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.

The Administrative Component

Topics: The Medical Record

a. Concept
b. Components of Medical Records
c. Reasons for Maintaining Medical Records
d. Medical Records Management

Learning Outcomes:

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 (Concept)

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.

b. What is Medical Record and Its Components?

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.

c. 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:

1. As the main source of information for coordinating and carrying out patient care among
all providers involved with the patient.
2. As evidence of the course of an illness and a record of the treatment being used.
3. As a record of the quality of care provided to patients.
4. As a tool for ensuring communication and continuity of care from one medical facility to
another.
5. As the legal record for the practice.
6. As the main record to ensure appropriate reimbursement.
7. 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, checkup 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.

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 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.

D. 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.

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 have 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.

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, and purple for the letters R through Z.

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.

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.

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 ultra-fiche (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.