Associate Level Material

Appendix B Office Comparison Interviews

One of the reasons that procedures vary for handling patient records is the volume of patients seen on any given day. By comparing and contrasting record management systems in different sized facilities, you will have information to contribute to several activities in this course. By Week Four you should have completed three interviews, which you may conduct in person or by phone. You need to use the list of uestions in the table on the ne!t page to gather information about each of the following" # small medical facility$an office for one or two doctors # medium%sized facility$a clinic where several doctors work in partnership # large facility$a hospital or medical center

&eople will be more likely to cooperate if you disclose that the information you want is related to schoolwork, you will not take up much of their time, and none of the information is confidential. 'onsider introducing yourself with something like the following" (ello, my name is )))))))) and * need some general information about filing systems for a school assignment. Would it be possible to speak to the person in charge of filing patient records for a few uick uestions, or may * call back at another time+ *f the facility needs proof that you are a student, you must provide your instructor with a name and e%mail address to send a permission notice, and then allow three days for your instructor to send the notice. *t is your responsibility to follow up with the prospective facility after your instructor has been notified. When you call back, be sure to ask to speak with the appropriate person, because you cannot e!pect that the person who answers the phone will know about your re uest. Once you have permission to proceed, verify that you are talking to a person who is knowledgeable about maintaining patient records there, and ask the uestions in the table on the ne!t page.

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INTERVIEW QUESTION .. #ppro!imately how many patient records does your department or facility handle in a typical day+ -. #re records in your facility paper, electronic, or both+ *f paper, are they centralized or decentralized+ 3. 4oes your facility use an alphabetic system or a numeric system+ *f numeric, is it" 5traight numeric order+ 6iddle%digit order+ 7erminal%digit order+ Other+ 0. (ow are reports organized within a patient9s file+ 3.

Sma !aci it" -0

#edi$m%si&ed !aci it" 1/

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Both centralized

Both centralized

2lectronic

8umerical%unit

#lphabetic

8umberical%unit

6ost pertinent information first

0. 1a. *f paper records" What determines if new information is allowed to remain loose or must be permanently anchored in the record+

#ll information for active charts stay in medical records for ; years after discharge, no loose information the 4O8 and #4O8 keep the copy records to put in the charts. #ll nurses must enter new information into progress note

8ame 6edical issues:medication s recent visit prior visit %all divided by tabs per department #ll anchored

visit dates patient information departmentalized records

1. 1b. *f electronic records" Where is new information kept until someone has time to enter the information into the electronic record+ <.

all records entered immediately following visit

immediately filed electronically

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<. *f paper records" (ow many different locations are there in your department that patient files may be found+ =For e!ample, are there some temporary holding areas in addition to a permanent area+> ;. ;. *f paper records" *s there a need to chart the circulation of files from one location to another, so that your staff knows where files are kept+

two" chart rack and medical records

two" records room and recent chart files in racks

we are inserviced on where the information is

?. What can cause the biggest problem for records management if it isn9t done right+ @.

./. What measures in terms of physical storage are taken to ensure the privacy of the medical record+ ... ./. What measures in terms of personal handling are taken to ensure the privacy of the medical record+

we can be tagged by state if information is a mess and we cannot find documents they need #ll records are locked up and only few people have access =keys> we use &(* system and comply w: (*&&#

staff is trained on time schedule and should know by date of last visit =found on electronic system> *naccuracy 8ot immediately enteredA inaccuracy

2lectronic security system, and locked physical location same as above

electronic security measures

.-. 4o you have a policy or mechanism to reproduce a lost record+ .3. .-. (ow do you handle records for patients who no longer visit your facility+

Yes

*nvestigation

#ccess log%ins are periodically checked by *7 5taff and access codes are changed consistently File *ncident report and investigate 5tays in electronic system until further access

Beep them in medical records for ; years after discharge ,ecords management would be much easier if we did

.3. What changes in procedures do you think would make record management easier or smoother for you+ What are

&hysical records kept for ./ years in records location, kept electronically indefinitely Beep everything electronically.

*naccuracy:lost files

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your greatest challenges+

not have to file in several different places =computers, charts, med books>. 5tream line filing process

*f you do not understand these uestions, be sure to ask your instructor for clarification before you begin your interviews. 8ot every office handles records similarly, and these general uestions are designed to get medical employees talking about their procedures. *t is possible for the answers you receive to vary substantially. 7ake notes during your interviews, because you will need this information in upcoming activities. You must complete this #ppendi! for the assignment in Week Four.

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