The accuracy, validity, and completeness of health data are all necessary in order for the data to be useful. Master Patient Index I have to write lots of papers every semester. Serial Numbering. serial numbering system The process of recording the registration data into the MPI and generating the MR # initiates the patient’s health record. Some health care environments may retain patient health records in manila folders, binders, envelopes, or expandable pocket files. 5. The modifier is a number attached to the MR# using a hyphen. 8. When they are identified, an HIM professional must carefully follow procedures to correct each error and to properly identify the patient in the MPI and with the correlating record. Log In or Register to continue • Mother’s maiden name File Folders When the HIM employee attempts to locate the patient’s folder, efforts will involve searching for a misspelled, misfiled record. Likewise, because the index cards are filed alphabetically, it is possible for cards to be misfiled and problems to occur as they do in alphabetical filing. admission The act of accepting a patient into care in a health care facility, including any nonambulatory care facility. The number assigned during each one of Molly’s encounters is recorded in the MPI under her name. Retention Any subsequent admissions (e.g., for a hip replacement later in life) are filed under the same number (Figure 9-5). File health records appropriately according to the file system used by the facility. For easy identification and filing, the file folder containing the patient’s health information was labeled with alphanumerical characters. For easy identification and filing, the file folder containing the patient’s health information was labeled with alphanumerical characters. This is because records with lower numbers can be identified with ease as they remain in the old file. Filing of all encounters in one folder can cause problems with incomplete records. index A system to identify or name a file or other item so that it can be located. Three types of numeric filing numbering system answers. Consider the following scenario: Molly Brabant is born at Diamonte Hospital on January 1, 2001. ADVANTAGES AND DISADVANTAGES OF ALPHABETICAL FILING.  electronic health record (EHR) A secure real-time, point-of-care, patient centric information resource for clinicians allowing access to patient information when and where needed and incorporating evidence-based decision support. The computerized MPI provides the opportunity to store more patient identification information for each admission—for example, patient financial class, marital status, social security number, and AKA functions, which link the patient to another name resulting from divorce or marriage or to a pseudonym. If the patient’s name is incorrect, this information must also be corrected wherever it appears to ensure accurate retrieval of patient information. Before computerized technology, health care forms were manually stamped with the patient’s name, MR#, account number, patient account number and room number by means of an addressograph. • Payer Patient Accounting • New: new to the facility as a patient; not registered or treated at the facility on a prior occasion This system requires a cross-reference system from the old MR# to the new number so that records can be located. health record Also called record or medical record. For many organizations, the manual/paper filing methods discussed in this chapter are legacy systems. Fourthly, it allows easy distribution of work among filing clerks through assignments to specific filling areas. Five types of health record identification are discussed here: alphabetical filing, unit numbering, serial numbering, serial-unit numbering, and family unit numbering. Because an entire chapter of this text is devoted to the EHR, much (but not all) of the discussion in this chapter focuses on the management of the paper health records. When the HIM employee attempts to locate the patient’s folder, efforts will involve searching for a misspelled, misfiled record. In this system, the primary section ranges from 00 to 99. Cloud Computing • Advance directive and surrogate decision making Illegible handwriting may cause problems with filing c. Serial-unit numbering Serial-unit numbering is an adaptation of the serial and unit numbering systems that combines both systems. Alphabetical filing systems can become inefficient in a facility that serves a large population with a high volume of patient records. This system is also beneficial in a small clinic or physician’s office setting where clinical and financial records are combined for claims processing. The U.S. Armed Forces have used the Social Security number as an identification number for Army and Air Force personnel since July 1, 1969, the Navy and Marine Corps for their personnel since January 1, 1972, and the Coast Guard for their personnel since October 1, 1974. If the patient had been treated at the facility on a previous occasion, the patient’s MPI card was retrieved from the card file, reviewed to make sure the patient’s information was correct, and the new admission information added (date of admission, type of service, account number for that visit, attending physician, discharge date). Patient data should include: Patient nameDate of diagnosis Medical record number Cancer primary site A paper abstract with the above information could be used as the suspense system, or an index card could be completed.. It is important to print clearly when labeling the patient’s file folder. 12. Any subsequent admissions of this patient to the facility would use the same MR#. In a small physician’s office, clinic, home health care facility, or nursing home, the patient health record file folders are often labeled using the patients’ names. What is the first step in locating Mr. Jones’s old record from a previous admission? At birth, Molly, being the first-born child, is assigned MR# 123456-03. The terminal digit filing system is remarkably efficient as it can allow the filing of large volumes of records. Determine whether a patient has a previous health record at the facility. Manual Systems Chapter 9 treatment A procedure, medication, or other measure designed to cure or alleviate the symptoms of disease. The difference is that each time the patient receives health care, the old records are brought forward and filed with the most recent visit, under a new medical record number. Therefore the records are not typically located together on the file shelf. Retrieving all the records for one patient involves going to multiple places in the files. If the hospital has a unit numbering system, all patient records will carry this identifying number. Chapter Outline • Physician Serial number inventory problem (RIINV00), Serial number History (RISERNR1), Copying of changed stock check flag (RISERNR9), MASE Correction report (RIMASE01). Question 10 0 / 5 points Which of the following is a numbering system in which a new number is assigned for each admission or ED visit? Disregard commas, hyphens, and apostrophes. Serial numbering is a set of unique identifiers assigned to individual items within a batch of products. Molly’s mother has MR# 123456-02. The data contained in the MPI are the data collected during the patient registration process. • Admission date(s) HIM professionals should monitor the accuracy of the manual MPI conversion. Each family members file is then identified by the one medical record number to the entire family (father/husband, mother/wife, and children). • Accrediting bodies review records to evaluate compliance with standards. Health care professionals in facilities using this system must take special care to protect the privacy of patient records because the patient health information is easily identified. Medical offices, libraries and other locations often use numerical systems for filing. Easy to learn Serial Numbering System Patient is assigned a number the first time they are registered and are reassigned the same number all subsequent admissions and encounters; all records are filed in one folder Unit Numbering System Table 9-3 summarizes the advantages and disadvantages of each numbering system. Space is a common problem in the alphabetical filing system. In some health care facilities the patient account number is used to identify the patient health record. This is an efficient way to maintain the original MPI system for future research if MPI data are questioned. When a patient receives a new number upon each admission, and his or her medical records are filed in various locations in the filing system, which numbering system is being used? Restoration of Information Lost Inadvertently Where physical records must be organized efficiently and kept securely, AMES® medical records storage systems deliver outstanding designs for durability, accessibility, and performance. The system being used is called A. numerical B. serial numbering C. serial-unit numbering D. unit numbering Usually contains at least the demographic data and contains space for the physician to record and authenticate the discharge diagnoses and procedures. Depend on the file shelf and treatment of the health care facility it indicates new... An occasion for fancy script or calligraphy addressograph is a list serial numbering system medical records all encounters one! 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