10. Medical Records Management

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:

        Medical information is always 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.

        The EMR can be linked to medical information such as information about medications or treatment protocols for specific medical conditions.

        Less time is spent filing.

        Less storage space is required.

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:

        Cost of computer hardware, software maintenance, and staff training

        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

        Structuring data so that they can be transferred among different digital systems

        Incorporating updates to the software and medical codes as well as meeting new standards for electronic data transfer (see Lecture 46)

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.

File Cabinets

Cabinets or shelves used to store medical records should always be of heavy construction, with proper weighting on the bottom so that they will not tip over, especially if the drawers or shelves pull out. File cabinets should have a locking system. Lateral drawer file cabinets are more common than vertical file cabinets for medical records, although vertical file cabinets may be used for storing other types of information. Lateral drawer file cabinets have drawers that open from the long side, resembling a chest of drawers.

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

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

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.

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 3/4 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).

Putting It All into Practice

HMy 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. ■

r

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.

Chart Dividers

Chart dividers are used to identify each section of the medical record by subject. Chart dividers are made of a heavy material such as manila card stock. Each divider has a tab for identification. Common categories include Progress Notes, History/Physical, Lab Reports, Diagnostic Testing, Hospital Reports, Immunizations/Medications, cardboard and has lines to write the name of the individual removing the record.

Figure 41-3 Laboratory reports are often mounted one above another so that the most recent is visible on top.

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?

Case Study 1

A patient has come to the office to request that a copy of her medical record be sent to another physician. She says that her name is Anna Soubrette and her birth date is April 25, 1952. She says that she has not been seen for 4 years, but her current physician had asked about various medications she had taken for a heart problem in the past. Ellen looks the patient up on the computer under Soubrette, but she does not find the patient listed. ■

Figure 41-4 Outguides.

Correspondence, but this varies according to medical office requirements.

Mounting Sheets

Laboratory reports, copies of prescriptions, and telephone messages are often filed on mounting sheets with adhesive strips. Usually several items can be filed on the same sheet. The medical assistant files the first item at the bottom, with each succeeding item shingled up the mounting sheet. With this system the most recent item is always on top. Figure 41-3 shows this type of mounting sheet.

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

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).

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:

NameUnit 1Unit 2Unit 3
Mary Ann StedeStedeMaryAnn
Alan StoneStoneAlan 
Alan C. StoneStoneAlanC.
Alan CharlesStoneAlanCharles
Stone
StonehamStonehamMedicalSupply
Medical Supply
Peter H. StonesStonesPeterH.

Rule 2: Prefixes

If the last name has a prefix, such as Mc, Mac, Van, de, Des, or D’, the prefix is considered part of the last name. There­fore it begins the first indexing unit. Traditionally these prefixes were lowercase, but today they may be uppercase or lowercase. The prefixes Mc and Mac are usually filed in regular order. In some medical offices, however, they may all be filed as Mc, often as a separate group from other names beginning with “M.” Examples are as follows:

NameUnit 1Unit 2Unit 3
Lyndon A. De LarosaDelarosaLyndonA.
Stephen P. DennisDennisStephenP.
Mary Ann d’EntremontDentremontMaryAnn
Joanne McCarthyMccarthyJoanne 
John VanderbiltVanderbiltJohn 
Joel P. van TwiskVantwiskJoelP.

Rule 3: Abbreviations and Nicknames

It is recommended that abbreviated first and last names be filed as written. If the patient commonly uses an abbreviated first name, the abbreviation is used as an indexing unit. If a nickname is used on the record, it is indexed as if it were the legal name (often it is). If an abbreviation is part of the last name (such as St.), it is part of the first indexing unit. (In some offices, abbreviations such as St. are filed as though they were written out.) Acronyms or initials in business names are indexed as one unit. Examples are as follows:

NameUnit 1Unit 2Unit 3
Dottie A. SettlandSettlandDottieA.
SSI Transport ServiceSSITransportService
Alex M. St. CroixStcroixAlexM.
E. V. ThomasThomasE.V.
Bill van der PostVanderpostBill 
Wm. T. VanderpostVanderpostWm.T.

Rule 4: Hyphenation

Hyphenated names are indexed as one unit, whether first names, last names, or names of children using both parents’ last names. Examples are as follows:

NameUnit 1Unit 2Unit 3
Eustace F. BrightfellowBrightfellowEustaceF.
Claire Bryant-LitsonBryantlitsonClaire 
Ann Marie SmithSmithAnnMarie
Annabelle SmithSmithAnnabelle 
Ann-Marie SmithSmithAnnmarie 

Rule 5: Titles and Seniority Terms

Disregard titles unless the complete name is not given or unless they are necessary to distinguish between two indi­viduals with the exact same name. Seniority terms, such as Jr., may be indexed as the last unit. Numeric seniority terms are indexed in numeric order before alphabetic terms. If a male child has exactly the same name as his father, he is called “Jr.” until his father dies. He is a “III” if his father is a “Jr.” In this case, he has the exact same name as his father and his grandfather. If he is named exactly for his grandfa­ther, who is still living, but not for his father, he is called “II.” Examples are as follows:

NameUnit 1Unit 2Unit 3
Samuel Molson Jr.MolsonSamuelJr.
Samuel Molson Sr.MolsonSamuelSr.
Dr. Patricia A. MoyMoyPatriciaA.

Rule 6: Names of Married Women

A married woman may take her husband’s surname, but she retains her own first and middle names. She may also retain her original name or use both her original name and her husband’s name. If two last names are used, they may or may not be hyphenated. It may be necessary to cross-index the name to prevent confusion.

A woman’s married name may take several forms. The examples assume that Helen Ann Thurman marries James M. Walker.

        She may keep her own first and middle names, and take her husband’s surname (Helen Ann Walker).

        She may keep her own first name, use her family’s surname as a middle name (her maiden name), and take her husband’s surname (Helen Thurman Walker).

        She may keep her own first and middle name and use a hyphenated last name consisting of her original name and her husband’s surname (Helen Ann Thurman-Walker).

        She may keep her own first name, middle name, and her original (family) surname (Helen Ann Thurman). Sometimes the hyphenated surname is used only for the couple’s children, with the woman using one of the other options. It would not be correct to use the husband’s first name as a filing unit of a married woman unless her given name is unknown. Examples are as follows:

NameUnit 1Unit 2Unit 3
Mrs. Arlene Sandra TrimTrimArleneSandra
Mrs. Joan Walker TrimTrimJoanWalker
Mrs. John (Sandra A.) TrimTrimSandraA.
Mrs. Ann WalkerWalkerAnn 
Mrs. Ann R. WalkerWalkerAnnR.
Mrs. Diane A. Walker-TrimWalkertrimDianeA.

Rule 7: Companies and Businesses

The names of companies and businesses are indexed in the same order as written. These are not used for medical records, but the medical assistant may use an alphabetic file for telephone numbers. Disregard punctuation, such as commas, apostrophes, or hyphens. Disregard articles such as a, an, and the. When indexing an acronym (a word formed using the first letters of all the words in a name, such as NYNEX), the acronym is Examples are as follows:

Company Name Unit 1 Edson’s Pharmacy Edsons The Redline         Redline

Supply Company

Rent-A-                       Rentacomputer

Computer Service

Rule 8: Identical Names

If two names are exactly the same, index them first under the name, and then under the location, beginning with the city as the first unit, state as second unit, street as third unit, and street number from lowest to highest. This applies to names of patients and businesses.

Numeric Filing

In many practices, each new patient is assigned a number. This number is used to identify the patient and file the paper medical record (Procedure 41-2). The patient’s number can be accessed with other data in the computer, usually from the name and date of birth, although the patient may also be given a plastic identification card with the medical ID number. A numeric system has two major advantages:

• It is easier to preserve confidentiality.

•In a large practice, it is easier to identify a patient by number when several patients have the same last name. The main disadvantage of using a numeric system for medical record management is that it is an indirect system. This means a cross-referenced index must be maintained to link the patient’s name with the record identification number. Computers can cross-reference information without difficulty, so the EMR is usually linked to a patient identification number.

Terminal Digit Filing Systems

The most common numeric filing system used in medical offices and hospitals uses a six-digit number with a hyphen between each group of two digits (e.g., 01-22-19). The filing system is called terminal digit filing, an indexing system that uses the final group of digits as the first indexing unit. A terminal digit filing system mixes up active and inactive records in the files, so the numbers of the newest (and usually most active) patients are not all located in the same section of the file shelves as they tend to be in a con­secutive numeric system.

What Would You Do? What Would You Not Do?

Case Study 2

Lorna Bennett, a 45-year-old woman with hypertension, has come to the office for a physical examination. When Ellen takes her to the examination room, the patient says, “I’m glad I had an appointment today because I can take care of two things at once. My husband and I are moving out of state next month, so I guess I will just take my medical record with me today so that I can give it to my new physician out there. That will give me a chance to read it, too. I’ve always wondered what was in there.” ■

With terminal digit filing, the numbers are indexed by group, working back from the final to the first group. Within each group the numbers are arranged from lowest to highest. To file the record with the number 01-22-19, the medical assistant would first locate the position of charts that end in 19 (first indexing unit). Assuming that there would be several records that end in -19, the medical assis­tant would then locate the position of charts that end in -22-19. Finally, the medical assistant would file the record between 00-22-19 and 02-22-19.

Examples using two-digit groups are as follows:

NumberUnit 1Unit 2Unit 3
89-25-68682589
48-31-69693148
48-35-69693548

Another way to provide nonconsecutive filing is to assign each patient a combination of both letters and numbers. The records are then filed under the letters alphabetically, followed by the numbers.

Consecutive Filing Systems

In consecutive filing systems, numbers are arranged and filed from the lowest to the highest. In such a system, zeroes are assigned or assumed as the first unit. This type of filing system may be used in a small medical office. Examples are as follows:

Number Unit 1 Unit 2 Unit 3 Unit 4 Unit 5 Unit 6

000642            0             0             0             6             4             2

000853            000853

Subject Filing

Filing systems for documents (e.g., preprinted forms, invoices, purchase orders, service agreements) are often arranged according to subject. Within the subject category, documents may be arranged alphabetically or by date. In the medical office, subject filing is often used for insurance, bills, research, or other documents related to running the practice rather than the patient records.

Chronologic Filing

A tickler file, which is used to “tickle” the memory by serving as a reminder that a specific action must be taken on a specific date, is a type of chronologic system. It may consist of cards or folders or it may be electronic. A card or folder is used for each day of the month, with file guides for each of the 12 months and each day of the month. As each month passes, the day guides are added to items for the current months. A manual system may be useful to identify bills to pay or other activities related to paper docu­ments, but a computer reminder system is often used for daily tasks and/or patient reminders.

Choosing a Filing System

It is important to consider several factors when choosing a filing system for paper medical records. Numeric systems are best for maintaining privacy, but they are more complex because of the need for cross-indexing. When the system is very large, it is easier to prevent confusion if each patient is given a unique number, because many patients may have similar names or even the same name. If several indi­viduals will be filing paper records, a nonconsecutive system such as the terminal digit filing system will make it easier for more than one individual to work comfortably in the filing area.

Outcome File patient records correctly using an alphabetic filing system.

Equipment/Supplies

        Patient records with patient names                                                        • Outguides

        Alphabetic sorter                                                                                    • Index cards

        File cabinet or shelves

PROCEDURE 41-1 Filing Patient Records: Alphabetic

         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.

         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.

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

         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.

         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.

Slide the record in front of the outguide.

PROCEDURES 41-1 and 41-2

PROCEDURE 41-2 Filing Patient Records: Numeric 
Outcome File patient records correctly using a terminal digit filing system.
Equipment/Supplies         Patient records with terminal digit labels         File cabinet or shelves         Numeric sorter        Outguides         Index cards 
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.

PROCEDURE 41-2 Filing Patient Records: Numeric—cont’d

PROCEDURE 41-2

        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.

        Procedural Step. Sort the records according to the terminal digit indexing units, using the sorter if available.

        Procedural Step. Find the correct location in the file for the first record, based on the final group of numbers.

Refine your search based on the middle group of numbers and then the first group of numbers. At the correct location for the record, pull the outguide halfway out, slide the record in front of the outguide, 6. and finish removing the outguide. If your office does

Figure 41-5 Placing an outguide.

RETRIEVING OR FILING A PAPER MEDICAL RECORD

Retrieving Patient Records

A patient record has to be removed from its proper location in the file whenever someone in the office wants to look at it (e.g., for an appointment, when a patient leaves a message).

The record is located using the filing guidelines of the particular office. Paper medical records needed for patients with appointments on a particular day are usually pulled the afternoon before the appointments, using the printed appointment list. Each time a record is taken from storage, an outguide is placed exactly where the record was removed, as illustrated in Figure 41-5.

The person removing the record fills in a card with the name or number on the record and the name of the person who will have the record. Although it seems cumbersome to fill in a card for every record removed, in the long run it is much less frustrating than searching the entire office for a record when the patient is in the waiting room.

not use outguides, use your hand to make a space between the record before and the record after the one you are filing.

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.

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

Filing Records

Each day, several records need to be returned to the file. In most offices, records ready for filing are placed in one location.

Before filing records or documents, the medical assistant should be sure that the records are ready to file. To condi­tion a record, the medical assistant takes several steps:

        All clips, pins, or other extraneous material should be removed.

        Any tears or broken punch holes should be repaired with tape.

        Any sticky notes or other loose papers should be either removed or filed in the record in the correct location.

A sorter is used to arrange the records so that they can

be filed efficiently according to name or medical record number. It is important to locate the correct position to replace the record and remove the outguide. Any items to be filed in the pocket of the outguide should be filed in the record at this time.

Filing Reports and Correspondence

All reports, letters, and other materials that come into the office should be reviewed by the physician, initialed, and then filed in the patient record. A date stamp is often used to identify exactly when a report or letter was received. If the physician dictates progress notes, these must also be reviewed and initialed before filing. With the paper medical record, there is no end to the number of papers that the physician must review. Sometimes physicians even come into the office on the weekend to catch up with all their paperwork. Because of this, there is often a stack of material to be filed on Monday. The physician may indicate an action for the medical assistant to take on a message form or sticky note. These actions can range from arranging labo­ratory or diagnostic follow-up to notifying the patient of results of laboratory or diagnostic tests to calling a phar­macy with a prescription. The medical assistant must complete any follow-up before filing the report (or record) (Procedure 41-3).

Several steps facilitate filing reports or other items in the paper medical record:

        Each report or note to be filed should be initialed by the physician, and any required action should be completed.

        Reports should be sorted before filing according to name or medical record number.

        Once the correct record has been located, the report is filed at the front of the appropriate section. It may be necessary to remove a section of the record to insert the new item.

        The record should be reassembled before being replaced in the file.

        Reports for items that are not in their correct locations should be set aside. After all other reports have been filed, if time permits, the medical assistant can search for the missing records.

Measures to Ensure Accuracy or Locate Misplaced Records

Seven steps can ensure accuracy in filing or locating a mis­placed record. A missing record creates multiple problems. Working carefully can help avoid lost records.

                  The medical assistant should work slowly and care­fully when filing records.

                   It is recommended to use outguides to keep track of the record.

                 Medical records should be returned to storage after use and not just handed on to others in the medical office. If it is necessary to give a record to the physi­cian, the outguide should be updated.

                 Physicians and other personnel should be discouraged from hoarding records. The medical assistant should encourage the physician(s) to finish all dictation each day, review laboratory reports, and sign off on them.

                 Records should be kept in orderly stacks when they are out of the files. This makes it easier to scan for one particular record.

                 If the medical assistant notices a misfiled record in the files, it should be removed and filed correctly without delay.

                 Hunting for “missing” records and being alert to find them in unexpected places are important. After all possible measures fail to locate a missing record, it may be necessary to create a second record for a patient until the record can be found.

What Would You Do? What Would You Not Do?

Case Study 3

When Ellen is pulling medical records for the next day’s appoint­ments, she does not find the medical record for Alan DuBois under “Dubois.” The file also has no outguide. Ellen remembers that the patient was seen within the past week or two. She also checks under “Bois,” but the record is not filed there, either. ■

PROCEDURE 41-3

PROCEDURE 41-3 Filing Reports

Outcome File reports, correspondence, and other material in a patient record.

Equipment/Supplies

              Medical records                                                                                      •     Tape

              Assorted reports                                                                                     •     Stapler

              Letters or other material to be             filed                                             •     Sorter

              Hole punch

         Procedural Step. Assemble materials to be filed and necessary supplies to assist in the filing process.

         Procedural Step. Remove extraneous materials, such as paper clips or pins; mend any tears with tape; and staple related pages together. Punch holes if necessary. Principle. Preparation before filing allows all materials in the record to be maintained in good condition.

         Procedural Step. Verify that each report is ready to be filed. In most offices the physician initials reports after he or she has seen them. If the initials are missing, the report should go back to him or her.

Principle. The physician must see each report that comes to the medical office. A procedure verifying that the physician has seen the report before filing prevents reports from being accidentally overlooked.

Procedural Step. Sort the reports using the sorter alphabetically or numerically, depending on the filing system. Sort by letters, numbers, or number groups first, then sort within each letter or number group. Principle. Even in a small office, large numbers of reports need to be filed in patient records if a paper record system is used. It is more efficient to file in order, especially when patients have more than one report to be filed.

Principle. The record usually contains several sections in a specific order. Reports need to be in the correct section to be easily located.

         Procedural Step. Put the record back together if neces­sary and file with other medical records.

Principle. It is easier to file reports in the wrong record when several records are out.

         Procedural Step. If the record is not in the file, place the report back in the sorter or in the pocket of the outguide.

Principle. It is more efficient to file reports in records you can find easily than to hunt for records just to file reports.

ELECTRONIC MEDICAL RECORD

The EMR is usually updated immediately by medical assis­tants, physicians, or other staff members who interact with patients. The physician may use voice recognition software to generate reports, or a transcription service may be used that links the transcribed reports directly into the patient’s record. Use of the EMR greatly reduces the need for filing, although paper reports, correspondence, and consent forms are usually scanned into the record as soon as possible. The originals may be shredded or stored in a paper record depending on the office.

EMRs are password protected, and patient data are com­partmentalized so that access can be limited to the informa­tion that any given staff member needs to view. A system administrator should authorize users and remove them from the system as appropriate. Data should be encrypted between the server and the user, and the infrastructure for access should be secure. The medical assistant should never allow other personnel to access patient information with his or her password.

STORING MEDICAL RECORDS

The storage area for paper medical records should be well- lighted and climate controlled. It is important to maintain the relative humidity at 48% to 52% to prevent deteriora­tion of the records. Basement storage is not recommended unless the humidity is well controlled. The records should also be protected from dust, insects, rodents, fires, and floods. As discussed earlier, records should be secure when the office is closed so that unauthorized personnel do not have access to them. The Occupational Health and Safety Administration (OSHA) requires that main aisles leading out of a room or to a fire exit must be a minimum of 5 feet wide, and secondary aisles, such as between shelving units, must be a minimum of 3 feet wide.

The shelf files should be full enough to allow the folders to stand upright but loose enough to allow folders to be easily stored and retrieved.

Active Records

Active records (records regarding patients who have been seen within the past 2 to 5 years) are stored in the medical office as described earlier. These records need to be readily available for daily use.

Inactive Records

Paper records of patients who have not been seen within a time period specified by the practice (inactive records) are usually kept in the office in closed storage. If there is not enough space in the office to store inactive records, they are sometimes stored in a storage room elsewhere in the office building, or in rented storage space. If a patient has not been seen for several years, a new medical record may be created. However, the old record may still need to be consulted.

At regular intervals inactive records are removed from the active record area. Most offices place a sticker for the current year on a patient’s medical record at the first visit in a new year to show that the record is active for that year. This facili­tates removal of inactive records after a specified interval.

Retention of Records

The length of time that a medical record must be retained is difficult to determine. Each state has a law limiting the time period for beginning a lawsuit for malpractice. This is known as the statute of limitations for medical malpractice. A state may also have a minimum requirement for retaining medical records.

—————————–

Highlight on Electronic Signatures

When talking about electronic signatures, it is important to distin­guish between actual signatures that are captured electronically and an electronic entry specific to one individual that authenticates identity and can be linked to a specific date and time.

When a medical office uses an electronic medical record (EMR), the staff can use two ways to handle actual patient signatures. With the first method, the patient signs a paper consent form and the paper consent form is then scanned into the electronic record. With the second method, the patient reads the consent form, either in a paper version or on a computer screen, and then the patient signs an electronic signature pad that captures an image of the actual signature and inserts it into an electronic version of the form being signed.

Physicians and other staff in the medical office usually use an electronic signature, an electronic sound, symbol, or process added to an electronic record that indicates intent to sign. These processes are built into the software with safeguards to validate the time of the entry and the identity of the individual making the entry. Electronic signatures are also used for transmitting insur­ance claims and for validating entries to the EMR. Electronic sig­natures are valid in all states and are accepted by the Health Insurance Portability and Accountability Act (HIPAA), provided that the software being used validates identity, validates that the docu­ment was not altered later, and provides that the user cannot later repudiate the electronic signature.

The term digital signature is used for a form of encryption that binds electronic records to an “electronic fingerprint.” Digital sig­natures require validation by private companies called certification authorities. The entire document is encrypted and decrypted using public and private keys (mathematic formulas). Digital signatures are used for transferring money and signing legal documents elec­tronically. This level of security is currently not required for EMRs. ■

medical office can review retention guidelines established by the American Medical Association (AMA) in 1994. The AMA recommends that records be retained primarily based on the health needs of the patient, but at least as long as the state requires or the length of time of the statute of limitations for malpractice claims. For a minor, the time period should be considered to begin at the age of majority. Records of Medicare and Medicaid patients should be retained for at least 5 years after the last contact.

At the end of the retention period, the inactive medical record may be destroyed (by shredding or burning) or put in a final storage place to be kept permanently. The AMA recom­mends that the patient have an opportunity to claim the record before it is destroyed, if possible. Records that are closed (it is known that the patient will not return) may be trans­ferred to microfilm or microfiche. They can also be copied using a laser beam and stored on laser disks. These options are expensive and time-consuming, but may be worthwhile for larger practices. Other records that should be kept indefi­nitely are insurance policies, licenses, and Drug Enforcement Administration (DEA) controlled-substance records. All tax records should also be kept for 7 years; after that, back­ground records used to determine taxes can be destroyed, but copies of tax forms should be kept indefinitely.

Storing Computerized Records

EMRs should be backed up regularly and securely. The system manager is usually responsible for ensuring that the backup system is implemented according to plan. Backups may be done to network storage and/or storage devices, such as hard drives, DVDs, or other devices. It is important to maintain some kind of backup off-site in case of fire or disaster. Inactive electronic records can be transferred to separate storage if the system capacity becomes strained. The system administrator must also be sure that program updates are compatible with previously stored data.

MEDICAL PRACTICE and the LAW

Legal Implications of the Medical Record and Protected Health Information

The medical record is initiated by the medical office and belongs to the person or group who produced it. The physician or office owns the physical record whether its form is paper or electronic.

The information in the record belongs to the patient, however, and the patient controls access to the information. Any request to release copies of records must come from the patient or someone who is authorized to act for the patient.

The original record must never be released. If the original record is subpoenaed by a court, an employee of the office should travel with the record to safeguard it and be sure that no part is lost or tampered with. A copy of the record should be left at the office.

The office should have a form for patients to sign that gives permission to release the medical record or information about specific conditions that require separate consent forms (e.g., HIV or AIDS). The release must be signed by the patient or by a guard­ian if the patient is a minor.

When a patient begins a new relationship with a physician’s office, the patient routinely signs a release form allowing the physi­cian to send necessary information to an insurance company. One of the standards being developed under the Health Insurance Portability and Accountability Act legislation concerns a standard format for electronic signatures.

Another time that records are usually released is when a patient moves away or begins a relationship with another physician. Offices usually charge a copying fee, a handling fee, and postage, especially if the record is requested by a lawyer for litigation. The amount that can be charged may be regulated by state law.

Under the Health Information Technology for Economic and Clinical Health Act (HITECH), health care facilities using EMRs are required to keep track of every access of patient information through logs. If a patient’s unsecured data are accessed without authority, the patient must be notified. The patient also has the right to an accounting of disclosures of private information to anyone outside the office within the previous 3 years. The patient can also request that an office not disclose certain information to a health plan or insurance company. Finally, only necessary infor­mation can be shared with other entities (if the information is shared for purposes other than treatment). In order to meet these requirements, all health care institutions using electronic medical records must keep extensive logs showing who accessed informa­tion and when. ■

What Would You Do? What Would You Not Do? responses

Case Study 1

What Did Ellen Do?

           Made every possible attempt to find the patient’s record.

           Asked the patient if she could have been seen under another last name.

           Tried to locate the patient under her maiden name.

           Attempted to locate the patient in the computer using the birth date and/or the first name.

           Attempted to locate the record in the storage area for inactive patients under Soubrette.

           Even if Ellen was not able to locate the record, she asked Ms. Soubrette to fill out a release of information sheet, took her telephone number, and said she would contact her to let her know if she had been able to locate the record.

           Asked the office manager for other ideas to locate the record.

What Did Ellen Not Do?

           Did not tell the patient that she must have been thinking about a different practice.

           Did not assume that the record had been lost or destroyed.

           Did not tell the patient that after such a long time, the informa­tion probably would not be useful anyway.

What Would You Do/What Would You Not Do?

Review Ellen’s response and place a checkmark next to the infor­mation you included in your response. List the additional informa­tion you included in your response.

What Did Ellen Do?

          Explained that the office would be glad to send or provide a copy of the medical record to the new physician as soon as Ms. Bennett provided a physician name and address.

          Encouraged the patient to fill out a release of information sheet or to take a copy to mail back when she had selected a new physician.

          Explained that Ms. Bennett was in charge of the information in the medical record, but the original record belonged to her physician.

          Notified Ms. Bennett how long it would take to prepare a copy and if any copying fee would be required.

What Did Ellen Not Do?

          Did not allow the patient to take the original medical record.

          Did not promise to prepare a copy of the entire medical record that day.

What Would You Do? What Would You Not Do? responses—contd

What Would You Do/What Would You Not Do?

Review Ellen’s response and place a checkmark next to the infor­mation you included in your response. List the additional informa­tion you included in your response.

What Did Ellen Not Do?

           Did not give up looking for the record until she had made an extensive search.

           Did not accuse any staff member of hiding the medical record.

           Did not call the patient and change his appointment in case the record could not be located.

What Would You Do/What Would You Not Do?

Review Ellen’s response and place a checkmark next to the infor­mation you included in your response. List the additional informa­tion you included in your response.

Case Study 3

Page 1001

What Did Ellen Do?

           Looked up Allan DuBois in the computer to identify the date of his last appointment and who saw him.

           Checked the physician’s office, as well as the billing desk.

           Looked behind furniture, especially in the physician’s office.

           Asked other staff members if they had seen this medical record.

TERMINOLOGY REVIEW

Acronym Active record

Cross-index

Electronic health record (EHR)

Electronic medical record (EMR)

Filing system

Health information exchange (HIE)

Inactive record Indexing units

Medical record management

Nationwide Health Information Network (NHIN) Outguide Sorter Surname

Tab

Terminal digit filing

Medical Term

Word Parts Definition

A word formed from the first letters in a name.

The medical record of a patient who has been seen within a time frame specified by the office (usually 2 to 3 years).

To file under one unit and use a guide or card filed under another unit that refers to the primary filing location.

An individual patient’s health record in digital format. Also called an electronic medical record.

An individual’s medical record in digital format. Also called an electronic health record.

The way in which records are arranged. Common filing systems in the medical office include alphabetic, numeric, by subject, or chronologic.

The electronic exchange of health care-related data among different institutions.

The medical record of a patient who has not been seen within the past 2 to 3 years, or some other time frame specified by a given medical office.

Pieces of information used to identify a correct filing location.

Activities related to the creation, management, use, and disposition of patient medical records.

A set of standards, services, and policies to facilitate national HIE (health information exchange.)

A cardboard or plastic card to insert in a file when a medical record is removed.

A device that facilitates putting papers or records in alphabetic or numeric order.

Last name or family name of an individual; used as the first indexing unit in alphabetic filing.

A projection of a folder that extends beyond the top or side of the folder.

A chronologic filing system that uses the last number or number group as the first indexing unit.

^ ON THE WEB

For information on record management:

American Health Information Management Association: www.ahima.org ARMA International: www.arma.org

National Information Standards Organization: www.niso.org

Nationwide Health Information Network: www.hhs.gov/healthit/healthnetwork/background/

U.S. Department of Health and Human Services—Office of the National Coordinator for Health Information Technology (OCN): www.hhs.gov/healthit