Hope-Hcmt2030-Final Project

DESTRUCTION OF PAPER CHARTS
HEALTH INFORMATION SYSTEMS TECHNOLOGY

November 23, 2016
Prepared by: Angelique Hope
TABLE OF CONTENTS
Practicum Site Overview...............................................................1

Thank-you Letter........................................................................... 2
Goal Statement.............................................................................3
Project Scope................................................................................4
List of Deliverables........................................................................ 5
Destruction of Paper Charts..........................................................6
List of Resources...........................................................................6
Risks............................................................................................. 7
Timeline........................................................................................ 8
Tasks............................................................................................. 9
Project Progress Report...............................................................10
Summary of Results....................................................................12
Success, Failures & Follow-ups....................................................13
Project Presentation....................................................................14
Forms and Tools..........................................................................34
Assessments...............................................................................47
Acknowledgements.....................................................................49
PRACTICUM SITE OVERVIEW

Practicum Site Overview
Destruction of Paper Charts
Anderson Hills Pediatrics is a physicians practice serving patients

in the Cincinnati area. Care is provided for patients from birth to
the age of 21 in one of two locations. One is in Anderson and one
in Amelia, which are staffed by thirteen physicians. Additionally,
there are dieticians and certified lactation nurses on staff.
Anderson Hills Pediatrics is committed to the physical,
developmental and emotional well-being of their patients.
Debbie Fronsoe
3, 2016
Health Information Specialist
Anderson Hills Pediatrics
7400 Jager Court
Cincinnati, OH 45230
October
Thank-you Letter
Practicum Project-Destruction of Paper Charts
Dear Debbie Fronsoe,
I appreciate the opportunity to perform my Professional Practicum
at your facility. I am looking forward to working with you and the
other staff to understand daily operations and work flow of a
private practice. I am excited to expand my knowledge and
experience in HIM and I am thankful for your time and guidance.
The practicum is more than just obtaining the required hours for
my degree. My previous experience has always been in a hospital
environment for the providers. My goal is to gain as much
knowledge and experience as possible in a private practice to
make my contributions as an employee more rounded. I also hope
to accomplish as much as I can towards the completion of this
large project.
Sincerely,
Angelique Hope
Debbie Fronsoe:
_____________________________
Angelique Hope
Anderson Hills Pediatrics
7400 Jager Court

Goal Statement
The goal of the project is to learn the process of paper chart

destruction in a private practice facility. This will be accomplished
by assisting Anderson Hills Pediatrics staff in the step by step
process that is required before destruction of the paper chart. This
is a very large project that will not be completed during my
practicum however, the goal is to complete as much of the project
as I can.
Angelique Hope
Anderson Hills Pediatrics, Inc.
7400 Jager Court

Project Scope
The scope of the project is to prepare a paper chart for
destruction. This will be achieved in a multiple step process.
Abstract height charts, immunization records, and information
with mothers blood type
Scan this information into the patients electronic record
If the patient is over 28 years of age the chart is ready for
destruction.
If the patient is between 21 and 28 years of age or the patient
is inactive the chart will be kept in storage with the date of
destruction marked on the front of the chart.
Angelique Hope
7400 Jager Court

List of Deliverables
The deliverables of the project are:
Pull all height charts, immunization records and information
with mothers blood type for all obsolete or terminated
charts for patients 21 years of age or older
Scan all documentation that was pulled from charts
Transfer scanned documents in patients electronic medical
record
Charts for patients that are currently over 28 years of age
put in locked shredder bin for destruction
Charts for patients that are older than 21 years of age and
younger than 21 years of age are marked with the date the
patient turns 28 years of age which is also the date of chart
destruction
Angelique Hope
7400 Jager Court

List of Resources
Resources used for this project:
Centricity
Computer
Scanner
Site Supervisor (health information professional)
Scissors
Tape
Staple puller
Patient charts
Marker
Stapler
Angelique Hope
7400 Jager Court

Risks
The risks of the project are:
Transferring scanned material into incorrect medical record

Destroying a chart in error
Not abstracting all the documents needed
Leaving the computer unlocked
The volume of the project
Reading the writing of the providers of the paper charts
Angelique Hope
7400 Jager Court

Timeline
September 30, 216-Received site supervisors name and number.
October 3, 2016-Spoke with Kim Egan from Anderson Hills
Pediatrics, Inc. to determine the starting date, my schedule and
discuss the project. Starting date was set as Thursday, October
13, 2016.
October 13, 2016-Met Debbie Fronsoe, my site supervisor. The
project is a long-term project so the goal is to complete as many
boxes as possible throughout my practicum. There is 40 years of
charts, totaling 725 boxes and due to the volume of the project
there is no specific timeline.
October 20, 2016October 27, 2016November 3, 2016November 10, 2016-
10
Angelique Hope
7400 Jager Court

Tasks
The tasks of the project are as follows:
Received Practicum Site and Supervisor Contact:
Contacted Kim Egan at Anderson Hills Pediatrics, Inc.
a Discussed starting date
b Discussed schedule
c Discussed project
Project 10/13/16 11/10/16
October 13, 2016
a Abstract immunization records, height and weight
charts and anything with mothers blood type from the
chart
b Register these charts into the computer with name and
date of birth
October 20, 2016
a Scan abstracted documents into the computer
b Transfer scanned documents into the appropriate
electronic record
c Charts of patients over 28 years of age put into locked
shredder bin
d Mark patients over 21 and under 28 years of age with
date of destruction and file
October 27, 2016
a Same as October 20, 2016
November 3, 2016
a Same as previous weeks
November 10, 2016
11
a Same as previous weeks
12
Angelique Hope
7400 Jager Court

Project Progress Report
Date of Project Progress Report:
October 13, 2016
Activities conducted this week included:

Abstracted immunization records, height and weight charts, and
anything with mothers blood type from the chart.
Registered the charts into the computer with patients name and
date of birth
Completed one box
Activities planned for next week include:
Scan items abstracted into the computer
13
Angelique Hope
7400 Jager Court

Project Progress Report
Date of Project Progress Report:
October 20, 2017 (10/27/16, 11/3/16 and 11/10/16)
Activities conducted this week included:

Scanned abstracted documents into the system
Transferred scanned documents into the appropriate chart
Dispose of charts of patients over 28 years of age into locked
shredder bin
Mark charts of patients over 21 and under 28 years of age with
date of destruction
Activities planned for next week include:

The same
14
SUMMARY OF RESULTS
Summary of Results
Prepared 36 boxes of paper charts for destruction
Discussed the release of information process
Learned how to add and edit patients electronically
15
Success, Failures & Follow-ups

SUCCESS
Was able to prepare 36 boxes of paper charts for destruction
Was able to see day to day operations in a private practice
FAILURES
Project not complete
Scanner created delays although minimal
FOLLOW-UPS
I plan to keep in touch with Debbie and hopefully use her as
a reference for future job prospects.
Getting this experience in a private practice has enabled me
to see other opportunities in the field.
16
Project Presentation
PROJECT PRESENTATION
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36
Forms and Tools

FORMS AND TOOLS
37
(TO BE PRINTED ON AHP LETTERHEAD)
DRAFT
RECORD RETENTION AND DESTRUCTION POLICY

1
PURPOSE
The purpose of this Policy is to ensure that necessary records and documents
of Anderson Hills Pediatrics are adequately protected and maintained and to
ensure that records that are no longer needed by Anderson Hills Pediatrics or
are of no value are discarded at the proper time. This Policy is also for the
purpose of aiding employees of Anderson Hills Pediatrics in understanding
their obligations in retaining electronic documents-including e-mail, Web files,
text files, sound and movie files, PDF documents, and all Microsoft Office or
other formatted files.
Policy
This Policy represents Anderson Hills Pediatrics policy regarding the retention
and disposal of records and the retention and disposal of electronic
documents.
Administration
Attached as Appendix A is a Record Retention Schedule that is approved as
the initial maintenance, retention and disposal schedule for physical records
of Anderson Hills Pediatrics and the retention and disposal of electronic
documents. The Practice Administrator (the Administrator) is the officer in
charge of the administration of this Policy and the implementation of
processes and procedures to ensure that the Record Retention Schedule is
followed. The Administrator is also authorized to make modifications to the
Record Retention Schedule from time to time to ensure that it is in
compliance with local, state and federal laws and includes the appropriate
document and record categories for Anderson Hills Pediatrics; monitor local,
state and federal laws affecting record retention; annually review the record
retention and disposal program; and monitor compliance with this Policy.
Suspension of Record Disposal In Event of Litigation or Claims
38
In the event Anderson Hills Pediatrics is served with any subpoena or request
for documents or any employee becomes aware of a governmental
investigation or audit concerning Anderson Hills Pediatrics or the
commencement of any litigation against or concerning Anderson Hills
Pediatrics, such employee shall inform the Administrator and any further
disposal of documents shall be suspended until such time as the
Administrator, with the advice of counsel, determines otherwise. The
Administrator shall take such steps as is necessary to promptly inform all
staff of any suspension in the further disposal of documents.
5
Applicability
This policy applies to all physical records generated in the course of Anderson
Hills Pediatrics operation, including both original documents and
reproductions. It also applies to the electronic documents described above.
This Policy was approved by the Board of Directors of Anderson Hills
Pediatrics on ________, ____, 2016.
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APPENDIX A-RECORD RETENTION SCHEDULE

The Record Retention Schedule is organized as follows:
SECTION TOPIC
A
B
C
D
E
F
G
H
I
J
K
L
M
Accounting and Finance

Contracts
Corporate Records
Correspondence and Internal Memoranda
Electronic Documents
Medical Records
Insurance Records
Legal Files and Papers
Miscellaneous
Payroll Documents
Personnel Records
Property Records
Tax Records
A ACCOUNTING AND FINANCE

Record Type
Retention Period
Accounts Payable ledgers and schedules
7 years
Accounts Receivable ledgers and schedules
7 years
Annual Audit Reports and Financial Statements

Annual Audit Records, including work papers and
other documents that relate to the audit
of audit
Annual Plans and Budgets
Permanent
7 years after completion
2 years
Bank Statements and Canceled Checks

Employee Expense Reports
General Ledgers
7 years
7 years
Permanent
Interim Financial Statements
7 years
Notes Receivable and ledgers and schedules
7 years
40
Investment Records
investment
7 years after sale of
Credit card records (documents showing customer

credit card number)
2 years
1
Credit card record retention and destruction

A credit card may be used to pay for services provided by Anderson Hills
Pediatrics.
All records showing customer credit card number must be locked in a desk
drawer or a file cabinet when not in immediate use by staff.
If it is determined that information on a document, which contains credit
card information, is necessary for retention beyond 2 years, then the
credit card number will be cut out of the document.
B CONTRACTS
Record Type
Retention Period
Contracts and Related Correspondence (including

any proposal that resulted in the contract and all
other supportive documentation)
or termination
7 years after expiration
C CORPORATE RECORDS
Record Type
Retention Period
Corporate Records (minute books, signed

Minutes of the Board and all committees,
Corporate seals, articles of incorporation,
Bylaws, annual corporate reports)
Permanent
Licenses and Permits
Permanent
D CORRESPONDENCE AND INTERAL MEMORANDA

General Principle: Most correspondence and internal memoranda should be
retained for the same period as the document they pertain to or support. For
instance, a letter pertaining to a particular contract would be retained as long
as the contract (7 years after expiration). It is recommended that records that
support a particular project be kept with the project and take on the retention
time of that particular project file.
Correspondence or memoranda that do not pertain to documents having a
prescribed retention period should generally be discarded sooner. These may
be divided into two general categories:
41
Those pertaining to routine matters and having no significant, lasting

consequences should be discarded within two years. Some examples
include:
Routine letters and notes that require no acknowledgment or followup, such as notes of appreciation, congratulations, letters of
transmittal, and plans for meetings.
Form letters that require no follow-up.
Letters of general inquiry and replies that complete a cycle of
correspondence.
Letters or complaints requesting specific action that have no further
value after changes are made or action taken (such as name or
address change).
Other letters of inconsequential subject matter or that definitely
close correspondence to which no further reference will be
necessary.
Chronological correspondence files.
Please note that copies of interoffice correspondence and documents

where a copy will be in the originating department file should be read
and destroyed, unless that information provides reference to or
direction to other documents and must be kept for project traceability.
2
E
Those pertaining to non-routine matters or having significant lasting

consequences should generally be retained permanently.
ELECTRONIC DOCUMENTS
1
Electronic Mail: Not all email needs to be retained, depending on the

subject matter.
All e-mailfrom internal or external sourcesis to be deleted after
12 months.
Staff will strive to keep all but an insignificant minority of their email related to business issues.
Anderson Hills Pediatrics will archive e-mail for six months after the
staff has deleted it, after which time the e-mail will be permanently
deleted.
All Anderson Hills Pediatrics business-related e-mail should be
downloaded to a service center or user directory on the server.
Staff will not store or transfer Anderson Hills Pediatrics related email on non-work-related computers except as necessary or
appropriate for Anderson Hills Pediatrics purposes.
Staff will take care not to send confidential/proprietary Anderson
Hills Pediatrics information to outside sources.
Staff with more than 500 MB in their e-mail account will be unable
to send or receive messages until the size of their account is
reduced. Staff will be notified by the IT Department as their account
size approaches 500 MB.
42
Any e-mail staff deems vital to the performance of their job should
be copied to the staffs S: drive folder, and printed and stored in the
employees workspace.
Electronic Documents: including Microsoft Office Suite and PDF files.
Retention also depends on the subject matter.
PDF documentsthe length of time that a PDF file should be
retained should be based upon the content of the file and the
category under the various sections of this policy. The maximum
period that a PDF file should be retained is 6 years. PDF files the
employee deems vital to the performance of his or her job should
be printed and stored in the employees workspace.
Text/formatted files-Staff will conduct annual reviews of all
text/formatted files (e.g., Microsoft Word documents) and will delete
all those they consider unnecessary or outdated. After five years, all
text files will be deleted from the network and the staffs
desktop/laptop. Text/formatted files the staff deems vital to the
performance of their job should be printed and stored in the staffs
workspace.
Web Page Files: Internet Cookies
All workstations: Internet Explorer should be scheduled to delete
Internet cookies once per month.
Anderson Hills Pediatrics does not automatically delete electronic files
beyond the dates specified this Policy. It is the responsibility of all staff
to adhere to the guidelines specified in this policy.
Each day Anderson Hills Pediatrics will run a tape backup copy of all
electronic files (including email) on Anderson Hills Pediatrics servers,
as specified in the Anderson Hills Pediatrics Disaster Recovery Plan.
This backup tape is a safeguard to retrieve lost information within a
one-year retrieval period should documents on the network experience
problems. The tape backup copy is considered a safeguard for the
record retention system of Anderson Hills Pediatrics, but is not
considered an official repository of Anderson Hills Pediatrics records. All
monthly and yearly tapes are stored offsite according to Anderson Hills
Pediatrics Disaster Recovery Policy.
In certain cases a document will be maintained in both paper and
electronic form. In such cases the official document will be the
electronic document.
MEDICAL RECORDS
Record Type
Retention Period
Master patient index
Permanently
Patient health/medical records
Age of Majority plus 10 years
43
Immunization Records
Diagnostic images (such as x-ray film)
Deceased patient records
1
Permanently
5 years
5 years from the date of death
Medical records retention and destruction

All records will be retained as outlined above. Records will be destroyed by
burning, shredding, pulping, demagnetizing, or pulverizing and a Certificate
of Destruction shall be completed for each item destroyed.
G INSURANCE RECORDS
Record Type
Retention Period
Annual Loss Summaries
10 years
Audits and Adjustments
3 years after final adjustment
Certificates Issued to Anderson Hills Pediatrics
Permanent
Claims Files (including correspondence,

Medical records, injury documentation, etc.) Permanent
Group Insurance Plans-Active Employees
terminated
Inspections
Until Plan is amended or
3 years
Insurance Policies (including expired policies) Permanent

Releases and Settlements
25 years
H LEGAL FILES AND PAPERS

Record Type
Retention Period
Legal Memoranda and Opinions (including

All subject matter files)
Litigation Files
appeals or time for
7 years after close of matter

1 year after expiration of
Filing appeals
Court Orders
Requests for Departure from Records
Retention Plan
Permanent
10 years
44
MISCELLANEOUS
Record Type
Retention Period
Consultants Reports
2 years
Material of Historical Value (including

Pictures, publications)
Permanent
Policy and Procedures Manuals-Original

revision history
Current version with
Policy and Procedures Manuals-Copies
Retain current version only
Annual Reports
Permanent
PAYROLL DOCUMENTS
Record Type
Retention Period
Employee Deduction Authorizations
4 years after termination
Payroll Deductions
Termination + 7 years
W-2 and W-4 Forms
Garnishments, Assignments, Attachments
Payroll registers (gross and net)
7 years
Time Cards/Sheets
Unclaimed Wage Records
K PERSONNEL RECORDS
Record Type
2 years
6 years
Retention Period
Commissions/Bonuses/Incentives/Awards
7 years
EEO-I/EEO-2-Employer Information Reports 2 years after superseded or

filing (whichever is
Longer)
Employee Earnings Records
Separation + 7 years
Employee Handbooks
1 copy kept permanently
Employee Medical Records
Separation + 6 years
45
Employee Personnel Records (including

Individual attendance records, application
Forms, job or status change records,
Performance evaluations, termination papers,
Withholding information, garnishments, test
Results, training and qualification records)
6 years after separation
Employment Contracts-Individual
7 years after separation
Employment Records-Correspondence with

Employment Agencies and Advertisements for
Job Openings
3 years from date of hiring
decision
Employment Records-All Non-Hired Applicants
(Including all applications and resumesWhether solicited or unsolicited, results of
Post-offer, pre-employment physicals, results
Of background investigations, if any, related
Correspondence)
2-4 years (4 years if file contains any
correspondence which might be
Construed as an offer)
Job Descriptions
3 years after superseded
Forms I-9
3 years after hiring, or 1 year after

separation, if later.
PROPERTY RECORDS
Record Type
Retention Period
Correspondence, Property Deeds,

Assessments, Licenses, Right of Way
Original Purchase/Sale/Lease Agreement
Permanent
Permanent
Property Insurance Policies
Permanent
M TAX RECORDS
General Principle: Anderson Hills Pediatrics must keep books of account or
records as are sufficient to establish amount of gross income, deductions,
credits, or other matters required to be shown in any such return.
These documents and records shall be kept for as long as the contents
thereof may become material in the administration of federal, state, and local
income, franchise, and property tax laws.
Record Type
Retention Period
46
Tax-Exemption Documents and

Related Correspondence
Permanent
IRS Rulings
Permanent
Excise Tax Records
7 years
Payroll Tax Records
7 years
Tax Bills, Receipts, and Statements
7 years
Tax Returns-Income, Franchise, Property
Permanent
Tax Work paper Packages-Originals
7 years
Sales/Use Tax Records
7 years
Annual Information Returns-Federal and

State
Permanent
IRS or other Government Audit Records
Permanent
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Our logo here
DRAFT
CERTIFICATE OF DESTRUCTION
The information described below was destroyed in the normal course of

business pursuant to proper retention schedule and destruction policies and
procedures.
Date of destruction:
__________________________________________________________
Description of records or record series disposed of:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Inclusive dates covered:
_________________________________________________________
Method of destruction:
( )Burning ( )Shredding ( ) Pulping ( )Demagnetizing ( )Pulverizing
( ) Other:
_____________________________________________________________________
Records destroyed by:

___________________________________________________________
Witness signature:
______________________________________________________________
Department manager:
___________________________________________________________
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Source: AHIMA Practice Brief Destruction of Patient Health Information

2016 by The American Health Information Management Association. All
Rights Reserved.
49
50
Assessments
ASSESSMENTS
51
REFLECTION
During my time at Anderson Hills Pediatrics and my
practicum experience I was able to observe the day to day
operations in a HIM department for a private practice. This was
very insightful because all of my previous experience has been for
a large physician group in a hospital setting. This gave me a new
perspective and enabled me to see other career options with my
certification and degree in the future. I enjoyed working with
Debbie Fronsoe and hope to be able to use her as a resource in
the future.
52
ACKNOWLEDGEMENTS
Acknowledgements
Dr. Karen Lankisch, RHIA, Program Director, University of
Cincinnati
Darlene Foltz, RHIA, Professor, University of Cincinnati
Kim Egan, Practice Administrator, Anderson Hills Pediatrics
Debbie Fronsoe, Health Information Specialist, Anderson Hills
Pediatrics
53

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DESTRUCTION OF PAPER CHARTS

HEALTH INFORMATION SYSTEMS TECHNOLOGY

Practicum Site Overview...............................................................1

PRACTICUM SITE OVERVIEW

Anderson Hills Pediatrics is a physicians practice serving patients

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

The goal of the project is to learn the process of paper chart

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Resources used for this project:

Destruction of Paper Charts

Destruction of Paper Charts

The risks of the project are:

Transferring scanned material into incorrect medical record

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

a Same as previous weeks

Destruction of Paper Charts

Destruction of Paper Charts

Activities conducted this week included:

Destruction of Paper Charts

Destruction of Paper Charts

Activities conducted this week included:

Activities planned for next week include:

Destruction of Paper Charts

Destruction of Paper Charts

Success, Failures & Follow-ups

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Destruction of Paper Charts

Forms and Tools

Destruction of Paper Charts

(TO BE PRINTED ON AHP LETTERHEAD)

RECORD RETENTION AND DESTRUCTION POLICY

Suspension of Record Disposal In Event of Litigation or Claims

Destruction of Paper Charts

Destruction of Paper Charts