The heart of any professional office is its records management system.
Preparing Records for Filing
Certain routines should be followed when 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”; and (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 whether 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 the making of a decision. For example, 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 patient’s name into the first, second, and third units to consider for filing. Electronic records are indexed by determining in which 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: After 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 and 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. The system then sorts the files either alphabetically by file name, by date, or by any other designation made.
• Storing: Put any necessary paper documents in folders and records in similarly organized file drawers. Check and double-check that the documents are being filed correctly.
Check and double-check that you are entering information into an electronic record correctly (e.g., confirm spelling) and that you are filing a paper document correctly.
Two other aspects of document storage—cross-referencing and retrieval—deserve special consideration:
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 can be found. This type of cross-referencing is often found in a library card catalog.
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 that 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 lessens the chance for a lost record, but loss can occur when coding is done incorrectly, when names or information is misspelled, when data is entered incorrectly, and when the record is not placed in the correct electronic file.
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. Check with your state dental board for state requirements. The National Archives and Records Service, a federal agency, has produced a helpful reference entitled Guide to Record Retention Requirements; it is available from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402.
The 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.
As a dental practice transitions from paper to electronic records, it may not be feasible or practical to store the paper records within the practice confines. After the contents of the paper record have been transferred or scanned into the electronic record (Figure 8-2), the paper record may be boxed according to one of the five basic systems listed below and relocated to a proper storage facility. These facilities provide off-site storage and retrieval services in a safe, secure, climate-controlled environment should a paper record ever need to be reviewed. The administrative assistant is typically responsible for communicating with these businesses and arranging for the transfer of records between the dental practice and the storage location.
Classification of Filing Systems
Five Basic Systems
The five basic classification systems of filing are the alphabetical system, the geographical system, the numerical system, the subject system, and the chronological system. All of these methods except the chronological system basically apply alphabetical procedures. The method used in a dental office depends on the type of practice and the sophistication of the office’s systems, but it is not uncommon to use several of these methods for various types of filing, whether electronic or paper.
Delay or failure to find information makes an office vulnerable to patient dissatisfaction, financial loss, and adverse legal judgments.
Selecting the Appropriate Filing System
In an alphabetical filing system, the arrangement of names appears in sequence from A to Z. The alphabetical filing system accounts for about 90% of the filing that a person is likely to perform, and it can be applied to various captions. Standard rules exist for alphabetizing correctly. Box 8-1 illustrates alphabetical indexing rules that can be applied to a variety of situations.
Box 8-1 Indexing Rules for the Alphabetical System
Names of individuals are indexed by units. The last name (surname) is the key unit. This is followed by the first name (given name), which is the second unit, and then by the middle name or initial, which is the third unit. Alphabetize names by comparing the first units of the names letter by letter. Consider second units only when the first units are identical. Consider third units only if the first and second units are identical, and so on.
If the last names are the same, consider the second indexing unit.
If the last names are the same but vary in spelling, consider each letter.
Initials are considered the same as a whole word and are filed before names beginning with the same initial. Names with no initial are filed before those with an initial (i.e., “nothing before something”).
If two people have the same name, they are indexed according to the alphabetical order of their city of residence and then by their state of residence. If two people have the same name and live in the same city, they are indexed according to the names of the streets on which they live.
Surname prefixes are considered part of the last name and not as separate words. A hyphenated surname (e.g., Meyer-Schafer) is considered a single indexing unit. A compound personal name that is not hyphenated (e.g., Catherine Myers Schafer) is treated as separate indexing units.
If the first word in a compound surname is one of the standard prefixes (e.g., “St.” in “St. James”), the surname is indexed as a single unit.
Titles and degrees are disregarded, but they may be placed in parentheses after the names.
A seniority designation is not considered an indexing unit, but it can be used as an identifying element to distinguish between identical names.
Titles used without a complete name should be considered as the key indexing unit.
Articles, conjunctions, and prepositions are disregarded in indexing.
A firm or business name is indexed in the order written unless it contains an individual’s name.
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