Medical Records

Question 1

5 basic steps for filing

Answer 1

1. Conditioning
   involves grouping related papers together, removing all paper clips & staples, attaching smaller papers to regular sheets & fixing damaged records
2. Releasing
   is marking the form to be filed of designated preference (ready to be filed, the provider’s initials, using a stamp)
3. Indexing & coding
   determining where to place the original record in the file & whether it needs to be cross-referenced in another section. A chart number is typically used for this
4. Sorting
   involves ordering papers in a filing structure & placing the documents in specific groups
5. Storing & filing
   is securing documents permanently in the file to ensure the medical record documents do NOT become misplaced

Question 2

3 basic filing methods

Answer 2

1. Alphabetic filing
   -traditional system for patient records
   -most widely used
   -arranged by last name, first name, & middle initial
2. Numeric filing
   -used for larger health centers or hospitals
   -allows for unlimited expansion without need to shift files to create room
   -saves time retrieving & filing charts
   -added patient confidentiality
3. Subject filing
   -used for general correspondence using alphabetic or alphanumeric filing method
   -all correspondence dealing a particular subject is placed under a specific tab with subject heading

Question 3

HIPAA

Answer 3

Health Insurance Portability and Accountability Act

a law implemented in 1996 to improve the portability and continuity of health insurance coverage; contain costs, fraud, and abuse in the health care industry; set a higher standard for electronic health information communications; and promote the privacy of health information

*does not require specific methods for disposing of medical records

Question 4

minimum 10 years

Answer 4

when there are no specific guidelines for retaining medical records, facilities should preserve records for 10 min. years

Question 5

Reverse Chronological Order

Answer 5

Arranged so that the most recent item is on top and older items are filed further back

Question 6

SOMR

Answer 6

source-oriented medical record

groups information according to its source: laboratory work, x-rays, examinations, consultations.

Question 7

SOAP

Answer 7

1. Subjective impressions
2. Objective findings or clinical indication
3. Assessment or medical diagnosis
4. Plan for treatment

Question 8

CHEDDAR

Answer 8

Chief complaint
History
Examination
Details
Drugs & dosages
Assessment
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