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hcr_210_1.pptx
Records ManagementPresentation
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
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 index
Identification data
Record retrieval
Centralized Records Management
One file room
Responsibility for record keeping is easily identified
Effective use of equipment, supplies, space, and personnel's made
Improved security
Creation of manual records
Face Sheet
Problem oriented record
Database
Problem list
Initial plan
Progress notes
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
Temporary and Permanentinsertion of loose reports
Clinical data
Permanent
Administrative data
Temporary
Organize loose for MS according to numeric filing system
Storage of Patient Files
Short Term
Two to three days
Permanent
Currently under care
Archive
Has 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 records
Shredding
Certificate of destruction
Maintained permanently
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
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
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
