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Running head: HEALTH RECORDS RETRIEVAL PROCESS ASSESSMENT 1

Health Records Retrieval Process Assessment

Name

Walden University

NURS 6051 Section 01, Transformation Nursing and Healthcare Through Technology

Dr. Jennie De Gagne

January 24, 2016

Health Records Retrieval Process Assessment

Workflow is an essential aspect of every organization. In most cases, the commencement of a particular decision process depends on the successful completion of the prior decision, where a wrong decision or a delay in a particular decision point affects the outcome of the whole process (McGonigle & Mastrian, 2012). As such, an evaluation into the workflow of activities in an organization is essential to ensure efficiency in resources and time. The purpose of this paper is to present an assessment of the patient health records retrieval activity at the healthcare facility. The paper includes a workflow flowchart for the health records retrieval, an explanation of the various decision points, and an evaluation of the activity. The paper also includes some suggestions on how the workflow can be improved for efficiency in health records retrieval in the organization.

Start

Patient records required

Place request

Clinical doctor?

Record chart number

Electronic?

Yes

Decline request

File in main folder?

Notify for reprocessing

Yes

Process and avail file(s)

Yes

End

Request delivered to record Dept.

Yes

File in use

Check appropriate folder

Patient identification details

Yes

Staff/Concerned person?

authorized?

Details & file available?

Yes

Misfiled?

File out?

Notify for reprocessing

Yes

Figure 1. Workflow of Patient Medical Records Retrieval Process.

Explanation of the Workflow Process

Document Requirement and Request

Health records are an important element in the well-being of a patient (McGonigle & Mastrian, 2012). As such, the records may be referred to from time to time by a myriad of personnel and persons of interest in the health of an individual. The Hospital understands this and makes sure that the requested documents are availed as required. However, the confidentiality of the client should always be taken into consideration in the process. Once an individual requires reviewing the documents pertaining a particular patient, the same is expressed to the hospital though the records person. The concerned person may do so in person, in writing or through a telephone conversation, which should be followed by a written request or physical visit (Koppel & Kreda, 2011). The request may be from a clinical doctor with the hospital, a staff member of the hospital who is not a medical doctor or a concerned individual such as a relative or a personal physician to the patient (Koppel & Kreda, 2011). This step may involve the use of a computer or a telephone.

Authorization Checks

Confidentiality is critical to maintaining a healthy organization-client relationship, and the client should always feel secure entrusting confidential information to the hospital (McGonigle & Mastrian, 2012). As such, certain procedures are followed with the release of a patient’s medical record to a concerned person. Upon receiving the request for a particular patient’s documents, the medical records personnel follow it with checks to ascertain the authority of the requester. A clinical doctor in the hospital is allowed access to the patient’s record unconditionally. Concerned members of staff other than the medical doctor are authorized access to the documents so long as their are providing direct care to that patient. Other concerned individuals such as personal doctors, relatives among others, may access the documents with the patient’s consent. The medical records officer is responsible for checking the authority of the individual requesting access to the documents (Soualmia et al., 2013). Usually, no technology is involved in this step.

Form of Filing Checks

After verifying the authority to access the required documents, the medical records officer embarks on the process of retrieving the documents from their storage. The first thing is checking the form in which the documents are filed. These may be electronic or paper records, which is determined by the patient’s details as detailed in the database, and the documents required. Electronic records are often recent records, and those pertaining regular clients (Soualmia et al., 2013). Paper records often belong clients who came in the long past. The filing system of the paper records is also determined to facilitate access to the documents. No technology is required here.

Checking for Requested Records

The medical records officer embarks on checking the requested documents. Electronic records often take the shortest time to retrieve (McGonigle & Mastrian, 2012). One of the advantages of electronic health records is the ease of retrieval, which saves on time and resources (Koppel & Kreda, 2011). On the other hand, paper records take a long time to trace, and the search may not always be successful. Paper filing is time-consuming, laborious and is error prone, such as misfilling or misplacement (Koppel & Kreda, 2011). The technology involved is the computer for electronic records.

Records Availability Status

This step mainly applies to paper documents. An advantage of the electronic health records is the ability to be available to different users at the same time without the need to spend the time of photocopying (US Department, 2011). On the other hand, only one person may use paper documents at a time unless copies of the same are made, which is both time consuming and wasteful of resources (Uslu & Ju¨rgenStausberg, 2008). The records may be unavailable due to several reasons, including being used by a doctor, filling in the wrong document folder (misfilling), misplacement, or erroneous request (McGonigle & Mastrian, 2012). Manual search, as well as the computer search, is used in this step.

Processing and Handing the Requested Files

Once the required documents have been retrieved, the medical records officer counterchecks with the concerned person to ensure their validity and accuracy of results. It involves checking for the names of the particular patient, the dates or specific records, among other characteristic details specific to the request (Uslu & Ju¨rgenStausberg, 2008). The person requesting the documents signs for the receivership of the documents on receiving the correct records. No technology is used in this step.

Metric used for Workflow Evaluation

Time for Records Retrieval

Time is a critical element in the workflow. Time wastage is the greatest impediment to the smooth workflow of in any process or activity (Huser, Rasmussen, Oberg, & Starren, 2011). As such, the time taken to retrieve any requested health record is used as metric to improve the efficiency of the retrieval process and assessing areas with the greatest wastage. The time for each decision step is analyzed for time wastage to reduce time wastage (Huser et al., 2011).

Number of Negative Results

Often, the search for particular documents results in no outcomes. It is referred to as a negative outcome. The number of negative outcomes is recorded and evaluated against positive outcomes. The possible causes for the negative results are evaluated and the necessary improvements enacted (Soualmia, et al., 2013). These could be in the filing system, errors in spellings, negligence, among others.

Number of Manual Searches

The goal of the medical records department is to have all the health records stored electronically, which will result in the department enjoying the benefits of electronic health records. The benefits are numerous, including fast document retrieval, facilitates concurrent viewing of the documents, ease of sharing the records among others (Uslu & Ju¨rgenStausberg, 2008). Thus, the number of manual searches that the department receives is to process is regarded as an impediment to the achievement of this goal, and also a drawback in the workflow. On the other hand, an upward trend in the requests for electronic records marks huge strides towards smoothening the workflow and towards the achievement of the department’s goals.

Areas for Improvement

Filing Systems

Filing systems are integral to ensuring efficiency and smooth workflow in the records department (Koppel & Kreda, 2011). One drawback identified in the records department is the existence of different filing systems, such as numerical and alphabetical systems. The existence of different filing systems consumes precious time as the records officer decides what type of system is used for a particular record. The department can improve workflow by using a particular filing system for all the records. Moreover, the records should be categorized into different groups, which will facilitate the access to specific files as required (Huser et al., 2011).

Accuracy of Requests

Placing erroneous requests to the records department is not only wasteful of time and resources but also frustrating. Erroneous requests should be minimized as much as possible to ensure efficiency in the search for records (Soualmia, et al., 2013). As such, the concerned individuals should countercheck their requests to ensure they are error-free, such as spelling errors, and be confident the records exists to avoid many fruitless searches.

Automation

The use of electronic health records has been found to be efficient in facilitating fast and accurate retrieval of health records (Uslu & Ju¨rgenStausberg, 2008). The Department should endeavor to transfer all the records to the electronic system completely to reap these benefits. The records allow for specific searches and in the shortest time (Soualmia, et al., 2013). The system also facilitates ease in sharing of resources with different health facilities, which will not only save time, but also on the resources (US Department, n.d).

Conclusion

Health records are central to the quality of care accorded to patients. As such, the proper storage and retrieval of these records are paramount. The process of creating an efficient workflow in the records department is integral, and should start with an evaluation of existing procedures for improvement. At the health facility, the process is hindered by different systems of filing, erroneous requests and manual searches for health records. The process can be improved by automation, accuracy of requests, and streamlining the filing system.

References

Huser, V., Rasmussen, L. V., Oberg, R., & Starren, J. B. (2011). Implementation of workflow engine technology to deliver basic clinical decision support functionality. BMC Medical Research Methodology, 11(1), 43–61. doi:10.1186/1471-2288-11-43

Koppel, R., & Kreda, D. A. (2010). Healthcare IT usability and suitability for clinical needs: Challenges of design, workflow, and contractual relations. Studies in Health Technology and Informatics, 157, 7–14. doi:10.3233/978-1-60750-569-3-7

McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge. (Laureate Education, Inc., custom ed.). Burlington, MA: Jones and Bartlett Learning.

Soualmia, L. F., Sakji, S., Letord, C., Rollin, L., Massari, P., & Darmoni, S. J. (2013). Improving information retrieval with multiple health terminologies in a quality-controlled gateway. Health Information Science And Systems, 18. doi:10.1186/2047-2501-1-8

U.S. Department of Health & Human Services. (n.d.b). Workflow assessment for health IT toolkit. Retrieved, Jan 18, 2016, from http://healthit.ahrq.gov/portal/server.pt/community/health_it_tools_and_resources/919/workflow_assessment_for_health_it_toolkit/27865/

Uslu, M. A., & Ju¨rgenStausberg. (2008). Value of the electronic patient record: An analysis of the literature. Journal of Biomedical Informatics, 41:675–682. doi:10.1016/j.jbi.2008.02.001