Modul Pelatihan Praktisi rekam Medis Unit 3 ” Record Identification syatem,Filing and Retention Of Health Record”

Education Module for Health Record Practice

based on IFHRO Modul

UNIT 3 ‑ RECORD IDENTIFICATION SYSTEMS, FILING AND RETENTION OF HEALTH RECORDS

This unit introduces the participant to different record identification and filing systems used in health record management.  Record identification may be either alphabetic or numeric, and the filing system used is dependent upon the type of record identification system employed.  Although some health care facilities have electronic health records,  most health care facilities still maintain patient records in a paper-based format.  

This unit deals with the various methods to identify and file paper-based patient records.

The record identification and filing systems form the first step in a series of procedures in the management of health record services.  A medical record has no value if it cannot be found once it is stored somewhere in the file area.

Careful planning of the record identification and filing systems to be used is of great importance.  The choice of the system, however, also depends on the specific type and circumstances of the health care facility for which it is selected.

Planning of filing activities should also include a policy on record retention.  Storage space is generally a scarce commodity, so usage of it has to be maximised.

OBJECTIVES:

Upon the completion of this unit, the participant should be able to:

1.     compare and contrast the different methods of record identification and list the advantages and disadvantages of each

2.     give specific examples of serial and unit numbering

3.     explain what is meant by a unit numbering system

4.     compare and contrast filing systems for health records.

5.     explain relational numbering with advantages and disadvantages

6.     define record linkage and explain how it is used

7.     demonstrate an understanding of terminal digit filing and cite the advantages and disadvantages of its use.

8.     define what is meant by a centralized filing system and delineate the advantages of this system

9.     describe the methods that may be used to assign patient healthl record numbers

        10.     explain the various control methods used to facilitate the location of health records

        11.     state the general rules for record control in a hospital or clinic and the specific filing rules required to maintain an efficient health record service

        12.     identify and compare the different types of filing equipment used to file health  records

        13.     delineate characteristics which should be considered in choosing folders, guides and outguides

        14.     outline criteria which must be evaluated when establishing record retention policies

        15.     explain the storage options for health records with advantages and disadvantages.

A.      RECORD IDENTIFICATION SYSTEMS

It is important that each record has a unique identifier, either alphabetic or numeric. The collection of patient identification data and the assignment of a record number or verification of an existing record number should be the first step of every admission or visit to a hospital or health center.  It is the only way to ensure properly identified health records.

          1.     Alphabetic Identification

The simplest form of record identification is alphabetic, using the patient’s name to identify and file the patient’s health record.  And because only the patient’s name is used to identify the record, it is also the easiest method of record retrieval, as the master patient index (MPI) is not needed to cross-reference the patient’s name to the health record number.  The accurate spelling of the patient’s name is of extreme importance.  It is also important to create a system to track name changes, such as from marriage or divorce.  It is necessary to thoroughly train staff to verify patient names and spellings, and to accurately and consistently file the health records.

One concern with this type of record identification is patient confidentiality.  Since the outside of the record is identified only with the patient name, and not a number, the patient’s identity is not protected.

This type of record identification system is most practical in smaller health care facilities with stable patient populations.  Larger patient populations would result in multiple patients with the same name, leading to possible mix-ups of patient files.  It is also most practical for facilities with little or no computerization. 

2.     Numerical Identification

A numerical record identification system requires that a unique health record number be assigned.  It requires the use of a MPI to cross-reference the patient’s name with his or her health record number.

There are two main systems of numbering patient records:

  • ·Serial numbering
  • ·Unit numbering

 

a.  Serial numbering

With this method the patient receives a new health record number on every inpatient admission or outpatient visit to the hospital or clinic.  That is, the patient is treated as a new patient each time with a new number, new index card and new record, filed totally independently from previous records.

Serial numbering is not used extensively today and is only useful in small hospitals with a low rate of readmission.

b.  Unit numbering

The patient is assigned a unique identification number on his first contact with the hospital, whether it is for an admission, emergency room or outpatient clinic visit.

The same health record number is kept and used on all subsequent visits, whether as an inpatient, outpatient or emergency patient. A unit health record number results in the creation of one, central health record for the patient.

This number is normally related to one single record, where all the information on the patient is brought together.  These data can originate from different clinics or units, at different time periods. If a unit record is not possible, the unit numbering system can be used to link health records that are physically located in different places.

      1) The advantages of using a unit number for filing are:

  • the number is unique to the individual and therefore distinguishes him/her from any other patient in the hospital or clinic

 

  • the number does not change regardless of how often a person is admitted to hospital or attends a clinic

 

  • patients’ health records are centralized in a single folder

 

  • this system provides the medical staff with a complete picture of the patient’s medical history and treatment received over a number of admissions and attendances.

 

  • health records are filed in one place.

 

      2)    The disadvantages of using a unit number for filing are:

  • health records may become quite thick and additional folders may be required

 

  • space needs to be allocated to allow for the expansion of records as more admissions are added to a folder.

 

It is important to note that when a unit record is used, it is essential for all staff to check the patients’ master index before issuing a new record folder.  This ensures that a duplicate health record is not produced.

  1. Serial-unit numbering

 

Serial-unit numbering is an adaptation of the serial and unit numbering systems that combines both systems.  With this system, the patient receives a new number on every contact with the hospital, but previous records are brought forward and filed under the latest number, so only one record will remain in the files.

It is necessary to leave either the old health record folder or an outguide (or tracer card), referring to the new record number, in the place from where the old records are removed.

1) The advantages of serial‑unit numbering and filing are:

  • §a unit record is created

 

  • §record retention is easier as records with lower numbers automatically remain in the old file.

 

2) The disadvantages of serial-unit numbering and filing are:

  • §gaps are left in the file area when medical records are brought forward.

 

  • §time is needed for back shifting and for cross‑reference from old record and record number to the newest one. (Huffman 1994)

 

d.  Conversion to a unit system

The change from one system to another should not be underestimated.  It implies an increased workload, since two filing systems have to be used for an undetermined period of time.  Many records have to be controlled and shifted, especially in the first months.

      The steps proposed for a conversion are:

      1)    Select a date to make the change, and begin issuing patients new unit numbers on that day.

      2)    Check if the patient already has a record (or records).  Bring forward these previous records and file them under the new number.

      3)    It is best to convert the records of old patients to the new system as they come back to the health care facility, rather than attempt to convert the entire file at one time.

      4)    The Master Patient Index has to be adjusted or a new MPI started from day one of the changeover.   As a dual control, empty folders of previous records or out guides (tracers) should be left at the original places in the old file, with cross‑reference to the new unit record number.

      5)    After a predetermined period of time, the records still in the old file can be considered as inactive and eventually removed to inactive storage.  This also applies to old MPI cards, if a new MPI was started.

2.     Types of numbers

a.  Sequential numbering

Records are assigned a sequential number in chronological sequence commencing at 1.  For example, if the last number to be assigned was 010524 the number issued to the next patient would be 010525.  This method is simple, easy to assign, and easy to control.

This is the way numbers are issued in both serial and unit numbering systems.

Often when using a serial numbering system, some hospitals connect  this sequential numbering system with the year as a prefix, for example:

     05‑0024, represents the 24th patient of 2005

Other types of numbering are described below.  They are not generally considered to be better than a straight numbering method, nor as commonly used.

b.  Alphanumeric numbering

This is a combination of letters and figures, for example:

     AA 99 99 instead of 99 99 99

This method has the advantage of a greater capacity with the same number of characters, for example, letters:  A‑Z (26); figures: 0 to 9 (10).

This method, however, is not extensively used.

c.   Relational numbering

Relational numbers are numbers that, totally or partially, have a certain significance in relation to the patient.  There are various types of relational numbering systems that may be used, including:

   1)    Birth number

This number is derived from the date of birth.  That is, the number is based on six of the eight digits of the birth date.

To these digits other digits may be added.  For example, two, three (or even more) digits for the serial number (can be odd for males and even for females), a digit for gender, or digits representing a geographical code, for example:

    50            06                24            1                  05                    2

  Year      Month             Day         Gender       Serial       Geographic

Number          Code

In addition, one or two check digits may also be included, particularly, in computerized systems.  The total number, therefore, could consist of 9 to 12 digits.

           a) The advantages of using a relational number include:

  • The record number has built‑in information (age and sex)

 

  • Easy to remember, because of date of birth.  If difficulties occur in retrieving information from the MPI (misspellings, husband’s name, common names, etc.) the date of birth gives enough information to find the record.

 

   b) The disadvantages, however, must be taken into consideration, and include:

  • Long number, increasing the risk of transcribing errors, particularly in non‑automated systems.

 

  • A limited capacity, since a maximum of 31 numbers can be used for the day digits and a maximum of twelve numbers for the month.  Only the year digits have a range of 00 to 99.

 

  • If the birth date is unknown pseudonumbers (eg. 99 99 99) have to be used, and conversion procedures must be developed once the birth date is available.

 

  • Folders and MPI cards cannot be prenumbered.

 

 Although useful for identification, it is not generally considered a 

 good number for filing purposes.

   2) Social security numbering

Social security numbers are used, mainly in the USA and in some countries where the social security administration operates health facilities, but are also not recommended for filing purposes.

        a) Advantages of using a social security number are:

  • It is a unique identification number.
  • No reference to the Master Patient Index is necessary, and therefore faster retrieval.

 

  b) The disadvantages, however, outweigh the advantages and 

       include:

  • Some patients do not have or cannot give a social security number at the time of their admission or visit (eg. newborns, children, patients from abroad). Pseudonumbers must be assigned if no actual social security number is present, and again conversion procedures are needed, once the real social security number is available.

 

  • Threat of identity theft.

 

  • Control and verification of the number is out of the hands of hospitals using it.

 

3)  Family numbering

Another type of number used is a family number.  This type of numbering system is most appropriate for primary care clinics where all members of a family may receive health care.

With this system one unit number is issued to a household, and extra digits are added to indicate every individual in the household.

Example:       01        =          head of household

                02        =          spouse

                03        =          children and other family members (con’t)

                04

                05

                 06

Examples:

Mrs. Mary Smith            01 6436          Pamela Smith           03 6436

Mr. Donald Smith         02 6436          John Smith               04 6436

All health records are then grouped numerically by families, but separate folders can be maintained for each individual patient.

a)    The advantage of this method is that it is useful for ambulatory care centers, which emphasise the family as a unit (eg. family counselling).

b)    The major disadvantage is that families change.  Marriage and/or divorce cause changes of household number and/or extra digits.

When it is important to link family numbers a combination of a family number with another individual number is suggested.  It is safer and easier to use.

3.     Assignment of numbers

As previously mentioned, whatever method of numbering used it is important to have a unique identifier (medical record number) as soon as possible. The gathering of patient identification data and the assignment of a medical record number to new patients should be the first step of every admission or visit to a hospital or health center. 

How health record numbers are assigned is dependent upon if the registration process and MPI are computerized or manual, and if unit or serial numbering is used.

a)  Manual system

In a manual system that uses unit numbering, the responsibility for number allocation is retained in one place, usually the health record department. This ensures that controls are in place to prevent more than one patient from having the same number, or that a patient will have more than one number.  If a new patient arrives at a registration area, the health record department is contacted in order to get a new number.

The procedure for assigning numbers should be clearly recorded and monitored.

In a manual system that uses serial numbering, either the health record department may issue the numbers or the registration staff may be responsible.  If the registration staff assign the health record numbers, predetermined blocks of numbers are often issued to patient registration areas having a high volume of new patients.  The amount of numbers in each “block” should be determined by the activity of each area and should be limited and carefully controlled.  Since each area is allocated a specific block of numbers, duplicate numbers should not be assigned.

b)  Computerized system

The best system for number assignment exists in facilities having computerized registration and unit numbering.  With computerized registration, number assignment in every registration area is possible because computer systems are available to check the MPI and to verify that the patient does not have an existing medical record number.  As the patient is registered, the staff searches the computerized MPI database to determine if the patient has already been assigned a unit number.  If so, the demographic information is updated as necessary and the current visit information is entered.  It is important to note, however, that if more people are responsible for assigning numbers, the risk of duplication will increase.

4.     Number control

It is important in both manual and computerized systems to have an established method of number control.  Numbers should not be pre‑assigned unless good control processes are in place.

In a manual system, this can be a permanent number index, or master control book, where all assigned and unassigned numbers are held.  As a number is allocated the name of the patient is immediately entered beside that number.  Date of issue is also recorded.

For example:

Number                Name                         Date                Where issued

102642                Brown, John             09/27/2004    Outpatient Department

102643                                                    Miles, Andrew           09/27/2004    Outpatient Department

102644                West, Julia                09/27/2004    Admission Office

In computerized systems, a check digit is determined by performing some calculations on the basic number.  Thus, check digit verification is a way of detecting errors, caused by transcription of a data field or transposition in the use of the number.  It contains information about the magnitude and the position of each digit in the field.  Transcription (a wrong digit) or transposition (two digits reversed) errors lead to a calculation result, different from the check digit, and therefore an error message will be printed.

The way a number is presented also adds to the efficiency of the system. For example, an all-numeric number, presented in a fragmented form (eg, 10 26 42) or in boxes helps to reduce the misquotation rate.

5.     Record linkage or longitudinal records

The main goal of record linkage is the centralization of all medical data about a particular patient to enable essential information, about that patient, to be more readily accessible, and thereby creating a longitudinal record.  This type of system requires the use of electronic health records in order to share patient information.

Hospitals and governments, concerned with an expanding volume of medical information, are developing systems, designed to link all health records belonging to one patient that are physically located in different buildings or hospitals, within a city, state or province or across a country.

In order to link records or data within or between hospitals, accurate and fast patient identification and number assignment are of prime importance. As mentioned previously, in many countries a unique number, often based on the birth date, is assigned at birth, and remains the standard identifier during the individual’s lifetime.  This system readily enables record linkage.

 

The perfect standard identifier, and thus the perfect record linkage number, should be:

  • §    unique (assigned to one person only)
  • universal (covering the population involved, eg. hospital or nation)
  • §    permanent
  • §    available (it must be present on each of any pair of records to be linked)
  • §economical (it should consist of no more characters of information than necessary, as each character creates additional computer storage space).

 

It should also be noted that controversy exists surrounding the use of unique personal health identifiers because of the possible security issues, and many view it as a means of invasion of privacy

 

B.      FILING SYSTEMS

Record identification systems and filing must go hand‑in‑hand, as the filing system depends on the identification system used.  Filing is the systematic arrangement of records in a specific sequence so that reference and retrieval is fast and easy.

Daily procedures in many areas of a clinic or hospital can be severely affected by poor management of health record services.  It is therefore the responsibility of the health information professional/health record administrator to establish systems and procedures to ensure the efficient production of health records for patient care, medico‑legal purposes, statistics, teaching and research.

The health record department is judged on the efficient service it provides to the rest of the hospital or clinic. That is, health records must be readily available when required for patient care.  Departmental efficiency and record control are therefore two of the most important things to consider in the management of the health record services.

1.     Alphabetical filing                   

When no health record number is assigned, and the patient’s name is the only identifier, then alphabetical filing is the only possible method to use.  Filing is by patient surname first, then given name, and finally middle name or initial.  Records of patients with exactly the same name should then be filed according to their date of birth date.

This type of filing is time consuming and the risk of errors (change of name, misspelling) is extremely high.  Moreover, there is no way to control the use of the file area as it is not possible to know beforehand where the next new record will be filed.  Since names are not equally distributed, it is extremely difficult to avoid congestion areas and back shifting to open new file space.

Alphabetical filing is not recommended, and is only useful for facilities with a limited patient population and a small files area, with a very low patient turnover rate.

 

2.     Numerical filing systems

If a numerical record identification system is used, then a numerical filing system is used.  There are two main systems of filing records numerically:  straight numeric and terminal digit.

a.  Straight numerical filing

In this system, health records are filed in straight numeric sequence as follows:

8984                   108264

8985                   108265

8986                   108266

8990                   108267

This filing method reflects exactly the chronological order of the creation of records.  Straight numeric filing is typically used when serial health record numbers are assigned, however, a unit health record number may also be filed in straight numerical order.

1)    The advantages of straight numeric filing include:

  • people are used to this “logical” order and training is easy

 

  • easy to retrieve consecutive numbers for research or inactive storage.

 

2)    The disadvantages, however, outweigh the advantages, particularly in large hospital health record departments.  The disadvantages include:

  • easy to misfile, one must consider all the digits of the number in order to file the record

 

  • easy to transcribe numbers where one digit is wrongly written or read, for example: 1 for 7

 

  • easy to transpose numbers (reverse digits), for example, record number 194383 is filed as 193483

 

  • the highest numbers represent the newest, and therefore most active records, causing a concentration of record activity in one particular area of the file room, where these records are filed

 

  • it is not feasible to assign filing responsibility to one clerk since most of the records and loose sheets are filed in the same area.

 

b.  Terminal digit filing

1)    Whether using a serial, unit, or serial‑unit numbering system, the actual method used for filing is most important.  In place of straight numerical filing, other methods have been designed to improve retrieval and filing efficiency.  The most popular method in use today is the terminal digit filing system.

In terminal digit filing a six or seven digit number is used and divided into three parts.

Part 1 ‑    The primary digits, which are the last two digits on the right hand side

Part 2  ‑   The secondary digits, which are the middle two digits

Part 3 ‑    The tertiary digits, which are the first two or three digits on the left hand side

                                For example, the number 14 20 94 is divided as follows:

14                ‑             20                  ‑              94

Tertiary                   Secondary                     Primary

      2)    In the terminal digit file there are one hundred (100) primary sections ranging from 00 ‑ 99. When filing, the clerk considers the primary digits first, for example, the number 14 20 94 will be filed in the “94” primary section.  Within each primary section there are 100 secondary sections, also ranging from 00 ‑ 99.  The number 14 20 94 is filed in the 20 ‑ 29 secondary part of the “94” primary section.  Within the 20 ‑ 94 section the record is then filed in numerical order by the tertiary number.  The sequence of the file is as follows:

13 20 94             02 21 94                     11 21 94

14 20 94             03 21 94                     12 21 94

15 20 94             04 21 94                     13 21 94

16 20 94             05 21 94                     14 21 94

17 20 94             06 21 94                     15 21 94

18 20 94             07 21 94                     16 21 94

19 20 94             08 21 94                     17 21 94

00 21 94             09 21 94                     18 21 94

01 21 94             10 21 94                     19 21 94

      3)    The file clerk considers the record number in parts, going from the right to the left.  For the number 142094 he first locates the primary section (94). Within section 94 he looks for the secondary or subsection (20). There he files in numerical order, using the tertiary digit 14.

Adaptations can be made when more or less than six numbers are used.

 

        For example:

02               ‑                   44                    ‑           87

107          ‑           09                    ‑           14

      4)    The advantages of terminal digit filing include:

  • Records are equally distributed throughout the 100 primary sections.

 

  • Only every 100th new medical record will be filed in the same primary section of the file.

 

  • Congestion of personnel in the filing area is eliminated.

 

  • Clerks may be assigned responsibility for certain sections of the filing area.

 

  • The work can be evenly distributed among file clerks.

 

  • Inactive health records may be pulled from each terminal digit section as new ones are added, thus eliminating the need to backshift records.

 

  • Misfiles are substantially reduced with the use of terminal digit filing

 selesia@hak cipta Dr iwan Suwandy,MHA 2010

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s