Records Management Presentation

AXIA College of University of PhoenixLavora Moses

Overview• Indexes for administrating health care information• Centralized records management• Creation of new records• Straight numeric filing• Permanent and temporary insertion of reports• Storage of patient files• Circulation and tracking of files• Retention schedule• File security• Legal and Ethical responsibility

(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 room• Responsibility for

record keeping is easily identified

• Effective use of equipment, supplies, space, and personnel is made

• Improved security

(Flickr, n.d.)

Creation of manual records

• Face Sheet• Problem oriented record– Database– Problem list– Initial plan– Progress notes

(istockphoto, n.d.)

Straight Numeric Filing System

• Office personnel can be easily trained

• Enhances file security• Files can be expanded

for additional space• Purging is easier• File numbers are

organized 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 request records

from their computer– Clerks sign out patient

files from file area– Outguides are used to

indicate removal• 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• Secure records from fire

or water damage– Keep records in locked

file or room• Protect records from theft– Authorized personnel

in file area– Lock file room when

unstaffed– Password protect

computers

(flickr, n.d.)

Legal and Ethical Responsibilities

• Maintaining the Patient’s Records

• Confidentiality of Information

• Release of Protected Health Information

• Patient access to records• Protected Health

Information must be tracked

(istockphoto, n.d.)

Review

• Centralized Records Management• Archive files kept Five years• Problem Oriented Records• Straight Numeric Filing System• Automated Chart Tracking System

References• ARMA (2009). What is Records Management?. Retrieved

February 18, 2012, fromhttp://www.arma.org/pdf/WhatISRIM.pdf

• FotoSearch (n.d.). File Room Stock Photo & Images. Retrieved February 18, 2012, fromhttp://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 andpractices. Clifton Park, NJ: Thomson.

• Istockphoto (n.d.). Photos. Retrieved February 19, 2012, fromhttp://www1.istockphoto.com/file_thumbview_approve/457238/2/istockphoto_457238_reviewing_medical_chart.jpg