Medical Records Management

1. Provide base for managing patient care

2. Provide interoffice and intraoffice communication as necessary

3. Determine any patterns that surface to signal provider of patient needs

4. Serve as basis for legal information to protect providers, staff, patients

5. Provide clinical data for research

purpose of medical records.

1. Property of those who create record

2. Information belongs to patient and is protected with privacy and confidentiality

3. Patients are allowed to access their medical records and can ask certain questions

4. Providers who include their patients in their medical record keeping foster trust and respect with their patient

ownership of medical record.

1. Patient is notified and written approval received

2. Identify reason for release

3. Only that information released

4. Does not include release of information to patient’s chosen insurance carrier

authorization to release information.

1. Accuracy essential to patient care

2. Critical to facility’s smooth functioning

3. Important when referring patient to outside specialist

4. Essential in controlling costs

5. May be needed in medical litigation

importance of accurate medical records.

Alphabetic Filing

simplest filing methods; strictly maintained by assigning label to each file.

Numeric Filing

organized by number rather than by letter; preserves patient confidentiality.

Subject Filing

convenient for locating frequently used services or for filing reference materials for patient needs.

1. Facility primary objectives with storage of patient files, business records, research files

2. Selecting alphabetic or numeric system

3. Confidentiality of charts

4. HIPAA compliant

choosing a filing system.

1. Clinical Notes

2. Correspondence

3. Laboratory Reports

4. Miscellaneous

types of reports.

1. Record Purging

2. Active Files

3. Inactive Files

4. Closed Files

retention and purging.

Electronic Medical Records

mandated; one day will replace all paper/manual medical records; fewer errors created.

Archival Storage

providers preserve patient medical records for life of practice; computers help to solve space issues through EMRs.

1. EMRs easily emailed in whole or in part

2. Faxing

3. Scanners

transfer of data.

Confidentiality

major issue in using computer and online devices for storage and transfer of medical information.