When torrential rains submerged
Calgary earlier this month, FP Dr Bill Emery thought
he'd already lived through the worst his medical records
could throw at him. He'd spent years painstakingly putting
in order the disastrous filing system he inherited when
he took over another physician's practice. He thought
he'd thought of everything. Then the skies opened up.
"I had a flood in my office," he says with a rueful
laugh. "Some of the older files sitting in boxes on
the store room floor got destroyed."
All the medical records buzz these
days is about electronic health records (EHR), but the
average solo practitioner simply doesn't have the time
or money to take that plunge. According to a recent
NRM physician poll, a whopping 46% have no plans
to switch to an EHR system. But with more patients than
ever, paper-based practices need better ways to manage
those mounting charts.
Here are some tips to help you
get to where Dr Emery was before the flood:
1. Everything in its place
The most important thing you can do is try to be as
tidy as possible. Sorting your files routinely will
save you a lot of hassle when you're searching for information.
"Keep only the files you need in your immediate filing
area," recommends administrative guru and former medical
assistant Jill Chongva of Winnipeg-based Virtual Assistant
Diva (VADiva.com).
2. What's in a label? A
decent labelling system will make accessing your records
a breeze. "Most label companies provide templates that
integrate with the most popular word processing software,"
says Ms Chongva. Colour code the different categories
for easy recognition. Numeric systems (as opposed to
alphabetical) are much easier to manage. Year bands
come in handy when it's time to purge.
3. Nix those abbrevs Years
of med school have taught you to use shorthand, but
abbreviations aren't always standardized for all healthcare
professionals. Don't leave the doctor who takes over
your practice in the mess Dr Emery found himself in.
4. In an orderly file When
he first took over his practice, Dr Emery says every
chart was a jumbled mess of papers. "I separated my
files into three blocks," says Dr Emery. "I have my
clinical notes, my investigation results and consultation
reports, and they're organized chronologically." Organizing
your charts chronologically allows for better patient
monitoring and follow-up.
5. Do random chart audits
"A chart audit by nurses or assistants can make sure
that the records are complete, that test results are
recorded and a final summary has been done," says Gail
Crook, of the Canadian Health Information Management
Association (CHIMA).
6. To catch a thief Sadly,
health card fraud is increasingly common, warns Ms.
Crook. "Make sure the nurse or assistant starting the
record checks another piece of ID," she advises. It's
a simple and effective way to catch medicare fraudsters,
as well as to avoid duplicate charts.
7. Go heavy on the details
Recording patient visits is a government requirement,
but if you also make a note of the patient's file number,
health card number and patient complaint in your daily
diary, you'll speed up the task of billing the province
later.
8. Thin and purge Have staffers
remove from the patient's active chart old reports that
are no longer relevant. However, they should make a
note in the current chart that the old documents have
been stored, and where. Larger practices might consider
converting certain reports into image documents for
storage on CDs, especially if the paper files are being
moved offsite (see below).
9. Box it up and move it out
If, like Dr Emery, you've got old charts in boxes stacked
on the floor, it might be time to consider off-site
storage until you're legally allowed to destroy them
(this varies province-to-province). "There are good
companies that provide storage with restricted access,"
notes CHIMA's Tamara Stefanits. Remember to check their
credentials and ask around first.
10. Under lock and key Lockable
shelving is one low-tech way of ensuring the privacy
of your paper files. "There's no public access to my
files," says Dr Emery proudly. "We have a 'what happens
in Vegas, stays in Vegas,' policy," he adds with a laugh.
|
