One of the reasons that procedures vary for handling patient records is the volume of patients seen on any given day. By comparing and contrasting record management systems in different sized facilities, you will have information to contribute to several activities in this course.
By Week Four you should have completed three interviews, which you may conduct in person or by phone. You need to use the list of questions in the table on the next page to gather information about each of the following:
A small medical facility-an office for one or two doctors
A medium-sized facility-a clinic where several doctors work in partnership
A large facility-a hospital or medical center
People will be more likely to cooperate if you disclose that the information you want is related to schoolwork, you will not take up much of their time, and none of the information is confidential.
Consider introducing yourself with something like the following:
Hello, my name is ________ and I need some general information about filing systems for a school assignment. Would it be possible to speak to the person in charge of filing patient records for a few quick questions, or may I call back at another time?
If the facility needs proof that you are a student, you must provide your instructor with a name and e-mail address to send a permission notice, and then allow three days for your instructor to send the notice. It is your responsibility to follow up with the prospective facility after your instructor has been notified. When you call back, be sure to ask to speak with the appropriate person, because you cannot expect that the person who answers the phone will know about your request.
Once you have permission to proceed, verify that you are talking to a person who is knowledgeable about maintaining patient records there, and ask the questions in the table on the next page.
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INTERVIEW QUESTION
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Small Facility
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Medium-sized Facility
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Large Facility
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1. Approximately how many patient records does your department or facility handle in a typical day?
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2. Are records in your facility paper, electronic, or both? If paper, are they centralized or decentralized?
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3. Does your facility use an alphabetic system or a numeric system?
If numeric, is it:
- Straight numeric order?
- Middle-digit order?
- Terminal-digit order?
- Other?
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4. How are reports organized within a patient's file?
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5. 5a. If paper records: What determines if new information is allowed to remain loose or must be permanently anchored in the record?
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5b. If electronic records: Where is new information kept until someone has time to enter the information into the electronic record?
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6. If paper records: How many different locations are there in your department that patient files may be found? (For example, are there some temporary holding areas in addition to a permanent area?)
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7. If paper records: Is there a need to chart the circulation of files from one location to another, so that your staff knows where files are kept?
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8. What can cause the biggest problem for records management if it isn't done right?
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9. What measures in terms of physical storage are taken to ensure the privacy of the medical record?
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10. What measures in terms of personal handling are taken to ensure the privacy of the medical record?
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11. Do you have a policy or mechanism to reproduce a lost record?
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12. How do you handle records for patients who no longer visit your facility?
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13. What changes in procedures do you think would make record management easier or smoother for you? What are your greatest challenges?
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