The role of the medical assistant is both clerical and clinical in nature. The most important clerical function is the careful management of the patient chart, or record. The management of these individual files is vital to the care of each patient and to the smooth operation of the medical office.

In this chapter you will learn about various options for handling large volumes of patient records. As you work through this chapter, you will begin to have an appreciation for the very important task of records management, and you will develop an organized approach to maintaining these critical files. As you read, watch for helpful tips that teach you how to locate and access patient records quickly and efficiently.

Outline

• The Importance of Records Management
• Filing Equipment
• Filing Supplies
• Filing Systems
• The Filing Process
• Inactive and Closed File Storage

Learning Outcomes

After completing Chapter 10, you will be able to:

 10.1 Describe the equipment and supplies needed for the filing of medical records.
 10.2 List and describe the various types of filing systems.
 10.3 Discuss the benefits of each type of system.
 10.4 Discuss the advantages of color coding the files.
 10.5 Explain how to set up and use a tickler file.
 10.6 Describe each of the five steps in the filing process.
 10.7 Explain the steps to take in trying to locate a misplaced file.
 10.8 List and describe the basic file storage options and the advantages of each.
 10.9 Identify criteria for determining whether files should be retained, stored, or discarded.

Summary

The organization of a practice's filing system depends on how files need to be retrieved. Alphabetic systems are the most common. Numeric systems are sometimes used in practices with patients who require a high level of confidentiality, such as those who are HIV-positive.

Color coding may be used to further identify files. In addition, special types of files, such as tickler files or supplemental files, are sometimes used.

The five steps in the filing process are inspecting, indexing, coding, sorting, and storing. Failure to follow each of the steps in order can result in misplaced or lost files.

Typically, only active files are kept in the practice's main file area. When patient records are determined to be inactive or closed, they are transferred to storage—either elsewhere in the office or outside the practice in a special storage facility. Files may be stored in a variety of formats: paper, microfilm or microfiche, recordable CDs, jump drives, or on the computer. Regardless of where files are stored and in what format, they must be kept safe and secure.

The amount of time that stored files are retained depends on legal, state, and federal guidelines. Offices manage the storage and destruction of files by developing a records retention program. Because even old files contain confidential information, they must be destroyed in an approved manner, not simply thrown away.