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Managing the Medical Office and Medical Records


Title: Slide 1 Author: janelle Last modified by: claubacher Created Date: 4/23/2013 1:59:33 PM Document presentation format: On-screen Show (4:3) Other titles – PowerPoint PPT presentation

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Title: Managing the Medical Office and Medical Records

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
  • Patients past medical records
  • History and physical
  • Insurance information
  • Office notes
  • Progress notes
  • Telephone messages
  • Pathology results
  • Nursing notes
  • 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
  • Alphabetic system
  • Numeric system
  • Subject filing
  • Color-coding
  • Lets take a closer look at each of these!

Steps for Using the Terminal Digit Filing System
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
  • Look for transposed letters
  • Look for different spellings
  • Look at folders filed before and after missing
  • 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

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 patients 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
  • The AMA recommends keeping records for 10 years

Issues Addressed in a Medical Record Destruction
  • 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
  • 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
  • Personnel management responsibilities
  • Employee records
  • Financial management
  • Scheduling
  • Facility and equipment management
  • Communication
  • Legal concepts
  • Lets look more in-depth at each one of these

Personnel Management Responsibilities
  • Recruitment and selection
  • Hiring new employees and establishing orientation
  • Annual performance review
  • An exchange between supervisor and employee to
    comment on job performance and set goals for next
  • 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
  • Gross salary amount (salary before taxes are
  • Deductions for social security taxes, federal,
    state and city withholding taxes, state
    disability tax, and state unemployment tax, if

Effective Scheduling
  • Can contribute to the satisfaction level of the
  • 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

  • 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 physicians 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
  • Acting as liaison between staff and the
  • 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
  • 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
  • Ensure all vacations have been approved
  • Compare the office calendar with the physicians
    calendar on a periodic basis and update the
    offices master calendar as necessary

Staff Meetings
  • To facilitate communication between staff and the
    physician, have the physician attend when
  • 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
  • Emotional rewards
  • Communication
  • Honesty
  • Visibility of the management
  • Empathy
  • Trust
  • Equal treatment of all staff

Ways to Show Respect
  • 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
  • Allow employees to place pictures in the area in
    which they most often work
  • Create a sense of affiliation to the medical
  • Help to ensure that employees feel they have been
    fairly compensated for the amount of work they
  • 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
  • Power of rewards
  • Legitimate power
  • Expert power
  • Referent power
  • Informative power
  • Connective power

Factors that Help to Create a Successful Office
  • Size
  • The smaller a team, the better it will work
  • 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
  • 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
  • Information seeker
  • Information giver
  • Coordinator
  • Energizer
  • Evaluator or critic
  • Recorder

Nurturing Roles that Team Members May Assume
  • 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 applicants 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 employees 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 employees 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

Considerations for Establishing a Time Management
  • Defining the office goals with the physician. For
  • 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)
  • 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
  • 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
  • Reduce the number of questions by telephone from
  • Enhance the offices 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
  • Make the booklet as appealing as possible.
  • Allow a white border around all the edges.
  • Use large print for the elderly readers 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
  • 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

Steps to Developing a Patient Information Booklet
  • Explain the procedure for processing medical
    insurance forms.
  • Include a general statement about payment of
  • 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
  • Provide a 24-hour emergency telephone number.
  • Include a telephone number at the end of the
    brochure in the event there are additional
  • 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
  • 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

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
    patients time and condition?

All patients must be treated with respect and
  • Collating Records

  • Developing a Patient Information Booklet

Small Group Activity
  • Create a Checklist for Managing Medical Records

Internet Activity Instructor Led
  • Medical Office Websites

  • Patient Experience at the Medical Office
  • Professionalism
  • Diversity

  • Topics Covered