Week 1 PP Flashcards
What does a Personnel Manual entail?
- Job description for each employee
- Pay periods
- Working hours
- Vacation
- Sick leave
- Disciplinary measures
- Termination
Computer Applications can…
…receive, store, process and send information.
* Appointment scheduling
* Electronic patient records
* Billing and collection
* Patient ledgers
* Processing insurance claims
* Online communication
What is a records management system?
Refers to a set of procedures used to organize, store, retrieve, remove and dispose of records
What is a record?
it is stored information on any media created or received by the office that is evidence of its operations or that has a value that required its retention at the time (photos, xrays, consent forms, etc.)
What are the 3 Types of Records in Dental Practice
- Patient dental records
- Patient financial records
- Practice business records
Patient Dental Records are…
-collection of all information about a patient’s dental treatment (their chart)
-provide legal value by providing evidence of treatment and business transactions
-provide evidence of day-to-day operations of the practice
-provide historic evidence of treatment
Multiple Forms of Patient Dental Records….
- Patient registration forms
- Medical and dental history forms
- Examination findings
- Diagnosis
- Treatment plans
- Record of treatment provided
- Correspondence
- Consent forms
- Radiographs
What are Patient Financial Records?
-These are maintained separately as a part of the practice business records
-Never filed with the patient’s clinical records.
-A patient ledger contains financial information for each patient or family.
- Payments
- Filed insurance claims
- Statements
- Reminder letters
Practice Business Records Include…
- Accounts receivable records
- Practice expenses waiting to be paid
- Expense records
- Business correspondence
- Bank statements
- Records of income and expenses
- Financial statements, tax records and corporate records
- Practice reports
- Personnel records
What is HIA?
Health Information Act governing Alberta
When does PIPEDA come into play?
For electronic records/communications
What is Filing?
The method of classifying and arranging records so they are preserved safely and can be quickly retrieved when needed
Basic methods of filing in a dental office are…
-Alphabetical (by last name)
-Color coding - Speeds up and makes filing easier. Tabs combine colors and letters to speed up filing and finding of records
-Numerical - patient is assigned a number, must keep a cross reference file
- Electronic - dental software, stored on hard drive or network space
What is Numerical Filing?
- Each patient record is assigned a number
- A cross-reference file must be kept
- Each record is listed in alphabetical order by name along with it’s document number
ex. Smith, Erin 30256
Guidelines for Efficient Filing
- Keep it simple
- Label folders clearly and neatly
- Leave adequate working space between each folder
- Label shelves or drawers
- Use Outguides
- Presort
3 Subdivisions of Patient files
Active Files - patients seen recently (last 2-3 years)
Inactive Files - patients seen over 3 years ago
Archived Files - patients seen over 5 years ago
What are Purge Tabs (aging tabs)
- colour coded tabs are placed onto charts making it easier to sort records into active and inactive categories
Example:
If a patient’s first visit is in 2021 a red 2021 tab is placed on the chart folder. At the patient’s first visit in 2022 a light orange 2022 tab is placed over top of the 2021 tab etc.
2020 –light orange
2021 – red tab
2022 – light orange
*In 2023 anyone left with a 2020 light orange tab is moved to the inactive file area
PIPEDA Electronic Safeguards
- Must ensure confidentiality and protection of the electronic files
- Passwords are used and changed often
- Maintain up-to-date anti-virus protection
- Firewalls should be constructed if working on a network.
- Computer screens must not be in plain sight of patients
- Never leave patient files open on your screen unless you are using them
Recommnedation for electronic storage backups?
It is highly recommended that at least two backup processes be used for electronic data
◦ One maintained locally
◦ One independently maintained off-site
* All electronic files should be backed up daily!
Protecting Paper Files
- Never leave paper records outside their appropriate file space.
- When done for the day, make sure all files are protected in cabinets and the cabinets are properly closed.
- Precautions need to be taken to ensure files are not cross-contaminated when they are being used in a treatment area.
