Storage and Organization of Patient Records
When proper maintenance and organization of records can be demonstrated, it is an additional indication of quality patient care. As a legal document, the dental team must know where to find the patient record at any given time. Electronic records can be retrieved by the patient name or birthdate. The records must be consistently saved. Because there is so much data to secure and protect, many practices use third-party or offsite backup systems, whereas another option is to use cloud-based systems. In the instance when an office computer system goes down, possibly due to a power surge, outage, or computer crash, the office must have protocols in place to treat patients using paper forms until restored.1 Options for backing up can be internet based to a third-party, CD-ROM, or external, removable hard drive.1
If the paper record has been pulled from its storage space, a tracking mechanism must exist. This is often done in the form of out-guide. An out-guide is a marker placed in the space that the pulled record had occupied. It may contain a note as to who pulled the record and where the record is being used within the practice until safely returned to the filing cabinet.
Offices utilizing paper files often use color coded tabs and aging labels along with space for a patient’s full name for ease in locating and retrieval. Patient files are stored in alphabetical order. Color coded tabs can be used for the patient initials. This helps to focus in on the area of that name by offering a color pattern. The aging label is applied new each year. This label allows the team to view in active files much more easily. Files that have not received a current year label for the last year or two can be tracked and contacted for a recall/recare appointment.
Filing cabinetry for paper records will dictate the type of file folder purchased by the practice. Vertical file cabinets consist of drawers. Each drawer has a handle and is pulled out toward the person who opens the drawer. The file folders for this type of cabinet have tabs at the top for the patient name. The files are often organized alphabetically from front to back. The top tabs can be staggered from left to right to make the task of looking at several tabs much easier.
Lateral filing cabinets hold the files side by side, resembling a book shelf. Each shelf will have a cover for file protection. This design is desired as it is viewed as a space saver. Files are read from left to right as the tabs for patient names are located on the side of the folder.6
Figure 7. Lateral Filing System.
As stated, files are organized in alphabetical order. In some practices, they are also given an individual patient number in case there are records that must be cross referenced. Files must be sorted accordingly and re-filed properly to maintain the organization. Files not returned to cabinetry are subject to loss or damage. In both types of cabinetry, files should be tightly compressed, closed, and locked each night. Compressed files in completely closed cabinetry are less likely to be destroyed in the case of fire or water damage.1