Storage of Business Records

LEARNING OUTCOMES

Vast amounts of information are generated in the dental office each day. The idea of a paperless office sounds exciting, but it has proved to be a myth. Reality dictates that traditional methods of record storage will be used for some time. In Chapter 7, disposition is identified as the final stage of a dental record—either destruction or storage. The administrative assistant is responsible for managing and maintaining records, both paper and electronic files. This chapter discusses records storage. A sound understanding of records management and the indexing rules associated with records storage will continue to be an essential skill for the administrative assistant.

A dental office produces many kinds of information, including clinical and financial records, radiographs, and diagnostic models. Inability to find a document quickly is frustrating and can often delay a decision, diagnosis, or payment. Such delays can be costly and stressful.

A record is stored information on any media created or received by the office that is evidence of its operations or that has value requiring its retention for a period of time. For example, information may be:

Records are assets to the dental practice. They provide legal value by providing evidence of treatment and business transactions. Records may provide information of articles of incorporation, real estate, and contracts. Records provide information on day-to-day operation of the practice and historical evidence of treatment, employee data, and financial activity. Thus the maintenance of these records becomes a major responsibility of the administrative assistant—to ensure a smooth flow of the practice as well as a safe and secure practice.

To many administrative assistants, filing is one of those dreaded, procrastinated, routine jobs done when the administrative assistant can “get around to it” or “has the time.”

Anyone with office experience knows that records must be readily available. Wise planning can save a tremendous amount of time and effort. The heart of any professional office is its filing system. Business office files should not be a place to put materials, but rather a place to find materials. A systematic plan for storage, retrieval, transferring, protection, and retention must be established. When planning for the office files, consider ease in retrieval, confidentiality, and safety. The needs of the office, the size of the dental practice, and the space available for equipment are determining factors in establishing an efficient filing system.

PREPARING RECORDS FOR FILING

Practice Note

The heart of any professional office is its filing system.

Basic Steps

Certain routines should be followed in preparing materials for filing: (1) set aside some time each day or every few days for filing paper records; (2) keep papers or records to be filed in a basket marked to be filed; (3) file electronic records immediately in the appropriate electronic folder. Make backup copies of all electronic files as they are completed.

Before mastering the different filing systems, it is necessary to learn and understand some basic steps, which are generally done in the order of inspecting, indexing, coding, sorting, and storing:

• Inspecting: Review each record to determine if it is something that must be filed. If it can be disposed of (check the retention schedule or the originator of the form), dispose of it. If it is to be retained, continue to the next step.

• Indexing: Determine under which caption or name an item is to be filed. Indexing is a mental process that requires making a decision. For instance, if the record is a receipt for a payment that was just made from the dentist’s checking account, the administrative assistant must decide into which file to place the receipt. If files are organized by subject, file the receipt under the subject to which it pertains (e.g., a receipt for an electric bill might be filed under “utilities” or “electricity”). For a patient’s clinical record, use an alphabetical system and break down the name into first, second, and third units to consider for filing.
Electronic records are indexed by determining in what directory the file should be located and by following a uniform procedure for naming the files. Do not name electronic files with characters or words that do not identify the subject of the record.

• Coding: Once the caption or title of the record has been determined, assign a code by highlighting, typing, or writing a caption on a paper record or by giving the electronic file a name. On an electronic record, this is done by creating a descriptive file name and including it on the document under the initials of the creator. If an electronic file also exists in paper form, the file name on the document allows for quick, easy retrieval. Examples of coding are shown in Figure 8-1. The clinical record is coded with the patient’s name, and the electronic document is coded with the name of the originator and other important information about the document.

• Sorting: The records are arranged in the order in which they are to be placed in the file (e.g., if the file is alphabetical, put the records in alphabetical order). Electronic files are sorted as the files are saved in the correct directory or on the correct disk. The system then sorts the files either alphabetically by file name, date, or by any other designation made.

• Storing: Put documents in folders and bulkier records in file drawers. Check and double-check that documents are being filed correctly. Also be sure to put CDs, DVDs, or other media, such as microfilm, in the correct place.

Practice Note

Check and double-check that you are filing a document correctly.

Two other aspects of document storage, cross-referencing and retrieval, deserve special consideration, as follows:

1. Cross-referencing alerts staff members that a record normally kept in a specific location has been stored elsewhere. A cross-reference can be provided by making a copy of the record and filing it in the referenced file with a note that it is a copy, or a cross-reference sheet can be put in the file. A cross-reference sheet contains the name of the document, the date it was filed, a brief description of the subject of the record, and the places where the record could be found. This type of cross-referencing is often found in a library card catalog.

Practice Note

Cross-referencing alerts staff members that a record normally kept in a specific location has been stored elsewhere.

2. Retrieval is the removal of records from files using proper “charge-out” methods. When an entire file folder is removed, an out-folder is put in the place of the removed folder. The out-folder has the name of the individual or department that removed the folder and the date it was removed. Out-guides or substitution cards may be used instead of an out-folder.

Although it does not commonly happen with patient clinical charts during routine treatment, a record may need to be removed from a file and used in another location for consultation or study. In such cases, the out-folder should denote the area to which the record has been taken. Electronic filing appears to lessen the chance for a lost record, but loss can occur when coding is done incorrectly and the record is not placed in the correct file.

Records Retention

It is not cost-effective to maintain unnecessary records and filing cabinets. Many records in the dental office are retained in accordance with state statutes. If the practice is large, a retention schedule may have been developed for various documents. If the office does not have a retention schedule, the administrative assistant should check with the dentist before deciding how documents should be transferred or destroyed. The National Archives and Records Service, a federal agency, has produced a helpful reference, Guide to Record Retention Requirements. It is available from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402.

Retention and destruction of files have taken on additional importance since the federal Revised Rule 26 of the Rules of Civil Procedure was approved in December 1993. This rule requires organizations to make available all relevant records that must be kept in compliance with prevailing statutes and regulations. Delay or failure to find information makes an office vulnerable to financial loss and adverse legal judgments.