Health Records Management 2 PDF

Patient Identification, Registration and the Master Patient Index This unit is designed to enable the participant to discuss methods of patient identification and registration and identify processes required to develop, use and maintain an effective patient identification system in a hospital, clin...

Patient Identification, Registration and the Master Patient Index This unit is designed to enable the participant to discuss methods of patient identification and registration and identify processes required to develop, use and maintain an effective patient identification system in a hospital, clinic or primary health care centre. PATIENT IDENTIFICATION The identifying information is an important part of a patient's health record. It should include enough information to uniquely identify an individual patient. Most facilities will ask to view and/or copy the patient’s driver’s license or identification card in order to verify this data. The patient identification data that is collected during the patient registration process is used to populate the Master Patient Index (MPI), which will be discussed later in this unit. The patient identification data may be entered into a computerized database, or manually typed onto a registration form. This section of the medical record should contain at least the following information: 1. The full legal name of the patient, including the surname (or family name), first name, middle name or initial, suffixes (e.g., Jr.) and prefixes (e.g., Doctor). It is also important to collect the patient’s alias, previous name, or maiden name, as the patient may have been seen at the facility under another name. 2. Internal identification number or hospital registration number. This is the number used to identify and file a health record, also called the patient’s health record number. (This number is may be assigned at the patient’s first inpatient admission or outpatient encounter at this facility, or a new number is also assigned for each subsequent visit.) 3. Place and date of birth (MM/DD/YYYY or DD/MM/YYYY), gender, race, ethnicity, marital status, address, phone numbers, and any unique identifying number, such as a national identification number or social security number. 4. Name, address and telephone number of nearest relative (next of kin) or friend. 5. Name and address of attending doctor, and name and address of referring doctor, if applicable. 6. Occupation, name and address of patient's employer. 7. Date and time of admission or encounter, and name of unit or clinic. 8. Details of health insurance and medico-legal information if appropriate. The above information should be obtained from the patient, if possible, or otherwise from the person accompanying the patient to the hospital or clinic. Care must be taken to ensure the correct spelling of names and that all names are recorded accurately and in full. Patients should be asked how they spell their names (both surname and given names) as names that sound alike may be spelled quite differently. Names should be recorded in the manner used for all official documents of the state or country. PATIENT REGISTRATION The complete and accurate collection of patient identification information is an important part of the patient registration process. For statistical purposes, a method for counting all outpatient encounters and hospital admissions each day is essential. Important aspects of patient registration are: 1. When a patient presents at a hospital or clinic for the first time, they should be registered as a new patient. However, to make sure that the patient is, in fact, a new patient they should be asked if they have been to the hospital or clinic previously. Even if they say no, the admission or clinic staff should still check in the facility’s computerized patient database, the manual master patient index or with the health record department, depending upon the level of computerization at the facility. This step is necessary to make sure that the patient does not already have a health record number at that hospital or clinic; and to ensure that duplicate records are not created. 2. If the patient does not have an entry in the MPI or a health record number, the identifying information is collected and either entered into the computerized database, or recorded on the front sheet of a new record. The patient is registered and a patient identification number is assigned. In most hospitals and health care centres, this registration number is used as the patient’s health record number. In a manual system, an Admission, or Patient Register is maintained at the point where the number is issued, and should contain the following information: HEALTH Record Patient Name Date of Issue Doctor/Clinic Number 102642 John Doe 01/01/2004 Dr. Lee This register is maintained as a control to avoid duplication of numbers and the issuing of the same number to two people. 3. If the patient has an existing file in the MPI and a health record number, the current identifying information should be checked with previous data and changes noted. MASTER PATIENT INDEX (MPI) Indexes are a must for any hospital, health clinic, or primary health care facility. They serve as a guide to the location of an item. An index can be a table, file, or catalogue, listing an item and furnishing information for easy access to that item. The Master Patient Index (MPI) is a permanent listing, containing the names of all patients who have ever been admitted to or treated in a hospital or clinic (also called Patients' Index, Master Person Index, Patient’s Master Index, or Master File). Because the Master Patient Index is the key to locating a patient's health record, it is considered to be one of the most important tools maintained in the health record department, clinic or primary health care centre. Since health records are filed numerically in most healthcare facilities, the MPI is used to identify a patient’s health record number and locate the record. Typically, a manual MPI is maintained using individual index cards for each patient that are filed alphabetically. In a manual MPI, each patient who is registered in the facility has an index card in the MPI that is maintained in the health record department. However, an increasing number of health facilities are maintaining computerized Master Patient Indexes and this is described in more detail in Unit 6, Hospital Medical Record Computer Applications. A computerized MPI is maintained using specialized database software. Reference to the computerized MPI will be made in this Unit, when applicable. The basic principles are the same, whether the data collection is done manually or by computer. 1. Content of the master patient index The information contained in this index varies with the needs of the hospital or clinic. Whether the MPI is computerized or manual will determine the amount of data that will be maintained, based on space limitations. In a manual system, only information of an identifying nature necessary for prompt location of a particular health record should be recorded on the patient’s MPI card. A computerized MPI will allow the facility to maintain additional information. Typically, the MPI contains two basic types of data: demographic level and visit level. The privacy necessary for maintaining confidential information should be considered when thinking of recording diagnoses and procedures on a MPI card, and should be avoided. The information recorded should include: Demographic Level Internal identification number – number assigned at the time of hospital registration, also called the health record number. It is the number used to file the health records. Patient’s full name - family name, given name, middle name or initial, and pertinent suffixes and prefixes Date of birth (MM/DD/YYYY or DD/MM/YYYY) - in cases where patients have the same name, the age and date of birth provides additional information for identifying and obtaining the correct health record Complete address – street, city, state, zip code/post code, country Gender Race/Ethnicity Other unique identifying information, which will assist the identification of the patient, such as the mother's maiden name, national identification number or social security number. (This information is limited by the amount of space available, i.e., computerized database or index card.) Visit Level The following additional information may also be listed on the patient's master index card if there is a need and adequate storage available: Account number – the billing number used to identify admission or encounter charges Admission and discharge dates - for inpatient hospitalizations Type of service – inpatient, emergency, outpatient surgery, etc. Encounter date or date of service – for outpatient visits Disposition – discharged, transferred, or died Admitting and/or attending physician's name The following is an illustration of a MPI card used in a manual master patient index. The information at the top is collected at the time of the first encounter of the patient with the hospital or clinic. If the entries on the card must be handwritten, a pre-printed card will help ensure that the required data elements are recorded and made in a uniform place on the card. 2. Manual Master Patient Index a. For inpatients, the procedure for a manual master patient index could be as follows: 1) Each day the admission registration staff notifies the health record department of all patients registered in the facility. This may be done by sending copies of the admission slips for all patients admitted to hospital, which are usually the carbon copies or computer printouts of the registration forms or face sheets. 2) The MPI is checked to see if any of the patients whose names appear on the admission slips have been previously admitted and if they have an index card. If yes, these cards are pulled out and the current admission information is recorded. The demographic information on the index card must also be checked for any changes in name, address, etc. 3) If the patient has had no previous admission, and therefore no card in the MPI, a new index card is prepared.  4) In some hospitals the completed cards of inpatients are filed in a separate file, called the "in-hospital" or “in-house” file, and remain there until the patient is discharged. 5) At discharge, the MPI card is removed from the "in-hospital box" and the discharge date is recorded. If a death occurred, the date may be recorded in red. The patients' index cards are then filed into the MPI. Given the importance of the integrity and accuracy of this index, many hospitals have a second person check the filed card for accuracy. b. Organization of the MPI In the absence of a computerized MPI, special index cards or books may be used for the listing of patients' names, with index cards being the most preferred. The most popular and efficient method of maintaining the MPI is on index cards arranged alphabetically in a vertical file with a separate card for each patient. Using this method, a single index card can be located readily in one search. If using a book, it is divided into alphabetical sections. Names are listed under the first letter of the surname in chronological order by date of admission. This method is only feasible for a small facility, but retrieval becomes cumbersome and increasingly difficult for large hospitals, or where the volume of patient admissions or encounters is great, because a strict alphabetical order is maintained. This method is NOT generally recommended for a MPI. It is not recommended to maintain the master patient index by year of admission or encounter. This is not a good method as patients often forget the date of their last visit, or if they were ever admitted to a particular hospital at all. Much time is lost searching through several sections of the index for the appropriate index card. Nor is it recommended to separate the MPI by sex, that is, to file the cards of male patients in one file and the cards of female patients in another. Methods used for filing 1) Alphabetical - The MPI cards are arranged in the file like the words in a dictionary, following letter by letter of the family name first, then by the given name, and last by the middle name or initial. If there are two or more patients with the same family name, cards should be filed alphabetically by the given name. If given names are the same, the middle name or initial should be used to arrange the cards. If the entire name is identical the cards are filed by date of birth, filing the earliest birth date first (the card of the patient who was born first is filed first). If an initial is given for a patient's first or middle name, the rule is to "file nothing before something" (Huffman, 1994). Thus, SMITH, P. would come before SMITH, PETER. Last names beginning with a prefix or containing an apostrophe are filed in strict alphabetical order, ignoring any spaces or apostrophes. For example, the name O’Leary would be filed as Oleary, and the name Mac Dougal would be filed as Macdougal. Compound or hyphenated names are filed letter by letter, as one word; thus Ai-Min would be filed A-I-M-I-N. 2) Phonetic - in phonetic filing systems the patients' master index cards are arranged in the file by the first letter of the surname, and then according to sound rather than spelling. Thus all surnames that sound alike, but are spelled differently, are filed together. For example: While an alphabetical filing system uses 26 letters the "Soundex" system uses only six code numbers. Names, which sound alike, but are spelled differently are grouped together in a phonetic patient index, rather than filed letter by letter as in an alphabetical patient index. Grouping similar sounding names together lessens the chance of lost index cards due to misspellings and index cards having misspelled names can be more easily located. d. General filing rules for a Master Patient Index 1. Rules for filing MPI cards must be very detailed. It is not easy to locate medical records if you cannot locate the correct MPI card. Filing rules should be posted near the patients' master index for easy reference. 2. Use of the MPI and filing of the cards should be by authorized personnel only. Careful orientation of new employees to the proper filing procedures is necessary, as is periodic follow-up on the accuracy of these procedures. 3. The MPI should be a continuous file, that is, not divided into years. 4. A MPI card should be removed from the file only for updating or placing in the in- hospital box. 5. Occasional auditing of the MPI is recommended to monitor filing accuracy. This can be done by having the file clerk place a slightly higher card of a different colour behind each individual card at the time it is filed. A second person, known as the auditor or checker, removes the audit card after checking that each card has been correctly filed. It is useful to audit the filing done by new personnel to ensure that they are applying the rules correctly. 6. A patient whose name has changed since a previous admission will need a new index card. The new index card should be cross-referenced to the original index card. All information recorded on the original card should be entered on the new card. The original card should be cross-referenced to the new card. 3. Supplies and equipment for a manual Master Patient Index Index cards, index guides and filing equipment are needed for maintaining a manual MPI. a) Index cards - 3 x 5 inch cards (7.5 x 12.5 cms) are generally used, but the size may vary depending on the amount of information to be recorded. Since the MPI is a permanent file, the card must be durable to withstand much handling. Remember, however, that the heavier the card, the more space required in the file. b) Index guides - Index guides for an alphabetical or phonetic MPI file facilitate the location of an individual patient's card. Being slightly larger than the patient's card, the top of the guide with an initial letter of a common surname is extended above the other cards, thus serving as a guide. Phonetic index guides will require, in addition to guides with initial letters or surnames, subguides indicating basic code numbers. The size and activity of the index will determine the number of guides needed. c) Filing equipment - Patients' index cards may be filed in cabinets suitable to the card's size. If 3 x 5 inch (7.5 x 12.5 cms) cards are used, they are usually filed in vertical, eight- drawer, triple compartment file cabinets. A power file is considered feasible when the MPI has more than 500,000 actively used cards. At the touch of a button, a power file delivers the required section of the index to the front of the file for easy access. 4. Computerized Master Patient Index It is also possible to maintain the MPI in a computer. At the time of admission to a facility, the registration staff searches the computer database for a particular patient. If the patient has been in hospital or attended a clinic previously, the patient’s information is displayed on the computer screen. The registrar then updates any demographic information that has changed since the previous admission or visit. If the patient has not been to the hospital previously, the registrar collects the patient demographic information and the system automatically assigns a new registration, or medical record number, and stores this information in its memory. At the time of the patient’s discharge, the date of discharge is entered into the system, thereby completing the current MPI entry. RECORD IDENTIFICATION SYSTEMS It is important that each record has a unique identifier, either alphabetic or numeric. The collection of patient identification data and the assignment of a record number or verification of an existing record number should be the first step of every admission or visit to a hospital or health center. It is the only way to ensure properly identified health records. Alphabetic Identification The simplest form of record identification is alphabetic, using the patient’s name to identify and file the patient’s health record. And because only the patient’s name is used to identify the record, it is also the easiest method of record retrieval, as the master patient index (MPI) is not needed to cross-reference the patient’s name to the health record number. The accurate spelling of the patient’s name is of extreme importance. It is also important to create a system to track name changes, such as from marriage or divorce. It is necessary to thoroughly train staff to verify patient names and spellings, and to accurately and consistently file the health records. One concern with this type of record identification is patient confidentiality. Since the outside of the record is identified only with the patient name, and not a number, the patient’s identity is not protected. This type of record identification system is most practical in smaller health care facilities with stable patient populations. Larger patient populations would result in multiple patients with the same name, leading to possible mix-ups of patient files. It is also most practical for facilities with little or no computerization. Numerical Identification A numerical record identification system requires that a unique health number be assigned. It requires the use of a MPI to cross-reference the patient’s name with his or her health record number. There are two main systems of numbering patient records: Serial numbering Unit numbering a. Serial numbering With this method the patient receives a new health record number on every inpatient admission or outpatient visit to the hospital or clinic. That is, the patient is treated as a new patient each time with a new number, new index card and new record, filed totally independently from previous records. Serial numbering is not used extensively today and is only useful in small hospitals with a low rate of readmission. b. Unit numbering The patient is assigned a unique identification number on his first contact with the hospital, whether it is for an admission, emergency room or outpatient clinic visit. The same health record number is kept and used on all subsequent visits, whether as an inpatient, outpatient or emergency patient. A unit health record number results in the creation of one, central health record for the patient. This number is normally related to one single record, where all the information on the patient is brought together. These data can originate from different clinics or units, at different time periods. If a unit record is not possible, the unit numbering system can be used to link health records that are physically located in different places. 1) The advantages of using a unit number for filing are:  the number is unique to the individual and therefore distinguishes him/her from any other patient in the hospital or clinic  the number does not change regardless of how often a person is admitted to hospital or attends a clinic.  patients' health records are centralized in a single folder  this system provides the medical staff with a complete picture of the patient's medical history and treatment received over a number of admissions and attendances.  health records are filed in one place. 2) The disadvantages of using a unit number for filing are:  health records may become quite thick and additional folders may be required  space needs to be allocated to allow for the expansion of records as more admissions are added to a folder. It is important to note that when a unit record is used, it is essential for all staff to check the patients' master index before issuing a new record folder. This ensures that a duplicate health record is not produced. c. Serial-unit numbering Serial-unit numbering is an adaptation of the serial and unit numbering systems that combines both systems. With this system, the patient receives a new number on every contact with the hospital, but previous records are brought forward and filed under the latest number, so only one record will remain in the files. It is necessary to leave either the old health record folder or an outguide (or tracer card), referring to the new record number, in the place from where the old records are removed. 1) The advantages of serial-unit numbering and filing are:  a unit record is created.  record retention is easier as records with lower numbers automatically remain in the old file. 2) The disadvantages of serial-unit numbering and filing are:  gaps are left in the file area when medical records are brought forward.  time is needed for back shifting and for cross-reference from old record and record number to the newest one. (Huffman 1994) d. Conversion to a unit system The change from one system to another should not be underestimated. It implies an increased workload, since two filing systems have to be used for an undetermined period of time. Many records have to be controlled and shifted, especially in the first months. The steps proposed for a conversion are: 1) Select a date to make the change, and begin issuing patients new unit numbers on that day. 2) Check if the patient already has a record (or records). Bring forward these previous records and file them under the new number. 3) It is best to convert the records of old patients to the new system as they come back to the health care facility, rather than attempt to convert the entire file at one time. 4) The Master Patient Index has to be adjusted or a new MPI started from day one of the changeover. As a dual control, empty folders of previous records or out guides (tracers) should be left at the original places in the old file, with cross-reference to the new unit record number.  5) After a predetermined period of time, the records still in the old file can be considered as inactive and eventually removed to inactive storage. This also applies to old MPI cards, if a new MPI was started. Types of numbers a. Sequential numbering Records are assigned a sequential number in chronological sequence commencing at 1. For example, if the last number to be assigned was 010524 the number issued to the next patient would be 010525. This method is simple, easy to assign, and easy to control. This is the way numbers are issued in both serial and unit numbering systems. Often when using a serial numbering system, some hospitals connect this sequential numbering system with the year as a prefix, for example: 05-0024, represents the 24th patient of 2005 Other types of numbering are described below. They are not generally considered to be better than a straight numbering method, nor as commonly used. b. Alphanumeric numbering This is a combination of letters and figures, for example: AA 99 99 instead of 99 99 99 This method has the advantage of a greater capacity with the same number of characters, for example, letters: A-Z (26); figures: 0 to 9 (10). This method, however, is not extensively used. c. Relational numbering Relational numbers are numbers that, totally or partially, have a certain significance in relation to the patient. There are various types of relational numbering systems that may be used, including: 1) Birth number This number is derived from the date of birth. That is, the number is based on six of the eight digits of the birth date. To these digits other digits may be added. For example, two, three (or even more) digits for the serial number (can be odd for males and even for females), a digit for gender, or digits representing a geographical code, for example: In addition, one or two check digits may also be included, particularly, in computerized systems. The total number, therefore, could consist of 9 to 12 digits. a) The advantages of using a relational number include:  The record number has built-in information (age and sex)  Easy to remember, because of date of birth. If difficulties occur in retrieving information from the MPI (misspellings, husband's name, common names, etc.) the date of birth gives enough information to find the record. b) The disadvantages, however, must be taken into consideration, and include:  Long number, increasing the risk of transcribing errors, particularly in non- automated systems.  A limited capacity, since a maximum of 31 numbers can be used for the day digits and a maximum of twelve numbers for the month. Only the year digits have a range of 00 to 99.  If the birth date is unknown pseudonumbers (eg. 99 99 99) have to be used, and conversion procedures must be developed once the birth date is available.  Folders and MPI cards cannot be prenumbered. Although useful for identification, it is not generally considered a good number for filing purposes. 2) Social security numbering Social security numbers are used, mainly in the USA and in some countries where the social security administration operates health facilities, but are also not recommended for filing purposes. a) Advantages of using a social security number are:  It is a unique identification number.  No reference to the Master Patient Index is necessary, and therefore faster retrieval. b) The disadvantages, however, outweigh the advantages and include:  Some patients do not have or cannot give a social security number at the time of their admission or visit (eg. newborns, children, patients from abroad). Pseudonumbers must be assigned if no actual social security number is present, and again conversion procedures are needed, once the real social security number is available.  Threat of identity theft.  Control and verification of the number is out of the hands of hospitals using it. FILING SYSTEMS Record identification systems and filing must go hand-in-hand, as the filing system depends on the identification system used. Filing is the systematic arrangement of records in a specific sequence so that reference and retrieval is fast and easy. Daily procedures in many areas of a clinic or hospital can be severely affected by poor management of health record services. It is therefore the responsibility the health information professional/health record administrator to establish systems and procedures to ensure the efficient production of health records for patient care, medico-legal purposes, statistics, teaching and research. The health record department is judged on the efficient service it provides to the rest of the hospital or clinic. That is, health records must be readily available when required for patient care. Departmental efficiency and record control are therefore two of the most important things to consider in the management of the health record services. Alphabetical filing When no health record number is assigned, and the patient's name is the only identifier, then alphabetical filing is the only possible method to use. Filing is by patient surname first, then given name, and finally middle name or initial. Records of patients with exactly the same name should then be filed according to their date of birth date. This type of filing is time consuming and the risk of errors (change of name, misspelling) is extremely high. Moreover, there is no way to control the use of the file area as it is not possible to know beforehand where the next new record will be filed. Since names are not equally distributed, it is extremely difficult to avoid congestion areas and back shifting to open new file space. Alphabetical filing is not recommended, and is only useful for facilities with a limited patient population and a small files area, with a very low patient turnover rate. 2. Numerical filing systems If a numerical record identification system is used, then a numerical filing system is used. There are two main systems of filing records numerically: straight numeric and terminal digit. a. Straight numerical filing In this system, health records are filed in straight numeric sequence as follows: 8984 108264 8985 108265 8986 108266 8990 108267 This filing method reflects exactly the chronological order of the creation of records. Straight numeric filing is typically used when serial health record numbers are assigned, however, a unit health record number may also be filed in straight numerical order. 1) The advantages of straight numeric filing include:  people are used to this "logical" order and training is easy  easy to retrieve consecutive numbers for research or inactive storage. 2) The disadvantages, however, outweigh the advantages, particularly in large hospital health record departments. The disadvantages include:  easy to misfile, one must consider all the digits of the number in order to file the record  easy to transcribe numbers where one digit is wrongly written or read, for example: 1 for 7  easy to transpose numbers (reverse digits), for example, record number 194383 is filed as 193483  the highest numbers represent the newest, and therefore most active records, causing a concentration of record activity in one particular area of the file room, where these records are filed  it is not feasible to assign filing responsibility to one clerk since most of the records and loose sheets are filed in the same area. b. Terminal digit filing 1) Whether using a serial, unit, or serial-unit numbering system, the actual method used for filing is most important. In place of straight numerical filing, other methods have been designed to improve retrieval and filing efficiency. The most popular method in use today is the terminal digit filing system. In terminal digit filing a six or seven digit number is used and divided into three parts. Part 1 - The primary digits, which are the last two digits on the right hand side Part 2 - The secondary digits, which are the middle two digits Part 3 - The tertiary digits, which are the first two or three digits on the left hand side For example, the number 14 20 94 is divided as follows: 14 - 20 - 94 Tertiary Secondary Primary 2) In the terminal digit file there are one hundred (100) primary sections ranging from 00 - 99. When filing, the clerk considers the primary digits first, for example, the number 14 20 94 will be filed in the "94" primary section. Within each primary section there are 100 secondary sections, also ranging from 00 - 99. The number 14 20 94 is filed in the 20 - 29 secondary part of the "94" primary section. Within the 20 - 94 section the record is then filed in numerical order by the tertiary number. The sequence of the file is as follows: 3) The file clerk considers the record number in parts, going from the right to the left. For the number 142094 he first locates the primary section (94). Within section 94 he looks for the secondary or subsection (20). There he files in numerical order, using the tertiary digit 14. Adaptations can be made when more or less than six numbers are used. For example: 4) The advantages of terminal digit filing include:  Records are equally distributed throughout the 100 primary sections.  Only every 100th new medical record will be filed in the same primary section of the file.  Congestion of personnel in the filing area is eliminated.  Clerks may be assigned responsibility for certain sections of the filing area.  The work can be evenly distributed among file clerks.  Inactive health records may be pulled from each terminal digit section as new ones are added, thus eliminating the need to backshift records.  Misfiles are substantially reduced with the use of terminal digit filing Location of files So far in this unit we have discussed how paper-based medical records are filed. Let us now look at where they are filed, meaning - are the files centralized or decentralized. a) Centralized The records of the patient are filed in one location, usually the health record department. The patient may have different records (inpatient records, emergency record, ambulatory care records), but they are brought together in one unit record, or at least filed under the same number in the same place. The main objective of the health record department is to maintain a continuous medical record of a patient, which is available at all times. The best way to achieve this objective is to establish a centralized unit record system. In a centralized unit record system, centralization refers to filing a patient's inpatient, outpatient and emergency records in one location. Ideally, for good control, all medical information about a patient should be stored in the one folder, in the one location or file. This makes retrieval of information easy because it is filed in one place under one number. b) Decentralized The records of the patient are filed in multiple patient care areas. This may be under the same unit number (linkage) or with totally unrelated numbers (no linkage). It is a good policy to keep decentralized record areas under strict supervision by the health information management/health record professional. c) Comparison between a centralized and decentralized record system Centralization has some significant advantages over decentralization: All information concerning a patient's care is stored in one place and open to all medical care providers. There is less duplication of information. Costs for creation and storage of records (space, equipment) are lower. Record control is easier. Implementation of overall administrative record procedures is possible. Standardized job descriptions and supervision of specifically trained personnel result in greater efficiency. When the hospital is a large complex of different buildings or health care units, some degree of decentralization might be necessary for reason of record availability and accessibility. In a large hospital there may be multiple and simultaneous requests for the same record. In those limited circumstances, centralization and unit records can cause disadvantages. When hospitals implement electronic health records, the issues surrounding paper-based records, such as filing and availability, are no longer of concern. FILING EQUIPMENT AND SUPPLIES FOR PAPER-BASED RECORDS There are many storage options available for health records. Although some facilities have electronic health records, or are in the process of implementing them, most still have paper-based records. This section will cover the types of filing equipment and supplies needed to properly store paper health records. Filing equipment In purchasing filing equipment, it is necessary to determine the number of filing units needed. It is number of linear inches or linear meters of medical records must be measured, and then the number of filing inches or linear meters; or provided in the type of filing unit under consideration must be determined. Detailed information on calculating filing space will be found in Unit 8 on Planning a Medical Record Department. a) File cabinets are the least efficient type of storage unit. Although they provide security for the records since they can be locked, they do not maximize the use of the floor space because of their size and number of available filing inches. Adequate aisle space between the cabinets must also be provided in order to allow the drawers to be pulled fully open. b) Lateral open shelves are preferred as considerably more records can be filed on open shelves than in cabinets within a given filing area. Also the aisles between units require less space for shelves than for drawers. The normal aisle space for open shelves ranges from a minimum of 75 cm (30 inches) to 90 cm (36 inches). Filing supplies a) Record folders Record folders have a double role. They protect and identify the medical record. When buying folders one should look at composition, size, expandability, reinforcement and possibilities for tabs or attachments. A variety of folders are now available and include plastic, manilla or pressboard covers, large envelopes, folders with fasteners, with special pockets, with pre-printed colour strips and record numbers. Usually folders can be purchased with the hospital identification and other information printed on the cover. A clear area for the patient's name and record number, however, should not be forgotten. b) Guides Guides should be placed throughout the files to assist finding and filing health records. The number of guides needed depends upon the thickness of the sections of the files. For medium thickness of records a guide after every 50 records is usually sufficient. For thicker records, more guides will be required. Usually with terminal digit filing two pairs of numbers appear on each guide. These are the secondary and primary digits. RETENTION OF HEALTH RECORDS Retention means the transfer of records from active to inactive storage, to microfilming, or eventually to destruction. It is generally accepted that health records should be kept for as long as they are being used for patient care, medico-legal and research and teaching purposes. If space is not readily available, a decision must be made to determine the length of time records should be kept in an 'active' file. After this time they should be transferred to an 'inactive' area. This decision is based upon legal requirements, and is usually made by the facility’s Governing Board on advice from its legal counsel, the Health Record Committee, and the health information management/health record professional. In a number of hospitals, the filing area space is limited; therefore many health record departments will keep a limited number of health records in an active file area, which is in or close to the department. Records that are considered to be inactive are then moved to another, more physically distant area. This area may be within the facility, or offsite at a space either owned by the hospital or stored at a commercial storage vendor. Typically, records are purged on a yearly basis and transferred to the inactive file. If a patient is readmitted and his health record is in the inactive file, it is "reactivated", that is, it is brought up to the active file and remains there for the next five years. The latest year of activity can be indicated on the record folder with special labels indicating the year of most recent activity. In automated systems the computer can generate a list of "older" records. The next decision to be made is how long health records are to be kept in the inactive file. Are they to be retained or destroyed after a certain time? If they are retained, are they going to be kept in their original form or are they going to be processed e.g. microfilmed? All these decisions must be made by the governing board of the hospital following discussion with the legal counsel, the medical staff, the health information management/medical record professional, and members of the Health Record Committee. Many countries around the world have national retention schedules for health records, which stipulate MINIMUM retention periods but hospitals may keep records for longer periods. Criteria for record retention The length of time of storage depends on different criteria. Influencing factors in retention decisions are: a) The type of the health care facility and the resulting type of records. b) Some records (e.g. newborn records, psychiatric records) must be kept for longer periods. c) The level of activity (readmission rate for inpatients and outpatients). For example, patients with chronic diseases will have very active records d) The yearly expansion rate, that is, how many new records have to be added every year, and how many filing metres are needed e) The cost of space, personnel, equipment, supplies, microfilming, off-site storage, etc., and the budget available. f) The amount of space available. The more space available, the longer records can be kept in the active or inactive file area. g) The volume of research activities. Universities and teaching hospitals have a lot of requests for older and inactive records for scientific and/ or evaluation purposes h) Regulatory requirements, such as the statute of limitations and other laws that may require retaining records for periods as long as 30 years Based on all these factors a decision should be made whether a record is to remain active, inactive, be microfilmed or destroyed. Methods of record retention a) Inactive file area Inactive records can be stored in an inactive file area of the health record department, or somewhere else within the health care facility, or even outside the facility in hired storage areas. Then, of course, messengers from the health record department or from the hospital are needed to bring records back and forth. Sometimes commercial storage companies are involved. If this is the case, a contract is needed to determine responsibilities and duties of the company concerning storage, retrieval, delivery and confidentiality. 1) Advantages of storage of a complete record include:  the record is retained in the original form.  the ease of reference of the original material and  the availability of the information. 2) Disadvantages include:  cost and space requirements  deterioration of paper with time passage  accessibility and possible fire hazard. b) Microfilming Another means of inactive storage is microfilming, requiring a minimum of storage space. Microfilming is a storage option that has been used for many years. It reduces the image of each document and places it on either a roll of microfilm or in a microfiche jacket. This can be done in-house or by commercial companies. 1) Advantages of microfilming include:  good alternative for inactive records  reduced storage space required  usually acceptable as legal evidence 2) Disadvantages include:  cost  accessibility  possible fire hazard and deterioration over time. c) Image-based storage systems Another newer option for long-term record storage is an image-based system. In this system, a document scanner scans the original record and creates a digital picture. Once scanned, the images are stored on an optical disk, which allows easier and faster retrieval of individual patient records. SUMMARY: There are two basic options for record identification, alphabetic and numeric. Which system is chosen is based upon the size and activity of the file. There are several types of numeric systems to choose from. The type of record identification system determines the type of filing system that may be used, such as alphabetic, straight numeric or terminal digit. The most important aspect of determining the filing system to be used is the ease in retrieval. Written policies and procedures must be in place to control the request, retrieval, and return of health records. These controls may be in a manual system or an automated record tracking system. Various options are available for storage of paper-based health records. Active and inactive files may require different storage solutions, such as offsite or commercial storage facilities. File folders offer various features, such as color-coding to identify the health record number, reinforcement, and fasteners. Various options are available in choosing the filing equipment to be used, including cabinets, open shelves, and mobile shelves. Record retention policies must be written that meet applicable legal requirements and the individual needs of the facility. The Governing Board must approve the record retention schedule.