Records Management Presentation

Overview

Directories for administrating health care informationIntegrated records managementMaking of new recordsStraight numeric filingPermanent and temporary attachment of reportsStorage of patient filesCirculation and following of filesMaintenance scheduleFile securityLegal and Ethical accountability

(Green & Bowie, 2006)

Introduction

What is records management?

Responsibility for managing records and information

Properly document information in time

Not duplicating records

(Flickr, n.d.)

Indexes for administering health care information

Master patient index Identification data Record retrieval

(Istockphoto, n.d.)

Centralized Records Management

One file roomAccountability for record

keeping is easily recognized

Operative use of equipment, supplies, space, and personnel is made

Better security

(Flickr, n.d.)

Creation of manual records

Face SheetProblem oriented record

Database Problem list Initial plan Progress notes

(istockphoto, n.d.)

Straight Numeric Filing System

Office personnel can be easily educated

Improves file security Files can be lengthened for

additional space Removal is easier File numbers are prepared

from lowest to highest

(Flickr, n.d.)

Temporary and Permanent insertion of loose reports

Clinical data Permanent

Administrative data Temporary

Organize loose forms according to numeric filing system

(istockphoto, n.d.)

Storage of Patient Files

Short Term Two to three days

Permanent Currently under care

Archive Has not been used

(flickr, n.d.)

Circulation of records within and outside our facility

Automated chart tracking system Providers call records from

their computer Clerks sign out patient files

from file area Out-guides are used to

indicate elimination

Lab reports are stored in an extra file cabinet

(istockphoto, n.d.)

Retention schedule-destruction of records

Archived records Shredding Certificate of destruction

Maintained permanently

(istockphoto, n.d.)

File Security

Protect records from fire or water damage Save records in locked file

or roomGuard records from theft

Approved personnel in file area

Lock file room when unstaffed

Password protect computers

(flickr, n.d.)

Legal and Ethical Responsibilities

Preserving the Patient’s Records

Privacy of Information

Issue of Protected Health Information

Patient admission to records

Secure Health Information must be traced

(istockphoto, n.d.)

Review

Centralized Records ManagementArchive files kept 5 yearsProblem Oriented RecordsStraight Numeric Filing SystemAutomated Chart Tracking System

References

ARMA (2009). What is Records Management?. Retrievedfrom

http://www.arma.org/pdf/WhatISRIM.pdf

FotoSearch (n.d.). File Room Stock Photo & Images. Retrieved, from

http://www.fotosearch.com/photos-images/file-room_1.html

References Continued

Green, M. A. and Bowie, M. J. (2005). Essentials of health information management: Principles and

practices. Clifton Park, NJ: Thomson.

Istockphoto (n.d.). Photos. Retrieved, fromhttp://www1.istockphoto.com/file_thumbview_approve/457238/2/

istockphoto_457238_reviewing_medical_chart.jpg