Week 21 Client Records Management PDF

Unit 2 Client Records RECORDS MANAGEMENT Client Records Records Management refers to how the client records are cared for in the dental practice. Clients’ Record or also known as the Clients’ File or Clients’ Chart Client chart Professional, ethical and legal...

Unit 2 Client Records RECORDS MANAGEMENT Client Records Records Management refers to how the client records are cared for in the dental practice. Clients’ Record or also known as the Clients’ File or Clients’ Chart Client chart Professional, ethical and legal responsibilities dictate that a record documenting all aspects of a client’s dental care be maintained All client records must be accurate, well organized, legible, accessible and understandable The purpose of the chart is to gather all relevant information that is needed by the dentist to make an accurate diagnosis and treatment plan Client Chart Charts need to be maintained for each client who is or has been seen in the dental office Files contains a complete and accurate record of the clinical and/or financial activities of the client Files are confidential document filled with subjective and objective data The office has a legal and ethical responsibility to treat these important legal documents with care. The documents are used for ongoing client care, client safety and client and office protection.  Separation of Clinical and Financial Records 1. Clinical-Medical history, Dental history, Updates, Vitals COE examination areas, Odontogram complete with perio pockets recordings Diagnosis and Treatment plan area, Informed consent and informed refusal area Treatment performed sheet- the entries of the care/ treatment that was performed Letters from specialist, referral letter/sheets Radiographs-current x-rays in mounts, while expired are in envelops 2. Financial-fees These fees are for service-charges to the client-outstanding account balances RECORDS MANAGEMENT ⚫ The documents are used for ongoing client care, client safety and client and office protection ⚫ EVERY OFFICE IS LEGALLY REQUIRED TO PROTECT, RETAIN AND TRANSFER THESE DOCUMENTS APPROPRIATELY Federal/Provincial Privacy Acts 1. Personal Information Protection And Electronic Documents Act (PIPEDA) Federal 2. Personal Health Information Act (PHIPA) Provincial PIPEDA Personal Information Protection and Electronic Documents Act. (PIPEDA) set the ground rules for how private organizations may collect, use or disclose personal information in the course of commercial activities. Gives individuals the right to access and request correction of the personal information these organizations may have collected about them.  PIPEDA 1. Accountability 2. Identifying purposes 3. Consent 4. Limiting collection 5. Limiting use, disclosure and retention 6. Accuracy 7. Safeguards 8. Openness 9. Individual access 10. Provide recourse PHIPA Personal Health Information Protection Act, 2004 Establish rules for the collection, use and disclosure of personal health information about individuals that protect the confidentiality of that information while providing effective of health care. RECORD PROTECTION and CONFIDENTIALITY RECORD PROTECTION/CONFIDENTIALIT Y All client records are strictly confidential and need to be protected. Never discuss any portion or type of a client’s record with an unauthorized person If someone telephones regarding any client record information, inform the person on the phone that you will need to obtain consent from your client to release information Take the persons telephone number and state that you will return this call once you have spoke to the client in question RECORD PROTECTION/CONFIDENTIALIT Y Dentists should also ensure that members of their office staff are aware of the confidentiality rules and need for patient consent regarding the release and transfer of any patient information and dental records Records should be stored securely, and destroyed effectively at the end of the required retention period RECORDS PROTECTION Legally the client records are the office/DDS property The information therein is the clients. The client may read their own records but they should not be permitted *unsupervised* access to their chart unless providing them a copy of their chart to take with them. RECORDS PROTECTION The dental office must be protected against loss, and damage Records should be locked away in fireproof cabinets Client charts should be kept out of view of other clients Clients charts should be filed away immediately after entries/care RECORDS RETENTION RECORDS RETENTION Recordkeeping regulation are made under the Dentistry Act, 1991 This act requires that clinical financial and drug records that are made in respect to an individual patient must be maintained for at least 10 years from that date of the last entry in that record RECORDS RETENTION In the case of a minor, these records must be kept for at least 10 years after the day on which the patient reached the age of 18 years. RECORDS RETENTION Records must be retained for 2 years after the death of the Dentist, at this time the estate will deal with the records and the practice RECORDS RETENTION Working models do not have to be retained for any specific period of time. A decision to keep working models should be based on the complexity of the case and is left to the judgment of the DDS Diagnostic or study models are considered part of the permanent patient record and therefore must be kept for at least 10 years RECORDS RETENTION Copies of dental claim forms (insurance) must be maintained for at least 2 years from the date the claim was provided to the patient or submitted to the insurance company An electronic copy on a backed up system is also acceptable Transferring of Client Records When clients/patients leave the dental office and continue their oral health care with another dentist it may be necessary to provide their dental history information to their new provider We must remember the patient’s chart is the property of the dentist but the information belongs to the patient For the legal protection of the dentist, it is necessary to obtain written consent from the client before transferring the records to anyone The dental office keeps the original chart and sends a copy to the receiving office Recent radiographs can also be duplicated and sent A fee can be charged to the client to cover the costs associated with the transfer of records Besides a patients new dental office, other organizations may request copies of dental files, including the following: o Insurance companies o Legal representatives o physicians CLIENT RECORDS ACTIVE VS. INACTIVE How a patient’s chart is stored depends on the status of the patient In most dental offices, each patient chart will be considered either active or inactive, both of which are open files, or files that are likely to be needed. ACTIVE PATIENTS are those who attend the dental office for regular care appointments INACTIVE PATIENTS are those who have not been into the dental office for the past 2-3 years Several attempt have been made to recall this client The timeframe to call someone inactive varies from practice to practice Notations must be made in the record of care These notations would show the number of failed to attend appointments, number of telephone calls made in attempt to schedule this client, any letters sent to the client to schedule the client in for care ACTIVE VS. INACTIVE CLIENT RECORDS Active files are kept in the primary filing system Inactive records are to be removed from the active filing system and are put into storage in a separate filing area labelled “Inactive” This storage area should be accessible in the office, but not in the main greeting/reception area PURGING RECORDS PURGING RECORDS After 10 years of the last entry the file may be destroyed unless the client is a minor A purging system is usually established to go through all the inactive files for a period of time and then the files must be shredded for confidentiality /or a shredding company brought in PURGING RECORDS Purging records also refers cleaning up the Active files in the cabinets Replacing torn file folders Going through the contents, throwing out outdated electronic transmissions etc.  Basis Types of Filing Index or Systems 1) Alphabetical filing-easiest and most commonly used-clients last name, first and initial (A to Z) Alphabetical Filing Systems Name 1 2 3 Alice J. Gooding Gooding Alice J. Alice May Goodman Goodman Alice May William Grafton Grafton William 2. The Numerical filing system uses a method of assigning number s to each new patient or account. ⚫ Numbers assigned are then recorded on computer file for reference ⚫ This is may be an advantage in computerized offices because computers handle numerical data faster than alphabetical characters. Basis Types of Filing Index or Systems 3) The Chronological filing system is a method of filing by date. It can be used within the alphabetical or numerical system by filing the most recent correspondence in front of the file folder. This system can also be used for treatment records in a patients clinical chart 4) Cross References-uses alphabetic and one other system Vertical Horizontal Storage Colour Coding File Folders ⚫ Most dental practice use patient file folder with labels that come in a variety of colors. ⚫ This type of file and label guards against misplaced records ⚫ In a group practice, a different color may be used to designate the patients of each dentist General Filing Rules Office Filing systems 1. Keep it Simple ⚫ The simpler the filing system, the easier it is to work with ⚫ For most practices, alphabetical filing with colour coding is the simplest and most efficient method 2. Leave Adequate Working Space in each file ⚫ Papers tightly wedged into the file slow down the filing process and make the records difficult to find, it also increases the risk of damage to filed materials ⚫ There should be ample working space left on each shelf or drawer for ease of movement between files General Filing Rules Office Filing systems 3. Label shelves or drawers if possible ⚫ It is easier to go directly to the proper file areas if the files are neatly and accurately labelled as to the contents 4. Clearly label folders ⚫ Neatly typed label showing the client’s full name ⚫ This ensures the correct file will be pulled 5. Use “out-guides” ⚫ Similar to a bookmark for the filing system, use when a folder is removed from a file. How to avoid a lost record The receptionist must keep track of the clients’ records, the receptionist gives the record out to the treatment staff to use in providing care and to make entries and must keep track of any outstanding records that are not returned back to the front desk and the filing cupboard when the client leaves the office. Some time the records end up on the DDS desk, or with the treatment co-coordinator, and/or with the consultation coordinator, or left in the treatment room drawers, In order not to loose a record-the staff must return the records immediately following treatment, if a record is not returned the staff must use the day sheet to follow up and file immediately after usage.