What are the two types of filing systems typically used for paper medical records?

1. Creation of the medical record or patient record. 2. Where the record is stored or filed. 3. How the record is maintained. 4. How medical information within the medical record is released.

For which 4 situations does a well organized, easy-to-use records management system include rules?

1. vertical files 2. open-shelf lateral files 3. moveable files

Name the 3 primary types of filing cabinets that can be used in medical offices.

Type of file cabinets that have pull-out drawers and stand vertically.

Vertical files, because cabinets can be locked for extra security. 

What type of filing cabinets is best for storing restricted access files?

1. psychiatric notes 2. information on treatment of substance abuse 3. information on treatment of human immunodeficiency virus (HIV)

Give 3 examples of restricted access files.

True or False: some offices may store financial documents, such as bank statements, and legal documents, such as rental agreements and malpractice insurance policies, in the locked files of vertical files to ensure they won't be lost. 

The type of filing system which enables easy viewing of the right side of each file.

Which type of filing cabinet is most commonly used for color-coded files?

True or False: because the side of the folder is visible, open-shelf lateral files should not be in an area where patients can see them.

True or False: the open-shelf file system would be inappropriate for clinics that treat patients with acquired immune deficiency syndrome (AIDS), sexually transmitted diseases (STDs), or substance abuse. 

Type of filing cabinets in which shelving can be rolled on rollers, moved with a crank handle, or operated electronically.

What type of filing cabinets are commonly used by hospitals?

When the practice has a large number of patient records and infrequent access to individual records. 

When would a medical practice use moveable files as filing cabinets?

Access to a large number of medical records without taking up a lot of space.

What do moveable files allow?

1. fasteners 2. tabs 3. units

What 3 elements do folders in most medical practices contain?

Any portion of a patient's name, accession number, or other numerical filing designation that is used to order and identify the medical record in a filing system.

1. Simple Alphabetical Filing 2. Color-Coded Alphabetical Filing

Name the 2 types of alphabetical filing systems.

1. Consecutive Filing 2. Middle Digit Filing 3. Terminal Digit Filing 4. Accession Log

Name the 4 types of numerical filing systems. 

Organizing system based on the alphabet, usually using the patient's last name.

Simple alphabetical filing

Which filing system is easy to use, but does not afford patients anonymity because their names must be prominently displayed on the file folder?

1. Last name (for hyphenated last names, omit the hyphen and file as if one name). 2. First name. 3. Middle name or initial. 4. Title if applicable

Name the order of the 4 units of a medical record in the Simple alphabetical filing system.

1. "Nothing before something." 2. Prefixes are part of the name (ex: St. Michel is filed as Saintmichel) 3. Titles without last name are the first indexing unit (ex: Sister Angela filed alphabetically by "Sister"). 4. Seniority units are filed alphabetically (ex: Gary Henderson, Jr. is filed before Gary Henderson, Sr.).

Name the 4 rules for organizing units in a simple alphabetical filing system.

Color-coded alphabetical system

Alphabetical filing system that adds colored stickers to the open end of a file to facilitate a visual maintenance of files.

True or False: Color-coded alphabetical systems can be designed for open lateral files or vertical file drawers.

True or False: In a color-coded filing system, each letter of the alphabet is assigned a colored label that is placed on the side or top of the file folder for ease of use. 

True or False: Adding colors to the side or top of the file does not affect the alphabetical filing rules of the alphabetical filing system.

3 stickers - two stickers for the first 2 letters of the last name and one for the first letter of the first name; or three stickers for the first 3 letters of the last name.

How many stickers are used for each medical record in a color-coded filing system?

System that assigns an identification number to each patient file.

Which filing system allows greater confidentiality, but has the added hassle of maintaining a record of the chart number for each patient?

Which filing system is a good choice for psychiatric offices, drug rehabilitation clinics, and social services agencies because of the increased privacy?

When a computer system is not functioning, medical record retrieval is difficult. When an office uses a numeric filing system, they must establish backup systems to find patient records. 

What is the downside of a numeric filing system?

1. Consecutive filing 2. Nonconsecutive filing 3. Accession log

Name the 3 types of numeric filing systems.

Filing system that uses six digits, broken down into three 2-digit segments, and records are filed in ascending order from smaller to larger numbers.

Filing system that uses six digits, broken down into three 2-digit segments, but that does not use consecutive ordering for medical records.

1. middle-digit filing 2. terminal-digit filing

Name the 2 basic forms of nonconsecutive filing.

Straight numerical filing

Another name for consecutive filing?

Another name for consecutive filing?

Numeric system that uses the middle digits of an identification number as the primary indexing unit.

Numeric system that uses the last digits of an identification number as the primary indexing unit.

True; for example, terminal-digit filing may be used for files where the last two digits indicate the patient's year of birth - in a pediatric office, these files could then be easily accessed to send reminders for vaccinations or school physicals. 

True or False: middle-digit and terminal-digit filing may be used to group files by common characteristics.

Filing system that assigns the next number in a sequence to each medical record created, and the records are then filed consecutively by number and the office keeps a log of all patient names and number assignments in a book or computer database. 

Which filing system is good in that it ensures confidentiality, but can create problems because the MA must look up a patient's specific number every time and the number does not provide any other useful information about the patient to help send reminders, organize patient demographic info, etc.?

Because the accession number gives an idea of how old the file is in relation to the other files, records with outstanding balances with lower accession numbers are longer overdue higher accession numbers. 

Why can the accession log number be used as a patient's financial account record?

1. Patient's name 2. Date of the patient's first visit 3. Accession number needed to find the medical record.

What 3 elements does a patient's accession log contain?

True or False: No medically sensitive information such as disease status or treatments received can be written on the outside of a medical record.

1. Colored label indicating the patient's primary care practitioner. 2. Numbered label indicating medical insurance coverage. 3. Drug allergies (commonly a red sticker). 4. Significant food allergies (commonly a red sticker).

Name 4 pieces of information that may be displayed on the outside of a patient's medical record.

True or False: regardless of the filing method used, a system must indicate when a medical record has been taken from the filing system.

A marker, usually made of lightweight cardboard or stiff paper, put in a certain medical record's place in the filing system to indicate that that record has been removed, as well as indicating the present location of that record.

1. When a patient changes his or her name (due to marriage, divorce, adoption, taking religious vows, etc.) 2. When it is difficult to differentiate a patient's last name from first name (ex: John James, Jim Paul, or Mei Le Huan).

Name 2 instances that would cause a staff person to search for or file a record in the wrong place of a filing system.

A guide placed in a filing system where a medical record could be misfiled that indicates the potential filing error and indicates the correct location for the record.  

What is one of the most common reasons for name changes?

1. Increased access to medical data. 2. Cost reductions. 3. Reduction in medical errors.

Name the 3 advantages of an EHR rather than a traditional paper medical or health record.

How much do patients in the United States spend on health care per year?

What percent of the amount per year that patients in the U.S. spend on health care is spent on administrative costs?

1. Costs of copying. 2. Costs of mailing. 3. Costs of storage space and associated costs (climate control, security measures, etc.). 4. Costs of treatment and diagnostic testing due to lack of access to data leading to repeated procedures.

Name 4 costs of a paper-based system that are reduced or eliminated with the electronic system.

True or False: medical errors are the 8th leading cause of death in the United States.

Defined as adverse events that could have been prevented based on current medical knowledge.  

1. Misfiled or lost paper medical records. 2. Unreadable information in written charts or prescriptions. 3. Mishandled or mislabeled laboratory specimens.

Name 3 communication failures that can cause medical errors.

True or False: many medical offices continue to use paper-based medical records because the conversion process is expensive and time-consuming.

Over $32,000 per physician, with ongoing monthly maintenance costs of about $1,200.

How much is purchasing and installing EHR estimated to cost?

Medical files of patients who are currently being seen in the office (have been seen within the last 1-6 years), which should be accessible for use. 

Medical records of patients who no longer seek treatment in the office (have not been seen for over 6 years) because they have moved from the area, changed doctors, or died.

Records of patients who have not been seen for an extended period of time (usually 1 to 6 years) but who may return for care. 

Storage place for records that are no longer in use but are kept for legal purposes.

What act determines record-keeping requirements in each individual state?

Permanent removal of medical records that are no longer in use. 

True or False: as more providers convert to EHR and become accustomed to its use, archiving EHR will become more common than purging. 

1. Key all data into EHR. 2. Use optical character reader (OCR) to convert files. 3. Scan paper medical record.

Name the 3 methods of conversion from paper medical records to EHR that medical offices have to choose from.

True or False: a medical record or a portion of it can be released to persons who demonstrate a "need to know."

1. Consultation by another physician. 2. Legal action. 3. Insurance processing.

Name 3 examples of a legitimate "need to know."

1. physicians 2. attorneys 3. insurance companies 4. government agencies 5. the patient in the medical record

Name 5 entities who may request copies of medical records.

True or False: a medical assistant can release original x-rays and magnetic resonance imaging (MRI) scans, as opposed to copies, as long as they are returned to the original medical record. 

True or False: a medical assistant must release the original documents to a court when a medical record is subpoenaed because photocopied documents are not acceptable in court. 

1. References to diagnosis and treatment of HIV or AIDS. 2. Sexually transmitted diseases. 3. Psychiatric disorders and mental health records. 4. Drug and alcohol abuse history.

Name the 4 types of information for which a medical assistant must obtain specific permission from a patient to release the information.

Pro: No handwritten material is used, reducing errors.
Cons: 1. Errors introduced while inputting information into EHR. 2. Increased cost of inputting all information from lengthy medical records.

What are the pros and cons of the conversion method of keying all data into EHR?

Pro: Possibly cheaper than hand keying documents.
Con: Generally only 90% to 95% accurate.

What are the pros and cons of the conversion method of using optical character reader (OCR) to convert files to EHR?

Pro: Cheaper and faster than other methods.
Cons: 1. Continued illegibility of poorly written charts. 2. Compared to new EHR, inconsistency in appearance and organization, which can cause confusion, frustration, and inefficiency.

What are the pros and cons of the conversion method of scanning paper medical records into EHR?

What two systems are commonly used when filing medical records?

What is the most common method for filing paper medical records?

What is the common equipment used to file and store paper medical records?

What is the most common type of filing system?