Question

1. Identify a minimum of 10 key contents within a medical record and explain how each is directly linked to the purpose of a medical record.
2. Explain the difference between alphabetic and numeric filing methods and determine which method may better serve HIPAA’s Privacy Rule requirements and why.
3. Identify 3 classifications of medical records and describe the purpose of each classification. Also describe how all three classifications collectively support compliant recordkeeping.

Answer 1

Every medical record contains many details about the patient that relates directly to the patient, including last name, first name, gender, DOB, marital status, street address, city, state, zip code, telephone number, social security number, employment status, address and phone number of employer,name and contact information for the person who is responsible for the patient's bill, and vital information for the person who is responsible for the patient's bill, and vital information concerning who should be contacted in case of an emergency, thus in the above way the contents within a medical record are directly linked to the purpose of a medical record.

Indexing alphabetically is easy to learn because anyone who can read knows the order of letters in the alphabet. Filing by a name is also very intuitive. You know you have the right file simply be reading its heading. Unlike numeric indexing, no cross-reference system is needed, so users of the system can find files simply by looking them up in the filing system. A file with an alphabetic heading is also easier to identify when it’s out of the file system and in use, whereas essential component of any numeric system is the cross-reference index. Users must have a way to look up file numbers quickly and make sure they are indeed the records that they need. The numbers are often assigned or tracked by computer software, which makes it easy to identify the records you want through search queries and sorting. Certain industries use numbers for security and privacy issues, such as keeping medical or financial information confidential.

Paper Systems - Filing systems for paper medical records take up lots of space. Shelves, cabinets and drawers with color-coded folders are commonplace. These kinds of systems vary based on the amount of linear filing inches available to store records and how records are organized. Records are commonly organized alphabetically or numerically.

Electronic Filing System - An electronic medical record is a digital version of the paper chart that contains a patient’s history within a single practice. A provider uses an EMR to identify patients for preventive visits and screenings, monitor patients’ health, track data and improve the quality of care.

Hybrid Systems - Some medical practices use electronic records and paper records. They may print digital information, scan paper records and access information from either type of system, so that their electronic and paper systems are compatible.