Records ManagementPresentation
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Transcript of Records ManagementPresentation
Records ManagementPresentation
Overview
Indexes for administrating health care informationCentralized records managementCreation of new recordsStraight numeric filingPermanent and temporary insertion of reportsStorage of patient filesCirculation and tracking of filesRetention scheduleFile securityLegal and Ethical responsibility
Introduction
What is records management?
Responsibility for managing records and information
Properly document information in time
Not duplicating records
Indexes for administering healthcare information
Master patient indexIdentification dataRecord retrieval
Centralized Records Management
One file roomResponsibility for record
keeping is easily identifiedEffective use
of equipment, supplies, space, and personnel's made
Improved security
Creation of manual records
Face SheetProblem oriented recordDatabaseProblem listInitial planProgress notes
Straight Numeric Filing System
Office personnel can be easily trained
Enhances file securityFiles can be expanded for
additional spacePurging is easier File numbers are organized
from lowest to highest
Temporary and Permanentinsertion of loose reports
Clinical dataPermanentAdministrative dataTemporaryOrganize loose for MS
according to numeric filing system
Storage of Patient Files
Short TermTwo to three daysPermanentCurrently under careArchiveHas not been used
Circulation of records within and outside our facility
Automated chart tracking system
Providers request records from their computer
Clerks sign out patient files from file area
Out guides are used to indicate removal
Lab reports are stored in an extra file cabinet
Retention schedule-destruction of records
Archived recordsShreddingCertificate of destructionMaintained permanently
File Security
Secure records from fire or water damage
Keep records in locked file or room
Protect records from theftAuthorized personnel in file
areaLock file room when
unstaffedPassword protect computers
Legal and Ethical Responsibilities
Maintaining the Patient’s Records
Confidentiality of Information
Release of Protected Health Information
Patient access to recordsProtected Health
Information must be tracked
• CENTRALIZED RECORDS MANAGEMENT• ARCHIVE FILES KEPT FIVE YEARS• PROBLEM ORIENTED RECORDS• STRAIGHT NUMERIC FILING SYSTEM• AUTOMATED CHART TRACKING
SYSTEM
Review
References
ARMA (2009). What is Records Management?. RetrievedMay 24, 2009 fromhttp://www.arma.org/pdf/WhatISRIM.pdf
FotoSearch (n.d.). File Room Stock Photo & Images. Retrieved May 24, 2009, 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 May 25, 2009, from http://www1.istockphoto.com/file_thumbview_approve/457238/2/istockphoto_457238_reviewing_medi cal_chart.jpg