Effective Document Management and Filing Systems
Definition of a File
A file is where all the documents of a professional or a business are kept. It also refers to a set of related data. As an active center for information, documents must be perfectly ordered. The storage of documents constitutes the memory or history of the office or unit.
File Functions
- Review clinical documentation before filing
- Clinical coding
- Warehouse and storage of documentation
- Control of loans and returns
- Treatment of liabilities (archiving documents with little chance of future use)
- Special custody
What is Clinical Coding?
Clinical coding is important to facilitate the subsequent recovery of data contained in medical records. The choice of code system can vary. If not all data can be coded, at least the Minimum Basic Data Set (MBDS) should be encoded.
Loan and Return Control
This involves processing loan applications for Health Records (HC), limiting who can perform this function. The file section must manage:
- Loan schedules
- Authorized persons
- Loan reasons
- Authorizing receipts
- Recording and archiving returned records
- Tracking document location (knowing who has it, why, and when it must be returned)
Special Custody
All health centers have a group of special records that require restricted access or special treatment, often because they are being used for judicial purposes. The custody of these documents requires stricter measures, and they are stored in a special way.
Types of Files
Classification Criteria
- Location
- Usage
- Physical Support (Hardware)
File Types by Location
- Centralized: All documents are kept in a single central location.
- Decentralized: Documents are stored in various sections or departments.
File Types by Usage
- Active: Documents that are frequently consulted, either recently created or related to ongoing processes.
- Inactive/Candidate: Documents saved for various reasons but consulted infrequently.
- Semi-active: Documents that are halfway between active and inactive status. These are often collected from the active archives when they are no longer in current use.
Note: When documents no longer have administrative, legal, or historical value, or have completed their mandatory conservation period, they will be moved to a passive file (if applicable) or securely destroyed according to policy.
File Types by Physical Support
- Manual: Requires physical effort for searching, sorting, and retrieving documents.
- Computerized/Digital: Managed using computer systems and digital storage.
File Classification Systems
- Alphabetic
- Numeric
- Subject
- Geographic
- Chronological
Alphabetic System
When a name or term comprises several words, one must determine which is the key word or reference guide for classification. The rest of the words are subordinate to the key word. There are specific rules for choosing the key word.
Numeric System
A unique number is assigned to each document or file. Items are sorted and classified according to this numerical assignment.
Subject System
Classification is based on the subject matter or topic of the documents.
Geographic System
Documents are organized by geographic areas (e.g., country, region, city). Within each geographic area, documents are usually managed using another method, typically alphabetic.
Chronological System
Classification is based on dates, typically in Year/Month/Day order.
The Business Letter
The business letter is the most common means of written correspondence used to contact suppliers, clients, and other external parties.
Functions of a Business Letter
- Allows the company to formally communicate with the outside world.
- Helps to create and maintain the company’s professional image.
- Serves as documentary evidence of communication and agreements.
Parts of a Business Letter
- Start: Letterhead (company info), date, recipient’s address.
- Content: Salutation/greeting, body text (main message).
- End: Closing (e.g., ‘Sincerely’), signature, typed name, and references to any annexes or enclosures.
Warehouse Management
A warehouse is where items or materials purchased for consumption or use within the hospital or clinic are placed, classified, and guarded.
Warehouse Types
- General Warehouse
- Specific Warehouse
Types of Specific Stores
- Pharmacy: Where pharmaceuticals are stored. This area is subject to specific conservation standards and strict custody regulations, especially for controlled drugs and psychotropics.
- Linen/Textiles: Stores items like clothes, blankets, and general linen used in healthcare settings, as well as staff uniforms required during working hours.