Question

Discuss how a chart is to be organized, include data elements, source oriented versus problem oriented, active, inactive or closed status. Describe protocols for retrieving, routing, purging, storing, transferring, retaining and destruction of medical records. What filing systems are available, i.e. numbering, alphabetical and alphanumeric and which one would you choose? Include what order would you organize medical encounters into one chronological file. What type of information (labs, x-rays, progress notes, etc.) would you gather? What supplies do you need to build that record? Answer in detail if the record belongs to the patient since he/she pays for the services?

Answer 1

Organizing chart based on source oriented and problem oriented

Source oriented	Problem oriented
It is traditional type of medical records Information is arranged according to who supplied the data Problems and treatments are described on the same form Presents some difficulty with tracking progress of specific events	Problem oriented medical record makes it easier to track specific illnesses It consists of following data: Data base Problem list Educational, diagnostic and treatment plan Progress notes
Each person or department makes notatios in a separate sections of the patient’s chart Different disciplines chart on separate forms Each reader must consult various parts of the record to get a complete picture Records become bulky Organizing pattern Each health care has its own section of the chart Sections for MD’s Nursing notes Laboratory Social services Physical therapy Procedure reports Use progress and narrative notes	Easy way of filling the record. Organizing pattern All health care disciplines use the same forms referencing patient problems SOAP or SOAPIE or SOAPIER (subjective, objective, assessment, plan, intervention, evaluation and response) The problems are arranged on basis of active problems and inactive problems.

Retention	Storage	Destruction	Transferring	Retrieving
It is outlined by public records administrator office It must be retained for the entire retention period as outlined in the schedule There should be right to maintain records longer than what is stipulated on the hospital policy During retention period the records will be protected from alteration, tampering, loss and physical damage For records maintained by health information management and other clinical areas, retention will follow hospital guidelines and each department will review and assess record needs based on space constraints and will determine if they are suitable for archiving based on specific departmental policy	Storage areas for inactive records can include either an area inside the facility that has been approved for records storage use, or an off-site Certain things are not approved for storage areas like storage ware houses, mini storage facilities, garages, basements, homes etc Storage areas approved for records storage must be physically secure and environmentally controlled to protect records from unauthorized access and damage or loss due to temperature fluctuations, fire, water damage,pests and other hazards Inactive records moved to off- site storage are boxed, labeled and logged out of our medical record tracking system to allow for efficient access and retrieval	No entire medical record shall be destroyed on an individual basis Records should be destroyed if they are currently involved in open litigation, lawsuit, subject of any government investigation or similar activities Paper records that are scanned into any electronic medical record system and it will be destroyed after scanning, indexing and 100% quality checking has taken place. Medical records will be destroyed in a manner that does not allow for the information to be retrievable, recognizable, reconstructed or practically read.	Transferring allows the user in the system from one file room toanother. This option might be used when a number of decentralized file rooms The process of transferring data is almost a mirror image of the creation of retirement index. The instructions to remove and add records to the index are identical	Inquiry and record ordering access to the medical registry system through website We need basic requirements Internet browser Active customer ID issued User created password Accessing the file index through the web interface Security alert Login processes Online record retrieving screen

Question 3:

Best method in filing is numeric system:

1. The first two digits are tertiary
2. The next two are secondary and the last two are primary
3. The primary digits remains constant eg: year 2007, 2017
4. Each staff may be assigned responsibility for certain section of files
5. This eliminates confusion and one person can be identified easily when needed
6. Also, missing can be reduced in this case

Question no:4 & 5

1. Record number as listed by hospital
2. Patient identification data
3. Etiology for admission
4. Consent form signed
5. Medical history- past/ present
6. Surgical history- past/ present
7. Physical examination report
8. Investigation report
9. Progress notes ( doctors and nurses)
10. Diagnostic and therapeutic
11. Reports and actions taken
12. If any alert notation
13. Discharge summary
14. Patient satisfaction/ feedback report
15. Indexing and labeling
16. Coding data

Question 6:

1. Appropriate chronological filing
2. Patient forms
3. Storage space
4. Personnel
5. Reporting
6. Electronic system
7. Pest control
8. Tracking and retrieving hardware system

Question 7

The records are owned by and the property of the health care provider.

Physician to provide a current copy of the record to the patient under most circumstances.

So it allows a patient or his/ her designee to receive a copy of the requested record. So payment is very important for the storage , retrieving the data.