining e-mail files • Set up an e-mail filing system • Procedure 8-3

  14. Commercial Filing Systems • Electronic filing system • Backing up computer files • Done on a regular basis • Electronic confidentiality guidelines • Protect computer access

  15. Commercial Filing Systems • Tickler filing system • Organize a tickler file • Procedure 8-4 • Short-notice reminder file • Temporary reminder file

  16. Alphabetic Filing Rules • General Guidelines • Rule 1: Individual names • Rule 2: Prefixes • Rule 3: Hyphenated names • Rule 4: Abbreviated names/nicknames

  17. Alphabetic Filing Rules

  18. Alphabetic Filing Rules • General Guidelines • Rule 5: Titles and degrees • Rule 6: Married women • Rule 7: Hospitals, facilities, businesses • Rule 8: Addresses used/identical names

  19. Alphabetic Filing Rules

  20. Alphabetic Filing Rules • General Guidelines • Determining filing units and indexing order to alphabetically file a patient’s medical record • Procedure 8-5

  21. Filing Equipment • Lateral files • Popular • Adaptable • Full-suspension drawer files • Useful for storage of business records • Automated files • Computerized system

  22. Filing Supplies and Their Uses • Guides • Provide support for folders • Visual guide to alphabetical section • Folders • Binder file folders • Stapled and shingled documents

  23. Filing Supplies and Their Uses • Color-coding folders • Miscellaneous colored labels • Tabs • Staggered projections • Labels • Label and color-code patient charts • Procedure 8-6

  24. Charge-Out and Control Systems • Charge-out system • Indicates who has the chart and why • Outguide • Substitution card • Outfolder • Substitution folder • Holds incoming papers

  25. Filing Documents in Patient Records • Prepare, sort, and file documents • Within patient records • Procedure 8-7 • Misfiling • Keep headings simple • Legible • Use guides • Do not overcrowd

  26. Filing Documents in Patient Records • Misplaced or lost records • Organized search • Locate a misfiled medical record folder • Procedure 8-8

  27. Record Retention and Storage • Financial and legal records • Vital papers – permanent • Financial statements – 7 Years • Active and inactive patient files • Active files – on shelves • Inactive files – in storage • State statute of limitations vary

  28. Record Retention and Storage • Micrographics • Microfilm • Miniature photographs on film • Microfiche • Miniature photographic images on cards • Electronic storage • Disk, CD, Flash Drive, Zip Disk

  29. Destroying Documents • Purging computer files • Completely erase the data • Recycling • Shred confidential documents

  30. Stop and Think • Determine document types and filing systems • Review the Scenario • What type of documents are they? • How should they be filed? • Where should they be filed?

  31. Stop and Think • Locate a missing record • Review the scenario • You have methodically checked the file cabinet • What staff members might have the file and for what purpose? • What procedures can be used to prevent missing records?

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