Medical record filing systems enable providers to store information securely and retrieve it efficiently. Filing systems also protect patient-identifiable data. The type of health information system that a provider uses often depends on the type of facility, its size, the number of patients it treats and the volume of records it keeps. Smaller facilities that deliver specialized care for fewer patients may choose paper records, while larger organizations with multiple departments and locations might use electronic records. Some care providers use a hybrid of paper and electronic medical record filing systems.
Medical records support quality care for patients and help ensure that those who provide the care are paid properly. By documenting symptoms, diagnoses and treatments, providers can use medical histories to help patients stay healthy and recover from illnesses more quickly. They also can get paid faster because insurance companies often require proof of quality care.
Health Insurance Portability and Accountability (HIPAA) standards help to protect your privacy by providing guidelines for what, when and how information about your care can be shared. All medical providers are required to adhere to these standards, no matter what type of filing system they use. In order to share certain information, they must obtain your written consent and a signed release form. For instance, your next door neighbor cannot call your doctor and find out if you are a patient, let alone why you saw the doctor. Even your spouse needs a signed release form to be able to talk with your physician. Insurance companies have access to limited information, like insurance billing codes, but are not privy to any other details about your care.
Filing systems for paper medical records take up lots of space. Shelves, cabinets and drawers with color-coded folders are commonplace.
These kinds of systems vary based on the amount of linear filing inches available to store records and how records are organized. Records are commonly organized alphabetically or numerically.
Numerical filing systems include the following.
- Straight, or consecutive, filing: Medical records are filed in chronological order by patient number (i.e. the date in a date-month-year record).
- Terminal digit filing: Also known as the reverse numeric filing system, this is the opposite of the straight numeric in that records are sorted by the last digit (i.e. the year in a date-month-year record).
Paper folders are usually stored behind locked doors and in locked drawers. Office workers track requests for records and the location of records, such as through a check-out system that requires someone to sign for a record. Only supervisors can access records after hours, as needed.
An electronic medical record is a digital version of the paper chart that contains a patient’s history within a single practice. A provider uses an EMR to identify patients for preventive visits and screenings, monitor patients’ health, track data and improve the quality of care.
With an EMR, a user can only access the specific information needed from the record. For example, if a user does not have to see a full-patient history, the system allows access only to information that they need to perform their job. EMR systems use security measures to prevent unauthorized users from accessing protected health information, like medical histories. This helps to ensure HIPAA standards are met, while at the same time allowing for ease of access to approved parties.
Robust electronic health records also include administrative and billing data. EMRs may be shared between practices to improve the quality of care, but sharing of records between providers and facilities must still be done in accordance with HIPAA regulations. Major software vendors like Cerner, Epic, McKesson and Meditech provide filing systems that let users access information for individual patients by searching for them by name. Electronic filing systems also allow users to view information for groups of patients, such as searching for shared demographics or medical histories so that they can improve the health of communities – for example, by identifying who is due for immunizations.
Some medical practices use electronic records and paper records. They may print digital information, scan paper records and access information from either type of system, so that their electronic and paper systems are compatible.
For example, some practices that use EMRs update their files by scanning paper information. Or they will print information from the electronic record so that a care provider can have it on paper when treating a patient.
A facility’s policies and procedures should determine which parts of the record will be paper-based and which parts are stored electronically. All new records are filed in the appropriate format. If a portion of the record is paper-based, it should reference the location of the electronic portion.