Transcript Slide 1

Unit 6
Managing the Medical Office and
Medical Records
Class Overview
Managing the Medical Office and
Medical Records
Categories and Reports Found in a
Medical Record
• Patient’s past medical
records
• History and physical
• Insurance information
• Office notes
• Progress notes
• Telephone messages
• Pathology results
• Nursing notes
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Medications
Physician orders
Radiology reports
Laboratory reports
Operative reports
Consultation reports
ECGs
Miscellaneous
Categories of Medical Records
• Active records
• Inactive records
• Closed records
Types of File Storage
• Vertical
• Lateral
• Movable
Systems Used for Filing
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Alphabetic system
Numeric system
Subject filing
Color-coding
Let’s take a closer look at each of these!
Steps for Using the Terminal Digit
Filing System
Step 4: Within the set of records with the same
tertiary numbers, locate the row of records with the
same secondary numbers as the record to be filed.
Step 3: Locate the set of files with the same tertiary
numbers as the record to be filed.
Step 2: Observe the numbers on the record to be filed.
Step 1: Locate medical record files or medical record room.
Steps for Using the Terminal Digit
Filing System
Step 7: If there is a marker or out guide in place of
the removed record, then remove the marker when
replacing the file.
Step 6: After placing the file in numerical order by
primary numbers, check once more to be sure the file
is properly placed.
Step 5: Within the set of records with the same tertiary
and secondary numbers as the record to be filed, place
the record to be filed in numerical order by primary
numbers.
Guidelines for Locating Missing
Files
• Look for a file with a “sound-alike” or “look-alike”
name
• For color-coded files, look for a folder with the same
color-coding
• For files filed numerically, look for transposed
numbers.
• Look for transposed letters
• Look for different spellings
• Look at folders filed before and after missing record
• Look in other areas throughout the office
Authorizing Release of Records
• Physician owns the
medical record
• Patient has the legal
right to access the
record
• To authorize release a
release form must be
signed by the patient,
parent, legal guardian,
or agent
Protected Information
• Substance abuse
treatment records
• HIV/AIDS information
• Mental health records
Disclosure Without Consent
• Instances when medical records can be released
without consent include:
– When records are needed by health care workers for the
care of the patient
– For qualified individuals who perform tasks such as data
processing, medical record transcription, and microfilming
• Instances when medical records can be released
without consent include:
– Government agencies who investigate or regulate health
issues such as child abuse and communicable diseases
– Lawyers and parties involved in a law suit related to the
patient’s medical condition
Ownership of Medical Records
• If a patient requests to view their own medical
record, access must be allowed unless the
physician determines it may be detrimental
• Prior to allowing the patient to view their
record, the MA must first check with the
physician or office manager for approval
• Never leave the patient alone with their
record
Guidelines for Retaining Medical
Records
• To be absolutely safe, medical records should be
retained forever
• Legal statues to keep records and documents vary
by state
• The standard set by most states for keeping
records is 2-7 years after the last treatment, or
seven years after the patient reaches the age of
majority
• The AMA recommends keeping records for 10
years
Issues Addressed in a Medical
Record Destruction Policy
• Length of time records are kept
• Where records will be kept
• Person responsible for deciding what to keep
and what to destroy
• Method used for documenting destruction of
records
• Method of disposal
General Office Management Skills
• Administrative ablities
• Communication
• Time management
General Duties of the Office
Manager
• Careful planning of activities
• Delegation of tasks
• Effective use of all personnel
Administrative Components of the
Systems Approach to Managing
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Personnel management responsibilities
Employee records
Financial management
Scheduling
Facility and equipment management
Communication
Legal concepts
Let’s look more in-depth at each one of these
Personnel Management
Responsibilities
• Recruitment and selection
– Hiring new employees and establishing orientation
training
• Annual performance review
– An exchange between supervisor and employee to
comment on job performance and set goals for next
year
• Discipline
– Should occur as soon as it is warranted and not held
over until the annual review
Employee Records
• Federal law requires records to be maintained for
every employee
• Payroll records must include:
– Social security number
– Number of exemptions claimed by the employee (W-4
Form)
– Gross salary amount (salary before taxes are removed)
– Deductions for social security taxes, federal, state and
city withholding taxes, state disability tax, and state
unemployment tax, if applicable
Effective Scheduling
• Can contribute to the satisfaction level of the
practice
• If the office staff is continuously scheduled
inappropriately, it affects morale and may
cause discontent among the physicians and
patients
• Flexibility must be built into the staff schedule
to allow for unanticipated occurrences such as
sick days and business appointments
Elements of Facility and Equipment
Management
• Facility layout and
planning
• Inventory
• Safety
• Maintaining OSHA
standards
• Equipment replacement
• Computer use
Communications
• Ability to communicate
at all levels
• Contributes significantly
to the cohesiveness of
the staff
• Includes written and
oral material
Responsibilities of Managing the
Clinical Part of the Medical Office
• Training new clinical personnel
• Tracking medical supplies
• Purchasing supplies when stock is low, making
sure the physician’s requests are met and
proper procedures are followed
• Handling safety issues (i.e., employee hepatitis
B injections)
• Maintaining OSHA regulations
Basic Duties of the Office Manager
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Acting as liaison between staff and the physician/employer
Conducting performance and salary reviews
Delegating responsibilities to staff
Orienting, developing, and training staff
Improving office efficiency
Maintaining the office procedure manual
Overseeing HIPAA compliance
Planning and conducting staff meetings
Preparing patient education materials
Providing guidelines for patient education
Recruiting, hiring, and firing
Supervising cash, banking, and payroll operations
Supervising employees on a day-to-day basis
Qualities of a Good Manager
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Effective administrative and communication skills
Ability to organize
Ability to communicate effectively at all levels
Ability to enforce policy when necessary
Ability to resolve conflicts
Creativity
Diplomacy
Excellent judgment
Managing the Monthly Planning
Calendar
• Develop a system in which the schedule for the entire
month is laid out on a calendar
• List staff vacations on the calendar because it helps to
prevent overlapping of vacations, which can leave an
office short staffed
• Note all physicians’ conferences, staff meetings,
vacations, accountant meetings, and other vendor
visits
• Ensure all vacations have been approved
• Compare the office calendar with the physician’s
calendar on a periodic basis and update the office’s
master calendar as necessary
Staff Meetings
• To facilitate communication between staff and the
physician, have the physician attend when possible
• Hold the meetings on a regular basis
• Compensate staff for mandatory meetings
• Manager conducts and facilitates the meeting
• Time, date, and agenda created by the manager with
input from the physician
• Ensuring staff meetings are focused helps to minimize
wasted time
• Minutes and names of attendees should be recorded
• Making Staff Meetings Successful
Staff Expectations of Management
• Respect
• Ownership of personal
space or environment
• A sense of affiliation
with the practice
• Fair compensation
• Acknowledgement and
recognition
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Emotional rewards
Communication
Honesty
Visibility of the
management
• Empathy
• Trust
• Equal treatment of all
staff
Ways to Show Respect
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Greet employees in a pleasant manner
Always acknowledge employees’ hard work
Never reprimand employees in front of their peers
Be accessible and listen to employees when they need to talk
Take employees’ suggestions into consideration
Work toward having satisfied employees
When possible provide personal space for each employee
Allow employees to place pictures in the area in which they most often
work
Create a sense of affiliation to the medical office
Help to ensure that employees feel they have been fairly compensated for
the amount of work they produce
Provide employees rewards beyond pay
Maintain a cohesive work atmosphere by ensuring that communication is
open and honest
Be available for employees
Show empathy
Attributes of a Good Leader
• Ability to make
appropriate calls of
judgment
• Willingness to learn new
ideas
• Staying calm during
stressful situations
• Always maintaining a
professional attitude
• Demonstrating good
listening skills
• Different Types of Leaders
Types of Power
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Power of rewards
Legitimate power
Expert power
Referent power
Informative power
Connective power
Factors that Help to Create a
Successful Office Team
• Size
– The smaller a team, the
better it will work
together
• Team personalities
– It is inadvisable to put
together a team made of
the same personalities
and similar mindsets
Factors that Help to Create a
Successful Office Team
• Responsible team members
–All members of the team must be accountable
for their actions
• Unified team approach
–Team members must come together to face the
project with the same purpose and goals
Have you ever worked on a successful team?
If so, what do you think made the team successful?
Task-Oriented Roles that Team
Members Can Assume
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Information seeker
Information giver
Coordinator
Energizer
Evaluator or critic
Recorder
Nurturing Roles that Team
Members May Assume
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Encourager
Harmonizer
Compromiser
Follower
Benefits to Having the Application
Completed at the Interview
• Ability to see how the applicant handles filling
out forms under a time constraint
• Obtain a visual of the applicant’s handwriting
• Learn how adept the applicant is at completing a
requested task
– Do they follow directions, take shortcuts, or do they
complete every line?
– How does she/he handle on-the-spot tasks that may
need to be resolved quickly and efficiently?
Considerations for a Job
Performance Evaluation
• The employee's job description should be
reexamined and the most important aspects
of the position should be identified
• Look at whether the employee’s performance
was outstanding, good, average, poor, or
unacceptable
Questions to Consider When
Rating an Employee
• What factors determine outstanding performance?
• What determines good versus poor performance?
• How are the employee’s social interaction skills,
many times referred to as their “soft skills”?
• How does the employee get along with the other
members of the office team?
• How does he or she interact with the patients?
Possible Disciplinary Actions
Every incident should be documented with time, date,
and an objective statement regarding what happened.
Considerations for Establishing a
Time Management System
• Defining the office goals with the physician.
For example:
– Collecting all payments at the time of delivery of
services
– Reorganizing or computerizing billing
– Limiting the practice
– Writing a textbook
• Creating a priority list of the goals
• Placing the priority list onto a TO DO list
Information Found in an Employee
Handbook
• Employer-employee
relationship
• Work environment and
expectations of the
particular medical facility
• General information about
office policies
• OSHA guidelines and
standard precautions
• Information related to
benefits and time off
The Office Policies and Procedures
Manual
• Contains detailed descriptions of the standard
operating procedure (SOP) and how to perform
both administrative and clinical tasks
• Policy refers to:
– A plan of action, such as “It is office policy that all
employees receive hepatitis B (HBV) vaccinations.”
• Procedure describes:
– The steps to be performed to carry out the policy
• The terms policy and procedure are used
interchangeably in many offices
Contents of a Patient Information
Booklet
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Office hours
Payment guidelines
Appointment and cancellation policy
Telephone answering service information
Information about the physician(s)
After-hours availability
Directions to the facility
Parking information
Benefits of an Effective Patient
Information Booklet
• Reduce the number of
questions by telephone
from patients
• Enhance the office’s image
• Reduce the number of
patients who fail to
remember instructions
• Used either for patients
with special needs or to
teach methods of disease
prevention
Steps to Developing a Patient
Information Booklet
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Make the booklet as appealing as possible.
Allow a white border around all the edges.
Use large print for the elderly reader’s benefit.
Make small enough that it will fit easily into a pocket or purse.
Write the booklet with the reader in mind and at a reading level
appropriate for your target audience. Avoid the use of technical
medical terms.
Avoid long paragraphs of explanation. Keep the sentences short
and concise and use as many bulleted points as possible.
Provide a listing of the regular office hours.
List any special services offered by the practice or clinic such as
patient education classes or blood pressure testing programs.
Explain the procedure for having a prescription refilled.
Steps to Developing a Patient
Information Booklet
• Explain the procedure for processing medical
insurance forms.
• Include a general statement about payment of fees.
• Provide information about the physician and the
staff, the name and telephone number of the office
manager, the personnel responsible for insurance
processing, and the patient educator.
• State what procedure to follow in case of an emergency.
• Provide a 24-hour emergency telephone number.
• Include a telephone number at the end of the brochure
in the event there are additional questions.
• End by thanking the patient for taking the time to read
the literature.
The Purpose of Marketing
Promote a new medical office or improve the image of
an established medical office
• Word of mouth
• Public relations activities such as local charities and
events
Questions to Ask When
Establishing a Practice Website
• Is it simply providing one-way information to the
patient regarding the practice?
• Is the website intended to provide interactive
communication allowing the patient to ask
questions and complete forms?
• Is the physician or medical office staff member
going to respond?
• Will the patient to be able to access different
forms and procedure instructions?
• Will patients be able to request appointments
online?
The Impact of Good Customer
Service
• Word of mouth can bring you many customers
• It can also drive patients away if poor services are
provided
• Areas to consider:
– What impression does the patient have?
– Is the staff helpful and empathetic?
– Is the staff attentive and considerate of the patient’s
time and condition?
All patients must be treated with respect and concern.
Competency
• Collating Records
Competency
• Developing a Patient Information Booklet
Small Group Activity
• Create a Checklist for Managing Medical
Records
Internet Activity – Instructor Led
• Medical Office Websites
Discussion
• Patient Experience at the Medical Office
• Professionalism
• Diversity
Summary
• Topics Covered