Medical Assistant Exam: Administrative Procedures - Medical Records

Computer Concepts
In order to use computers effectively, the medical assistant must know computer terminology and how to use the components of the computer.

Computer Components
A computer is made up of hardware (the physical components) and software (the programs stored inside the computer that perform functions vital to medical offices), and the operating system (the fundamental software program that controls how the entire computer system operates).
Many medical offices use email to remind patients of their upcoming appointments or to receive notices from patients of appointment cancellations. Because messages can be sent to a group of people at the click of a button, email is a fast, efficient, and inexpensive way to send interoffice information. Hard copies of the sent information can be printed and saved as necessary—for example, a printed copy of an email received from a patient canceling an appointment (for documentation purposes).
Computer networks are used to share information between two or more computers, exchanging information electronically. The information exchange can occur over cables, a satellite, or a modem hooked up to telephone lines or cable lines. The Internet is an example of a computer network.

COMMON TYPES OF STORAGE DEVICES

compact disc (CD)
unwritable disks; usually used for listening to music

CD-R
writable disk that cannot be changed once burned because entered data is permanent

CD-RW
rewritable disk used to enter data, erase data, and reenter data

flash drive
a small, removable, and rewritable storage device (also called a thumb drive or a jump drive)

COMMON TYPES OF PRINTERS

dot matrix
least expensive; produces the lowest-quality printout

inkjet
moderately expensive; produces average-quality printout

laser
most expensive; generally produces the best-quality printout

Key Components of a Computer
 

HARDWARE

central processing unit (CPU)
component that allows the computer to perform basic operations

keyboard
device used to enter data into the computer

hardware
devices connected to the computer, e.g., printer, monitor, keyboard

input devices
devices used to enter data or information into the computer system

modem
device that converts electronic signals information to travel over telephone or cable lines

monitor
screen used to view activity on the computer

motherboard
circuit board allowing communication between computer parts

mouse
handheld device that controls the cursor

printer
machine that produces a hard copy or readable paper copy of data

scanner
device that converts printed images and text into digital information

storage devices
used to provide a copy of the data entered, for review or editing

touch pad
a flat, sensitive device that allows movement of the cursor by sliding one’s fingers across the pad

touch screen
a screen sensitive to human touch, allowing interaction with the computer

trackball
handheld device that controls the cursor; has a rolling ball on top of the device

SOFTWARE
computer applications
software programs designed to control the computer, helping it perform a particular task

cursor
device used to point to a specific area on the computer screen

database
software program used to arrange and sort data for easy and fast searching

graphics
computer images (pictures or artwork)

menu
list of options available to the user

screen saver
protects the computer screen from burn-in

software
computer programs that perform tasks within a computer system

spreadsheet
database used for organizing and computing numerical data into charts, graphs, and models

utility software
computer programs for virus protection

word processing
software program used to create, edit, and produce text documents

OPERATING SYSTEM
operating system
software that controls the computer and helps it perform tasks

Random-Access Memory (RAM)
temporary memory storage that functions only while the computer is in use

Read-Only Memory (ROM)
permanent memory storage that cannot be altered

Security Measures
Security measures are essential when dealing with confidential information in a medical office. Some of the measures used to provide security and prevent unauthorized entry into the computer system include:
- Passwords track users entering a program. Each employee using the computer is provided with a password. Employees should be instructed not to share this password with anyone.
- Firewalls keep information secure on a computer by blocking outside information from entering or exiting a private network.
- Antiviral programs protect the computer from software programs and outside communications that aim to interfere with normal computer functioning or cause data to be deleted. Antivirus software must be updated continuously to protect the computer and data from damage.

Medical Management Software
Computers used in the medical office maintain electronic medical records (EMR) and electronic health records (EHR). An EMR is a type of computer-generated record of a patient’s care from one source, such as a medical office, a hospital, or a pharmacy. An EHR documents the total care provided to a patient from all sources. For example, an EHR contains records from all the physicians in different practices who are caring for the patient. It also contains information about medical services and procedures provided by other medical providers and facilities to the patient. The EHR is a more comprehensive record of the patient’s health history.
Computer software programs such as a total management system can help medical assistants to manage patient records, enter demographic data—such as birth dates—needed to complete essential forms, track and schedule appointments, complete billing statements and insurance claims, send claims electronically, post payments from patients and third-party payers, and generate needed reports.

Internet Services
A medical office uses the Internet to send insurance claims electronically; this is referred to as electronic claims transmission (ECT). Claims sent in this manner reach their destinations more quickly and with less expense than claims sent using the postal system. Payments can be made by direct deposit within a few days after transmission when an ECT system is used.

Medical Records Management
Managing medical records is one of the most important responsibilities of the medical assistant. Medical records have four uses.

1. The patient’s medical record is an ongoing source of information needed to provide comprehensive and quality care to the patient. It contains past and present medical information that can influence future care. The record makes needed information available to other medical personnel involved in patient care.
2. The medical record is considered a legal document and can be used in court to protect patients or medical staff members. All entries must be accurate, complete, and written in pen.
3. Clinical information collected from the medical record can be used in research projects, such as monitoring experimental drugs or treatments used for specific diseases.
4. Information collected from medical records can be used for statistics, such as the reporting of various types of contagious diseases.

All information contained in the medical record is confidential and should be viewed only by those in need of the information. Medical record information is released only with written permission by the patient and the patient has the right to decide who can have access to the information in his or her medical record.
The Health Insurance Portability and Accountability Act created the government agency overseeing rules and procedures protecting medical record confidentiality.  The medical assistant must always check for written permission from the patient before releasing any patient information.

Medical Record Ownership
The question often arises as to ownership of the medical record. The person or facility who created the medical record owns the actual paper record. The information within the medical record belongs to the patient. The patient has the right to see the information in the medical record, request a copy of any part of the medical record, and decide what information can be entered or left out of the medical record. Patients often express concern about keeping recorded information confidential and should be reassured that all precautions are taken to protect the material from unauthorized access.

Electronic Medical Records/Electronic Health Records
Although the terms electronic medical record (EMR) and the electronic health record (EHR) are often used interchangeably, there is a clear distinction between the two types of records. The EMR was developed to take the place of a paper record, storing the collected clinical data about the diagnosis and treatment provided to a patient in a computer. The EHR went beyond the immediate care of the patient in a particular facility by having a broader focus. The EHR had the ability to share all the data collected by the EMR to a variety of health care providers involved in all aspects of the patient’s care. The EHR allowed physician offices, hospitals, nursing care facilities, laboratories, community resources, and various specialists to participate in providing and using information from the EHR to ensure quality care to the patient regardless of where the patient was when medical treatment was needed.
EHRs have been used in some medical facilities since the 1960s. With the advancement of technology, computer software is now readily available to provide comprehensive medical information to physicians that can be used in the treatment of patients. Complex medical diagnoses have necessitated the need for prompt access to medical information on patients, a method of data management to locate important information when needed, and the ability to store the collected information for easy retrieval.

The advantages of an EHR include:
- Better patient care, due to available access to a patient’s medical record. For example, if the patient’s primary care physician’s office is closed or if the patient is traveling when he or she becomes injured or experiences an illness, the EHR can be retrieved quickly by the treating facility. EHRs provide up-to-date treatment protocols, recommendations for lab tests, contraindications for medications being prescribed, and can even print out patient instructions, all measures which will improve patient care.
- Less chance of a lost record. Having the patient’s medical record logged into a computer with a back-up system will prevent destruction and loss that can occur with a paper record.
- Multiple users at one time. With a paper record, only one health care provider can view the medical record at a time. With an EHR, the medical record information can be view by many health care providers such as the physician and the medical assistant, each entering data pertaining to the care they provided.
- Efficiency and savings. EHRs provide ease of locating data and save time since medical records are stored on a computer. Less time is spent locating EHRs than searching through rows of paper medical records that may even be misfiled. Eliminating the expense of supplies needed to maintain paper records, storage, and retrieval of active and inactive records has been an economic benefit of using EHRs.

However, there are also disadvantages to using EHRs, including:
- Cost of installing computer equipment. Technology is a big investment in a medical practice, although prices are more reasonable than in years past. The use of EHRs increases reimbursement due to coding programs which provide more accurate coding, and eliminates the need for added personnel to manage paper records and perform transcription.
- Computer downtime is always a concern since it might interfere with patient care.
- Fear of security leaks of privileged information has always been an issue as to why physicians didn’t want to use computers to keep medical records. The government has worked to overcome this problem by various methods such as encryption and government regulations for password setup and maintenance.
- Expense of training time needed for all personnel involved in managing and maintaining the EHR system. Most EHR computer software programs developed are being designed to be more user-friendly and less intimidating. Templates are being set up which make using an EHR easier and more time-efficient.
- Lack of compatibility among computers in different facilities has been a problem with establishing wide use of EHRs. The barriers to incompatibility between computers have been addressed and progress has been made in this area.
EHR use will be mandatory for medical offices and hospitals by 2014, as part of the Stimulus Act of 2009. Regulations regarding the use of EHRs have been established by the National Coordinator for Health Information Technology (HIT), with the requirement that every patient must have an EHR that meets the established criteria and objectives set by the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology. EHR systems have many benefits such as consistent documentation, secure patient privacy, fewer errors due to illegible handwriting, and available resources for provider use. The goal of the EHR is to provide more comprehensive care to patients regarding preventable diseases which will ultimately increase the health of the population and decrease the rising cost of healthcare.

Making Corrections to Medical Records
Even with close attention and extreme care, errors can be made when entering information in EMRs and paper medical records. The acceptable method when correcting a paper medical record error is to draw a single line through the error, write 'corr.' or 'correction' above the error, enter the correct information, and add the date and initials of the person writing the entry. The crossed-out error should never be scribbled out completely or made unreadable.
An error in the EMR can be corrected immediately if noticed or by following the directions of the EMR system used in the office. The error is corrected using the same procedure as the paper medical record by entering 'corr.' or 'correction,' writing in the new information, and adding the date and initials of the person making the correction.

Types of Medical Records
Medical assistants must be familiar with three types of medical records.

Problem-Oriented Medical Record
The EMR or paper medical record can be organized using different methods. The problem-oriented medical record (POMR) is designed to identify, name, and number patient problems and to list them in different sections for easy access and reevaluation using a problem-solving approach. The sections of the POMR include:

1. Patient Database
The patient database consists of the following items:
- patient profile: name, address, date of birth (DOB), phone numbers, emergency contacts, signed consent forms, insurance information, and other personal data about the patient needed by the medical office
- interview with patient
- information from prior medical records, if available
- family history (FH)
- physical examination with review of systems (ROS)
- laboratory and radiology reports
- medication list including prescription drugs, nonprescription drugs, and herbal supplements taken by the patient
- allergies
- previous immunizations

2. Problem List
The problem list keeps track of all patient health issues. The problem list can include current and past problems, active or inactive problems, and acute or chronic problems. The problems can be physiological, psychological, or socioeconomic. Once the complete problem list is developed, each problem is given a title and number. For example, the problem list could include: 1. Diabetes mellitus, 2. Hypertension, 3. Arthritis, and 4. Sore throat. As each problem is addressed by the physician, progress notes in the form of SOAP notes are written to record information about the problem. The acronym SOAP represents:
- Subjective impression: symptoms that are experienced only by the patient and are subjective (meaning that they cannot be objectively measured), such as headache, pain, and fatigue
- Objective clinical evidence: complaints or symptoms reported by the patient that can be measured or seen by others, such as bleeding, an elevated temperature, high blood pressure, or a laceration
- Assessment: an evaluation of the patient’s condition made using the subjective and objective information provided, including the physical exam and any diagnostic procedures performed; a diagnosis is made based on the assessment of all factors contributing to the specific patient problem
- Plan: management of the patient’s problem by ordering further tests and procedures, by implementing treatment for the problem, or by reevaluating the patient’s progress by requesting a return visit
Some facilities use SOAPER notes—adding an 'E' for Education of the patient' and an 'R' for 'Response of the patient to the education provided'—to the SOAP notes.

Example of a SOAP Note
Patient Name: George Jones
Date: February 2, 2011

S. Complaining of severe sore throat for x3 days.
O. Throat appears red. Patient’s temp 101.4º F
A. R/O strep throat.
P. Order throat culture. Will call patient in 24 to 48 hours with results and antibiotic if results are positive.

Source-Oriented Medical Record
The source-oriented medical record (SOMR) is the more traditional method of managing medical records and is still used in many medical offices. The SOMR method of record organization files patient information according to the type of source, or subject matter, generating the information. For example, all radiology reports would be filed together in one section, all laboratory reports would be filed in another section, and all physician entries would be filed in still another section. Within each section, the materials would be filed in chronological order, placing the most recent entry on top for easy viewing. Progress notes using the SOMR system do not use SOAP notes, but rather are written in paragraph style and include all pertinent information.

Strict Chronological Order
Organizing medical record information by using strict chronological order means that all incoming patient information is filed in the medical record with the most recent material on top. There are no separate sections for subject matter or lists of problems. Laboratory reports, radiology reports, progress notes, or any material needing to be added to the patient record is filed in the order it was received or written.
Patient information arranged using this system can make locating past medical information, such as the patient’s last chest X-ray, time consuming. If the specific date of the patient’s most recent chest X-ray is not known, then the medical assistant must search through the medical record, page by page, until the report needed is found.

Medical Record Storage Equipment
If the medical facility is using paper medical records, a storage method of records must be selected. Different types of storage units are available, each type having advantages and disadvantages to consider before a selection can be made. The type of filing cabinets used depends on the size of the storage area, the cost of the equipment, the estimated record volume, and the requirements for confidentiality.
Common types of filing cabinets often used to store medical records include vertical (or drawer) cabinets, lateral (or open-shelf) cabinets, and movable file cabinets (such as compacted cabinets or rotary cabinets).

Supplies Needed for Filing
The supplies needed for filing medical records will depend on the type of filing equipment used and the preference of the medical office.
1. File folders: File folders for vertical file cabinets are made with the tabs at top edge of the folders cut into different sizes. These tabs make it easier to read the labels on the folders in front to back filing. Folders used for lateral shelves are made with tabs that extend on the side of the folder, which makes it easier to read the file names. Color coding helps medical assistants easily recognize and properly file the medical records. For instance, it can help the medical assistant to recognize an active or inactive record based on the color of the sticker indicating a specific year.
2. Outguides or outfolders: Outguides are made of plastic (or a heavier type of material than that used in folders) and are used to keep track of medical records that are removed from the file cabinet for a length of time. Although medical records should be filed daily and remain in the medical office, occasionally the medical record may be needed by the physician to complete reports or needed for reference, preventing a timely filing. Outguides can provide information as to when the record was removed, by whom it was taken, and when it will be returned.
This information is placed in a clear plastic section of the outguide in order to help locate the medical record if it is needed before it is returned. All correspondence and information that needs to be filed for that medical record is placed in the outguide folder section, which prevents material from being lost or misplaced. When the medical record is returned, the patient information in the outguide can be placed in the medical record and the medical record file can be returned to its place in the filing system. Outguides are not used to replace medical records that are pulled daily for office visits.
3. Labels: Labels are used for patient identification, either by name or number. Many offices use a variety of color-coded labels designed to make retrieving and filing medical records easier and faster, to help prevent errors in filing, or to notice errors easily when they are made.
4. Divider guides: Divider guides are usually made of heavier material than folders so that they stand out for easy recognition. They are used to separate the files into specific sections. The divider guides have tabs that are labeled with captions identifying the major divisions of the files. For example, captions can be the letters of the alphabet, or breakdown of numbers into smaller sections, such as, tens, hundreds, or thousands. Organizing into smaller sections provides easier and faster retrieval and filing of medical records.

Filing Systems
The selection of a filing system depends on the volume of information to be filed and on the preference of the medical facility. Each type of filing system has advantages and disadvantages.

Three common filing systems include:

1. Alphabetic filing system. This system is simple to use, which makes it ideal for smaller facilities with limited records. Disadvantages to the alphabetic filing system include potential privacy concerns if patients’ names can be viewed easily by others. Expansion of alphabetic files can sometimes be difficult because the files may need to be moved to accommodate overcrowded sections within the various letter divisions.
2. Numeric filing system. This system provides the advantage of additional patient confidentiality since medical records are filed by number and not by name, and it offers easy expansion (especially when using straight numbers) because each new file is added after the last file entered, avoiding the need to shift or move files. This system is used mainly in larger facilities filing large numbers of records. A disadvantage of this type of system is the extra step needed because an alphabetic record of patient names is needed to locate the numeric file.
3. Subject filing system. This system is used to file business information such as inventory lists, paid invoices, warranties for equipment, vendors used for purchases, repair service records, financial reports, and insurance policies. Medical offices can use subject filing for many different topics. Each topic is arranged in alphabetical order for easy retrieval and filing.

Alphabetic Filing
Alphabetic filing is probably the easiest and most common method used in medical office records management. To perform strict alphabetic filing, certain rules must be followed for separating all items into smaller indexing units—for example, using the patient’s last name as your key unit. The key unit is also referred to as Unit 1. The units used in determining the alphabetic filing order include:
- Unit 1: last name
- Unit 2: legal given first name; no nicknames are used
- Unit 3: middle name or initial
- Unit 4: titles and other identifying information, such as MD, Sr., Jr., Prof., or III. If the office has patients who are couples who share the same last name, it may help to include each partner’s name on the other partner’s medical record as a fourth unit.

For example, Unit 1: Smith; Unit 2: Elizabeth; Unit 3: Lois; Unit 4: Mrs. Robert. This means that the record is filed first under the last name 'Smith,' but if there are other patients named Smith, then the next unit is the first name 'Elizabeth.' If there is more than one Elizabeth Smith, then the next unit is the middle name.

Basic rules have been established to standardize alphabetic filing and to maintain consistency among medical personnel responsible for managing patient records. Although there are variations for the rules used for alphabetic filing, many basic rules are used, including:

1. Complete names are filed in alphabetic sequence from last name, to first name, to middle name.

2. Hyphenated names are considered one unit, and the hyphen is removed.

3. Foreign names are considered as one unit and should be indexed as written, ignoring spaces, any capital letters, or punctuations. Some offices prefer to file names beginning with St. separately. The policy of the office should be followed.

4. Professional titles placed before a name or after a name can be added as Unit 4.

5. Married women use their legal first names as Unit 2. Unit 4 could be the husband’s first name.

6. Seniority titles are listed in alphabetic order as Unit 4.

7. Numbers come before letters; for example, Adam T. Brown III would come before Adam T. Brown Jr.

8. Identical names with no distinguishing titles can use date of birth as Unit 4, using either the month or year for filing arrangement.

9. Mac and Mc are filed in alphabetic order, although some offices prefer to file names beginning with Mc separately. The policy of the office should be followed.

10. Commercial business names can be filed using indexing units, disregarding the word the at the beginning of a name for indexing purpose, by either putting it in parenthesis or indexing it as Unit 4.

11. Identical commercial names can be filed using the address as indexing units.

Numeric Filing
Numeric filing uses numbers instead of letters to file patient medical records. Most large offices and hospitals filing thousands of medical records prefer this type of filing system (used with color coding) to manage medical records.
Numeric filing provides patient confidentiality and allows unlimited expansion of files. The different types of numeric filing include straight numeric filing, middle digit filing, and terminal digit filing. Straight numeric filing and terminal digit filing are most common.

Straight Numeric Filing
Straight numeric filing is the simplest type of numeric filing. In this system, medical records are arranged in ascending order, from the smallest number to the largest number. Examples of straight numeric filing would be 140, 141, 142, and so on, or 000123, 000124, 000125, and so on. In the example of files 140, 141, 142, and so on, the number 1 is the primary indexing unit; therefore, all records starting with a number 1 will be grouped together. Consideration is then given to the middle digits, arranging all records in sequential order, grouping all records having, for example, a number 4 as the middle unit. Finally, the items are then grouped in ascending order according to the last digits of the records. Zeros at the beginning of a group of numbers are ignored when arranged for records filing, so the file number 000123 would be arranged by using the number 1 as the primary unit, using number 2, the middle digit, as Unit 2, and finally, by using 3, the terminal digit, as Unit 3.

Terminal Digit Filing
Terminal digit filing is another common numeric system used in medical offices. In terminal digit filing, the digits, read from right to left, are separated by hyphens. The number of digits used can vary, but usually contain sections of two or three numbers.
Terminal digit filing is divided into 100 major or primary sections. Patients are given preassigned consecutive numbers when the medical record is set up, and the records are filed using the terminal digit, or last digit, in the number as Unit 1. In the number 42-65-26, the last two digits at the far right (numbers 2 and 6) are referred to as Unit 1, the middle two digits (numbers 6 and 5) are Unit 2, and the last two digits on the far left (numbers 4 and 2) are Unit 3. Using this example, all records in unit 1 (with terminal digits 26) are grouped together, then all records in Unit 2 (middle section) are arranged in ascending order, and finally, all numbers in Unit 3 are arranged in ascending order.
If color coding is used in numeric filing, then each digit—zero through nine—would be assigned a specific color. The terminal digits would have corresponding color labels attached to the tabs section of the file. This would make it easier to file records or to spot misfiled records.

Alphabetic Card System/Accession Record System
Regardless of the type of numeric system used, all numeric systems need an alphabetic card system to designate the number given to a specific patient’s medical record. This card system should be locked when the office is closed, in order to protect patient privacy. Each new patient must be assigned a number for the medical record being established. Preassigned numbers are usually prepared in duplicate on labels. When a medical record is needed for a new patient, one of the preassigned numbers is removed from the label attached to the tab on the file folder, and the other label is attached to the alphabetic card. These preassigned numbers are referred to as an accession record, and are assigned and kept on file by a computer system. Using preassigned numbers helps prevent errors when setting up medical records.

Subject Filing
Subject filing can use an alphabetic system (using the letters of the alphabet, such as A, B, C, and so on) or alphanumeric systems (using a combination of letters and numbers, such as A1-1, A1-2, and so on). This type of filing system is used for correspondence, invoices, warranties, or any other general paperwork in the office that needs to be filed. A cross-reference of the material filed may be needed because an invoice for supplies could be in a file labeled 'Invoices for Supplies' or in a file labeled with the name of the supply company from which the item was ordered.

Filing Procedures
Regardless of the system used to file papers or medical records, the following five specific steps should be used when filing.

1. Inspect the paper to be filed, locating the patient’s name or other identifying information to be used in the filing process. All paper clips and staples should be removed before filing, and any tears in the paper should be repaired with tape. All small papers should be affixed to an 8.5 by 11 inch sheet of paper in order to prevent the small paper from being misplaced or lost when filed in the medical record.
2. Index the paper to be filed; that is, decide how the medical record or paper would be located when it will be retrieved, and use the appropriate indexing units to classify it. For example, dividing patient names into indexing units using the last name as Unit 1 is a commonly used method of indexing.
3. Code the paper or medical record, indicating how and where an item will be filed by underlining, circling, or highlighting the selected area. If there is any ambiguity or uncertainty concerning where an item should be filed, then a cross-reference card noting an alternate place that a person may look for the record in the future can be used.
4. Sort the papers or medical records by putting them in the order that they are to be filed: alphabetically, numerically, or by subject. This technique will save time.
5. Filing is the actual placement of papers in the medical record or the placement of the medical record back into the file cabinet after use.

Release Marks
It is essential that the physician has seen and read all material before any patient data can be filed in the medical record. A release mark—either in the form of a stamp or a check mark and the initials of the physician—placed in the same area on all papers to be filed is a good quality control method to safeguard against the filing of unread patient data. If patient information is filed without being read by the physician, then information about negative test results may go unnoticed and the patient may not receive the necessary care.

Special Filing Systems and Techniques

Tickler Files
Tickler files are used as a reminder system that some type of action needs to be taken, and can be used for many purposes, depending on the needs of the office. Tickler file systems can be set up by day, month, or any time frame needed by the office. They can be set up for a variety of uses. Some common uses of a tickler system can include reminders:
- to remind patients about yearly physicals
- to remind patients about monthly or quarterly blood pressure checks
- to be sure that lab results were returned for scheduled patients
- to schedule lab work or outpatient procedures for patients
- to attend monthly hospital meetings
- to follow up on insurance questions from patients

Tickler systems can be manual or computerized, depending on the preference of the staff of the medical office. When set up properly, tickler systems can increase efficiency in the medical office by keeping the staff from overlooking important information.

Cross-Referencing
Cross-referencing is used with alphabetic filing systems to aid in the retrieval of filed material. It is a notation placed in one file area listing other areas within the file system where a specific piece of information may be found.
The most important step in using a cross-referencing system is to determine the primary filing location of the record and then to decide on what the cross-reference card should include. Identifying alternative location sites (usually one or more) where the record may be filed should be helpful when searching for a file.

Locating Misplaced Records
Even with prompt and careful filing, the use of color coding, and the insertion of outguides, medical records or important papers can be misplaced or lost. Spending time searching for a misplaced record wastes valuable time. Here are some helpful steps that the medical assistant may take in locating a missing record:
- Search the entire record page by page to find the misplaced item.
- Check the records that are located in the file immediately before and immediately after the record needed.
- Check the physician’s desk to see if the record is being used by the physician. An outguide may not have been prepared because the record was not removed from the office.
- Check records of patients with similar names to be sure that the item was not mistakenly filed in the incorrect record.

Active, Inactive, and Closed Files
Medical records can be divided into three categories of files.

1. Active files include the medical records of patients currently under the care of the physician or who were recently treated by the physician.
2. Inactive files include medical records of patients not recently treated. Each practice sets policies to determine when a record becomes inactive. Generally, a record is considered inactive two to three years after the patient’s most recent visit. Inactive files may be removed from the easily accessible file cabinets, but must be retained by the office for a number of years, as dictated by state laws.
3. Closed files include medical records that are no longer needed. For example, the medical record for a patient who died or left the practice is considered a closed record.

Record Retention, Record Storage, and Purging Records
Medical offices are constantly accumulating information from various sources, such as laboratory reports and test results needed for patient care, warranties on office equipment, insurance policies, financial records, inactive and closed medical record files, and other miscellaneous data. Some types of information (such as fire insurance policies and warranties) have value for a limited time and do not need to be kept indefinitely. Other types of information such as inactive and closed patient medical records can be destroyed only after the statute of limitations expires, based on the laws of each individual state. Inactive and closed medical record files are separated from active medical record files. However, they must be available if needed and stored following the standards of preserving patient confidentiality as set forth by HIPAA. Purging is the process of appropriately disposing of files or information no longer needed. Material containing patient information or sensitive information is shredded to ensure privacy and prevent exposure of confidential information.