How to Code Folders for Medical Filing

Patient medical information should be stored as a "unit record," meaning that all information is stored together or quickly accessible as one record. To store medical record information, there are many medical coding and filing methods. How records are coded for medical filing is determined by each medical facility and how it will best serve its needs. However, because of privacy concerns, it is not recommended that patient records be filed by social security number.

Things You'll Need

• Medical record file folders
• Labels

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Instructions

• 1

  Discuss needs with the staff. The best way to approach a medical filing system is to first discuss what the physicians, nurses, other clinicians and office workers need in their day-to-day treatment of patients. Understanding the pros and cons of current systems will ensure the success of a new medical filing system.

• 2

  Research the filing coding systems. Each medical filing system meets specific needs for different settings. Medical filing coding systems include:

  • Numeric with color codes, based on assigned medical record numbers (chronological numbers assigned by a computer system, or arranged by date, with a corresponding color for each number).
  • Alphabetical, generally by patient last name.

• 3

  Determine which system is best for your organization. Combination color-coded numeric systems are the most widely used forms of medical filing. These filing systems are best for larger organizations because there is room for additions of records within combinations of numerals. Some organizations might use alphabetical coding, usually by the patient's last name, to file medical records. However, this system is best used only in small facilities with low patient turnover rate because large numbers of common last names can cause file retrieval to be time consuming.

• 4

  Provide the appropriate code file folder. Once the filing method is chosen, then the appropriate information can be placed in the medical record file folder. Many file folders can be purchased with pre-printed colors and blocks of numbers. For smaller offices using color coding, color-coded numeric stickers can be purchased and placed on the tab-edge of blank folders. Once records have been coded, then patient name and medical record number also should be written or affixed with a label on the front of the file folder.

• 5

  Ensure file coding information matches patient information on the inside of the record. Because medical records are legal documents for patient care, it is imperative to be able to retrieve the correct information quickly while treating the patient.