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August 22, 2012

Essay Paper on Medical Records

Difference between Qualitative and Quantitative Medical Record Analysis
Qualitative analysis is the review of medical record entries for inconsistencies and omissions which may imply that the medical record is inaccurate or incomplete. Performing such an analysis requires the knowledge of medical terminology, anatomy and physiology, the fundamentals of disease processes, medical record content as well as the standards of licensing, accrediting, and certifying agencies. Such an analysis is usually done by a qualified medical record practitioner.
Quantitative analysis, on the other hand, is an examination of the prescribed areas of a medical record for identifying specific deficiencies in recording. The purpose is to ensure that the record is current, comprehensive and accurate. Items that do not meet the criteria should be noted on a check-off sheet for future review and processing by the responsible staff - medical, dental, nursing, and allied health providers (Analytic Services, 1990).
Basic Specifications for Designing a Form:
  • Before starting the design, the following should be considered:
    1. What is the rationale for the form?
    2. Are there any other forms that are similar or in which the same information has been collected?
    3. Can the form’s purpose be met by using other forms / modifying existing forms?
  • Consult the authorized member(s) of the forms committee and identify the sponsor for the proposed form.
  • Present the draft form at the meeting of the forms committee.
  • If need be, revise the form based on the feedback and present it again to the forms committee.
  • The form will first be approved for trial (including evaluation) in the clinical area.
  • The form will then be reviewed by the sponsor and/or the forms committee and amended if required.
  • Following the final approval by the forms committee, the presenter of the form shall organize its printing by contacting the ERC if artwork is required or the material resources in case no artwork required.

Types of Numeric Filing Systems:

Numeric filing, which is organized by number rather than by letter, has three types:

  1. Terminal-digit filing system.
  2. Middle-digit filing system.
  3. Straight numeric filing system.

Terminal-Digit Filing:

A terminal-digit filing system groups numbers into units containing two digits each. Usually a six-digit number is used and divided with a hyphen into three parts. The digits are read from right to left. The last two digits of a number are the first indexing unit and are called primary digits. The secondary digits are the middle two digits and are the second indexing unit. The tertiary digits are the first two digits and the third indexing unit.

In a terminal-digit file, there are 100 primary sections ranging from 00 to 99. The medical record is first taken to the primary section corresponding to its terminal digits. Within the primary section, groups of medical records are matched according to secondary digits. After locating the appropriate secondary section, the medical record is filed within it in numeric order by the tertiary digits. In the file, the tertiary digit changes with every medical record.

Middle-Digit Filing:

In middle-digit filing, numbers are grouped according to pairs of digits as in terminal-digit filing. However, primary numbers are the middle two digits of a six-digit number, secondary numbers are the first two numbers, and tertiary numbers are the last two digits of a number.

As with terminal-digit filing, middle-digit filing is by pairs of digits; therefore reducing misfiles. Middle-digit filing is more complicated, and training time of personnel is more extensive than with consecutive and terminal-digit filing. Middle-digit filing does not lend itself to numbers with more than six digits.

Straight Numeric Filing:

Also known as the consecutive numeric filing system, it is the arrangement of medical records by assigned numbers, starting with the lowest number and ending with the highest. Numbers are read from left to right. The greatest advantage of using straight numeric filing is the ease of training personnel. Another advantage is that shelving units or other filing equipment can be added as storage becomes full. Disadvantages include the following:

  1. The person filing medical records must consider all digits at one time, allowing for transposition of numbers, which may lead to misfiles.
  2. Work flow problems may develop, since 90% of file room activity will be centered in 10% of the available space, that designated for the newest record numbers; and
  3. As older medical records are purged, back shifting must be done.

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