Filing & Recordkeeping

Office Management

Overview

• Records should be– Accurate– Up-to-date– Organized so easy to find

• Misplaced records cost– Staff time– Direct financial losses– Client confidence

Before you start…ask yourself…

• What is the best way to arrange the records?• What is the type of material to be filed?– Paper– Computer files– X-rays/ultrasounds

• What equipment will I need for adequate storage and retrieval?

• What proper systems will complement the equipment– Paper– Electronic

• What means and schedule should I follow for retaining files

Computer vs. Paper

Paper• Cons

– Damaged by fire/water– Misplaced– Torn or crumpled– Yellows with age

• Pros– Easy to use

• Who uses?– Smaller businesses

Computer• Cons

– Damaged/lost

• Pros– Easy to use– Easier to access– Quickly copied– Easily transported

• Who uses?– Companies with large client base– Companies with multiple

locations

Ways to protect Computer data:

• Make frequent backups• Store backup tapes/disc off-site• Use write-protection disks• Creating access passwords/user log-ins• Limiting access of personnel to certain parts of

the computer system

Filing systems• Materials

– Drawer space– Index guides (place every 10-15 files to save time)– Folder tabs– Records per file

• Filing procedure– Inspecting – is it ready to be filed?– Marking – is the file marked appropriately by name or number– Follow-up and cross-reference – does the file need to go in another place for

follow up, if so make a cross reference– Sorting – how are the files sorted, by name or number, by each individual pet

or by client– Filing – be uniform (tops to the left), verify that you are putting Fluffy Smith’s

record sheet in Fluffy Smith’s record/file

Filing Systems continued

• Alphabetic systems– Most familiar– Provide a direct reference to names– Disadvantage: common names do not occur

evenly throughout the alphabet (more names start with S than Q), therefore one file may grow cumbersome in size, making identification difficult.

Filing Systems continued

• Numeric Systems/Terminal Digit Filing– Documents are numbered– All sections of the file expand evenly– Eliminates back-shifting to take up empty space where records have

been removed to make space for new records– Fewer misfiles because it is easier to read simple two digit numbers

separated into groups– Final numbers, secondary numbers, primary numbers

• 01-20-00• 10-20-00• 110-20-00• 264-20-00

Filing Systems continued

• Color Coding– Has become popular during the past few years– Cost-saving feature for the filing and retrieval of

records– Can be applied to every method of filing– Benefits

• Eliminates hidden misfiles• Speeds filing and finding• Easier to locate while out of the system• Eliminates the need for index guides

Filing Systems continued

• Chronological Filing– Filing by date– Copies of freight bills– Invoices– Normally used only where there is little or no

reference made to the record once the transaction is complete

Storage Options

• Standard Filing Cabinets– Vertical filing– Lateral filing

• Open Shelf Filing• Wire Inserts– Used to keep files vertical– Replace the expensive suspended pocket (hanging

file) system

Receipts

• Payment options– Cash – Personal check– Credit card

Cash

• Security risk b/c employees may pocket with recording the transaction

• More than one person should monitor cash receipts

• Large amounts should not be kept in facility for extended periods of time

Personal Check

• Record and verify the following:– Client’s name– Current address– Driver’s license number– Home or work telephone number– Initials of the employee who accepted the check

or witnessed the signature

• Is you suspect a problem – call the bank and verify funds.

Credit Card Payments

• Take the following steps– Verify that the person’s signature on the receipt matches

the one on the credit card– Check the expiration date on the card– Strictly enforce the rule regarding phone authorizations

above a set amount. Approval should be obtained before the client leaves the office.

• Policy for extending credit (Care Credit)– Complete application should be filled out– If the bill is of a significant amount, request a deposit.

Directory of Vendors & Suppliers

• Computerized list or written system– Pharmaceuticals– Biologicals– Diagnostic supplies– Laboratories– Medical equipment and supplies– Nutritional items– Dental equipment and supplies– Office equipment and supplies– Maintenance supplies– Miscellaneous

• Within each category include– Company – Contact person– Phone number for

• Ordering• Customer service• Technical support

– Account number

• Keep tract of– Date of order– Items, quantity and price– Date received

Medical Recordkeeping

• Many reasons for keeping accurate medical records– Legal reasons– Diagnostic reasons– Business reasons

Legal Reasons

• Many states and professional associations (AAHA) require them

• Essential in the defense of legal actions for malpractice, negligence or incompetence

• Used to establish that a legal contract existed for the care of a patient and collection of a fee

• Necessary for income and sales tax documentation purposes

Diagnostic Reasons

• Are essential for recording all pertinent facts & diagnostic data so a diagnosis, course of treatment and prognosis can be established

• Establish information about pervious medical problems and management of an ongoing medical ailment

• Serve as a source of data for research

Business Reasons

• Provide information about how to contact an owner

• Provide information for a recall system that will generate income

• Record what services were suppose to be rendered and what services were actually rendered

• Can be valued and sold as a depreciable asset of the practice

Keep it or toss it?• Tax records – at least 7 yrs• Employee records – 10 yrs or as long as the state’s statute of limitations• Controlled substance logs – 2 yrs• OSHA records of injuries or accidents on the job – 5 yrs• Records of improvements to the property or building – indefinitely (b/c will be

useful if business is sold)• Client records

– keep 3-7 yrs after the last transaction– Property of the hospital (never go to client or another clinic)– Make copies if client or another hospital needs the records

• Radiographs– Legally part of the permanent medical record– Never give to client, but can give copies– Can be mailed to another referral vet, but must be return to org. clinic

Changes to a Record

• Do not use white out!• Do not obliterate the text!• Only draw a single line through the error and

initial• Then write in your changes, including the

reason for the error.

Components of a Thorough Medical Record

• May be printed and kept in filing system• May be typed into a computer• Client information– Name– Address– Telephone numbers (home, work, emergency

contact)– Method of payment

Components of a Thorough Medical Record continued…

• Patient information– General

• Name, species, breed, DOB, color

– Routine preventive care• Vaccinations• Treatments/preventions

for internal & external parasites

• Behavioral consultations• Elective surgeries (spay,

neuter, declaw)

– Physical exam results– Presenting complaint– Problem list– Diagnostic test and their

results– Diagnosis list– Treatment list– Outcome

Components of a Thorough Medical Record continued…

• Consent sheets between the practice and the client• Telephone consultations• Anesthesia and surgery logs• Radiographs• Laboratory results• Euthanasia consents• Necropsy logs• Any client communications upon release (discharge

instructions/home therapy/handouts) should be noted in the record

• Any other material pertinent to the case

Identification Systems for Hospitalized Animals

• Every vet hospital has its own system• Cage card with feeding and medication instructions• Instructions must be clear to all staff!• Color tags– Each color represents a different need

• Record what has been administered to prevent errors– Amount and time– Food or medication

Identification Systems for Hospitalized Animals continued…

• Proper identification of individual animals is very important to prevent tragic mistakes– Paper collars to write the animal’s name– Special coding to identify • Aggressive animals• When lab samples are needed (feces or urine)• Those who need special monitoring