OAMT 40013 – MEDICAL OFFICE PROCEDURES

Module 2: The Administrative Component

Part 2 – The Administrative Component
Topics: Week 6
A. The Medical Record
a. Concept
b. Components of Medical Records
c. Reasons for Maintaining Medical Records
d. Medical Records Management

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First Reporter (Flor)
Overview/Introduction
Accurate and efficient records management is essential in medical offices. Records are useful if they can be located when needed, so
efficient filing of records is equally important. The medical assistant must understand the ways in which the office files are used, the
organization of the files, and the principles and procedures for accurate filing.

Attitudes are contagious. Patients judge the care they receive by the attitude of office personnel (reflected by the speaker’s voice, tone, and
choice of words in telephone situations) as well as by the actual medical service provided by the physician. The caller should be paid the
same attention given a person in a face-to-face consideration.

Learning Outcomes/Objectives:
At the end of the lessons/topics, the students should be able to:
 Discuss the importance of a medical record as a primary source of health information of patients and physicians;
 Identify the medical records used in documenting the patient’s health information and apply proper management of record.
 Evaluate the effective application of records management for the benefit of physicians as well as the patients.

Course Materials:

A. The Medical Record

The patient medical record, also referred to as the patient’s “chart” or “file,” is the source of information about all aspects of a patient’s health
care. Accurate and up-to-date medical records are vital to a medical practice. Current records are necessary for enabling a continuum of care
for patients, for financial and legal success, and for research purposes. It is not surprising, therefore, that one of the most important skills an
administrative medical assistant can demonstrate is the ability to maintain accurate and complete medical records.

Medical Records as Legal Documents

A patient’s medical record constitutes the legal record of the medical practice. On occasion, patient’s records may have to be produced in
court, either to uphold the rights of the physician if the physician is involved in litigation or to substantiate the claim of the patient if the
physician is called as a witness. In malpractice cases, the content and quality of a medical record can be pivotal, leaving a greater impression on
a jury, and even in the physician’s credentials, personality, or reputation. If the data in a medical record are incomplete, illegible, or poorly
maintained, a plaintiff’s attorney may be able to make even the best patient care appear negligent. Therefore, it is important for the
administrative medical assistant to help the physician maintain medical records as carefully as possible. The assistant should bear in mind that
any record could become a vehicle for defending a clinical course of action down the road.

What is Medical Record?

A patient’s medical record holds all data about the patient.
Medical records generally include the following items:
 Chart Notes. A chronological record of ongoing patient care and progress. Chart notes are entries made by the physician, nurse, or other
health care professional regarding pertinent points of a given visit or communication with the patient. The chart notes for a new patient
may be extensive, often containing the details of a medical and physical history.
 History and Physical (HP). History refers to the patient’s complete medical history (usually obtained by the physician during an
interview with the patient on his/her first visit); physical refers to the initial results of a physical examination by the physician.
 Referral and consultation letters. Copies of letter sent to other physicians, referring the patient for specific examinations, tests and so
on.
 Medical Reports. Lab reports, x-ray reports, and reports from special procedures such as electrocardiograms are kept in the medical
record.
 Correspondence. Copies of all correspondence with the patient, including letters, faxes, and notes of telephone conversations and e-
mail messages are part of medical record.
 Clinical Forms. Forms such as immunization records and pediatric growth and development records are included.
 Medication List. A listing of all medications prescribed, including dosage, dispensing instructions, as well as a list of the patient’s known
allergies to medications, if any, are in the medical record.
In addition to medical data, the patient’s record contains administrative data, such as the patient’s personal information, including
insurance and billing records, and release of information and assignment of benefits .

Reasons for Maintaining Medical Record

Medical records provide the practice with complete information regarding the patient.
Thus, they are used by the practice in the following ways:
 As the main source of information for coordinating and carrying out patient care among all providers involved with the patient.
 As evidence of the course of an illness and a record of the treatment being used.
 As a record of the quality of care provided to patients.
 As a tool for ensuring communication and continuity of care from one medical facility to another.
 As the legal record for the practice.
 As the main record to ensure appropriate reimbursement.
 As a source of data for research purposes.

Because the medical record is the basis for so many activities in a practice, every effort should be made to maintain it well. Each time the
patient is seen by a provider, such as for blood pressure check up or a special procedure, or on a return visit for a medication, whether in the
office or at another location, an entry or notation must be made in the patient’s medical record. Entries must be keyed or handwritten.

Remember that no part of a record should be altered, removed, deleted, or destroyed. Only proper correction procedures may be used. Great
care must be taken when entering data to ensure that they are inserted in the correct chart. If an error or discrepancy is discovered in the
medical record at a much later date, the physician may dictate an addendum to the record to correct the discrepancy.

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Second Reporter (Del Ayre)
Ownership
The medical notes made by the physician, the actual chart notes, reports and other materials are the physician’s property. The notes are for
the physician’s use in the treatment of patient. However, the physician cannot use or withhold the information in the record according to
his her own wishes. It is understood that even though the notes made by the physician are the physician’s property, the information in the
record, the nature of the patient’s diagnosis and so on, belongs to the patient. For this reason, patients have the right to control the amount
of type of information that is released from their medical record. Furthermore, patients alone hold the authority to release information to
anyone not directly involved in the care.

Records Management
Records management is the systematic control of records from their creation through maintenance to eventual storage or destruction.
Recorded in any form whether in a computer file, in a paper document, or stored on disks is considered a record. In medical offices, the three
main types of records are:

1. Patient medical records. The central responsibility of the physician’s practice is patient care. For this reason, the proper handling of the
patient medical record is critical. This record is also known as the patient “file” or “chart,” contains chart notes, all medical and
laboratory reports, and all correspondence about the patient.
2. Correspondence related to health care: includes general correspondence about the operation of the business, orders for medical
supplies, research reports, journals, newsletters and announcements from professional organizations.
3. Practice management records. Business and financial management of the practice must also be carefully kept. These documents
include insurance policies, income and expense reports, copies of tax returns for the practice, financial statements, etc. Also kept are
copies of managed care contracts and the office’s compliance program and privacy policy. Personnel and payroll records are also part of
practice management.

The two broad categories of filing are:

(1) centralized – files are kept in one place used by many people in the medical office.
(2) decentralized – information of use to only one staff member, such as physician’s correspondence, is stored in a decentralized file
convenient to the user.

Filing Equipment
The kinds of filing equipment and supplies that best suit a medical office depend on how records are used and who needs to use them.
• Open-shelf files – are bookcase-type shelves that hold files
• Filing cabinets
• Rotary Circular File
• Vertical Files
• Lateral Files
• Mobile-Aisle Files

Filing Supplies
The important considerations in choosing filing supplies are durability of material and uses of color and positioning within a file to make the
user’s task easier.
 Folders – may be purchased in various colors, styles and tab cuts. Tabs are the projections that extend beyond the rest of the folder and
can be labelled and easily viewed. Tab cuts refers to the position of the tab. Folders are filed in such a way that tab cuts with the
accompanying labels are read in an orderly fashion from left to right.
 Labels - Oblong pieces of paper, frequently self-adhesive
 Guides - are rigid dividers placed at the end of a section of files to indicate where a new section or category of files begin, they support
folders and are visual clues to the user of the file, showing exactly where in the file drawer new main subjects begin.
 Out Guides - is a card placed as a substitute for a file folder that serves to indicate that a folder has been removed from the file. The
front of the out guide has lines to record the name of the person who is taking the file, the date the file was removed, and the material
contained in the file. When the file is returned, these annotations are crossed out and the out guide may be reused. Everyone always
knows where a particular file may be found.
 Cross-Reference Sheets – is prepared to indicate where the original material is filed and where in the files other copies may be found.
The cross-reference sheet may be in a different color from the file folders to make identification simpler.

Disposition of Records (Last topic to Report)

Records that have been closed or those that must be kept permanently, patient records, personal records, and business records may be
transferred and are said to be in dead storage, a storage area separate from the area where active files are kept. Dead storage need not be
easily accessible and can be in a location other than the office.

There are financial and storage considerations for every practice. All records cannot be kept indefinitely. Some states have laws related to
the destruction of records and even specify the method of destruction. General guidelines provided by AHIMA include the following:
 Appropriate ways to destroy records include burning, shredding, and pulping. Records must be destroyed so that there is no
possibility of reconstructing them.
 When destroying computerized data, overwriting data or reformatting the disk should be done. Other methods delete file names
but do not really destroy data. Microfilm, microfiche, and laser disks may be destroyed by pulverizing.

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Third Reporter (dela Cruz)
Steps in Filing
Following logical, consistent, systematic steps in preparing materials for filing enables the assistant to file accurately, to find materials
quickly, and to refile documents efficiently.
The steps in filing are:
Step 1. Inspecting documents
Step 2. Indexing
Step 3. Coding
Step 4. Sorting
Step 5. Storing

Step 1. Inspecting the documents - The assistant is responsible for inspecting the documents. Inspect if the document is in good
physical condition, and the information should be complete. Check the attachment and if action should be taken. The document
must also bear a release mark. Releasing is the indication, by initial or by some other agreed-upon mark, that the document has
been inspected and acted upon and is ready for filing.

Step 2. Indexing - One the document has been released, and is ready to be indexed. Indexing is the mental processing of selecting
the name, title, or classification under which an item will be filed and arranging the units of the title or name in the proper order.
Selecting the proper classification for an item is critical to finding the document when it is needed.

Step 3. Coding - It is the placing of a number, letter, or underscore beneath a word to indicate where the document should be filed.
For example, in the correspondence of Jose Gomez, the name Gomez would be underscored or coded. The code may written on the
document, usually in the upper-right hand corner.

Step 4. Sorting - The assistant working with a number of items prepares them for the file by sorting them, or arranging them in the
order in which they will be filed. Before they can be sorted, documents must be indexed and coded.

Step 5. Storing - It is the actual placement of an item in its correct place in the file. When the item is placed in the folder, the top of
the item should be to the left. Documents are placed in the folder with the most current document on top. The folder is then placed
in the file cabinet with the tab side to the rear of the file.

Reminders and Follow-up Procedures

Many items have been stored may require some further action to be taken. For example, Mr. Gomez may require a reminder to return for
his annual checkup. This special file used for follow-up actions is called tickler file. An arrangement of index cards by months of the year
and, within each month, by days of the month is practical. Notations of actions to be taken are placed on cards behind specific dates of the
month.
Another way to be reminded of a follow-up action is to use a colored index tab clipped to a patient’s record. The colored tab indicates that
some kind of action is required. Different colors may be assigned to stand for different kind of actions.
There are also electronic monthly calendars available in most software application suites. If actions to be taken are entered on specific
dates of the electronic calendar, the software will provide an automatic tickler, a message on the screen, on the appropriate date. The
assistant may find this system more efficient and easier to use.

Filing Systems
Effective records management requires records to be filed in the way they will accessed. Several filing systems are sued. Most offices
actually use more than one filing system to organize their different types of information. The major filing systems are alphabetic, numeric,
and subject. Each system has features that are advantages, as well as certain disadvantages.

1. Alphabetic Filing. In alphabetic filing, names, titles, or classifications are arranged in alphabetic order. The assistant must consider
each word segment a unit and must alphabetize unit by unit, comparing letter by letter within the unit. All punctuation marks are to
be ignored and the rule of filing “nothing before something” is followed. Advantages of alphabetic filing are that (a) because it is
based on symbols with which most people are familiar and (b) a misfiled document is easily found. Disadvantages of alphabetic filing
are that (a) it does not protect confidentiality because its symbol are so easy to read and (b) it offers limited filing space and makes
expanding system difficult.
2. Numeric Filing. It is a system in which each patient is assigned a number and the numeric value is cross-indexed to match the
number with the name. Numeric filing may either be straight number, using ascending numbers in systematic order, or terminal-
digit, using the last digit, or last set of digits, as the indexing unit.
3. Subject Filing. It is the placement of related material alphabetically by subject categories.

Color-Coding
Color-coding is used in many medical offices. In a colored-coded system, color folders are used for patients’ files to help
identify categories visually. Different colors stand for various letters of the alphabet or for numbers.
For example, to organize the file of patient medical records,
Red folders may be used to file the letters A through D;
Yellow to file E through H;
Green to file I through N;
Blue for O, P, and Q;
Purple for the letters R through Z.

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Last Reporter (Encinas)
Locating Missing Files
Even in a well-organized office, paper documents will occasionally be lost or misfiled. Here are a number of suggestions for locating missing
file.
• Look directly behind and in front of where the item should be filed.
• Look between other files in the area;
• Look in the bottom of the file drawer and under the file folders if they are suspended.
• Check for the transposition of first and last names, for example, Wheng, Hart instead of Hart, Wheng.
• Check alternate spellings of the name, for example Thomasen and Thomason.
• In numeric filing system, check for transposed numbers, for example, 19-63-01 instead of 19-01-63.
• In a subject filing system, check related subject files or the Miscellaneous files.
• With the permission of those who have used the file recently, search the desk or work area of previous users of the file.
• Check with other office personnel.

Retention of Records
Every medical practice has files from previous years and all types of information. For example, patient medical records include files for
patients who are currently being treated by the physician, those who have not seen the physician for some time, and those who are no
longer patients for one reason or another.
For management purposes, these files are classified as:
 Active files, pertaining to current patients.
 Inactive files, related to patients who have not seen the physician for six months or longer.
 Closed files, containing the files of those patients who have died, moved away, or terminated their relationship with the physician.
Each office sets the criteria and time frames for placing files in one of the categories. This policy is part of a larger policy for record retention
– the length of time records must be retained and the proper disposition of them when they should no longer be stored. Record retention
policies project physicians from exposure to risk and legal problems.

American Health Information Management Association: 1991 – Present

AHIMA is the leading voice and authority in health information, wherever it is found. AHIMA-certified professionals ensure that sensitive
health stories remain accurate, accessible, protected and complete at all times.

Philippine Records Management Association, Inc. or PRMA, Inc. is a professional organization that specializes in the sharing of
knowledge about records and information management at the national and international levels.
The following time frames have been recommended by AHIMA as retention schedules, subject to local laws and regulations:
• Patient health records (adults): Ten years after patient’s most recent encounter.
• Patient health records (minors): Age of majority plus statute of limitations on malpractice.
• Diagnostic images (such as x-rays): Five years.
• Master patient index, register of births, register of deaths, register of surgical procedures: Permanently.
The office policy should include a variety of other records related to the physician’s practice Management:
 Insurance policies: Current policies are kept in safe storage in an accessible file. Professional liability policies are kept permanently.
 Tax Records: Tax records for the three latest years are kept in a readily accessible file. The remaining records may be kept in a less
accessible storage area.
 Receipts for equipment. Receipts for both medical and office equipment are kept until the various pieces of equipment are fully
depreciated, that is, until the value of the equipment has completely diminished.
 Personal records and licenses. Professional licenses and certificates are kept permanently in safe storage. Banking records such as
statements and deposit slips are kept in the file for three years. They may then be moved to a storage area. Other personal records,
such as noncurrent partnership agreements, property records, or other business agreements, are also kept permanently in a storage
area.

Paper versus Electronic Records

To save space, paper records can be stored through a process called micrographics in which miniaturized images of the records are created.
These images are usually in a microfiche (sheet of film holding 90 images) or ultrafiche (compacted film holding up to 1000 images) format
and are viewed on readers that enlarge the images. Micrographic records may be stored in card files or binders. With the increased use of
the large memory capacity afforded by computers, paper records may also be scanned and stored records must be kept according to the
same retention schedule as paper records.

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