Manual - Record Management
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Software
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The data is stored in a MySQL database on the server as well as in an AtoZ directory on the server for scanned document files. The hard drive where this data resides is an Apricorn hardware encrypted external hard drive. Both directories are backed up using CrashPlan software. The backups run every half hour and results in encrypted backups to both a second external drive on the server and also to a separate physical location. These backups can be restored to a particular point in time, individual files can be retrieved securely, etc.
Customers who request anonymity will have their name entered into the software as John Doe, regardless of gender, and will only be able to be matched to paper charts and tissue by the PatNum ID.
Paper Charts
Paper charts are being used temporarily as we transition entirely to software. They are stored in a locked fireproof filing cabinet. There is one drawer for patients in storage and a separate drawer for living members who have signed a contract. Paper charts are labeled by PatNum. Name is also usually shown unless there is a privacy request.
Not every digital record requires a paper chart. Only the following billing types indicate that a paper chart exists:
-SignedUp
-FullyFunded
-PetInStorage
-InStorage
-PendingStorage
For these billing types, we will have at least have a contract and anatomical gift authorization, and the paper chart is where we store these documents. Do not change someone to one of these billing types without starting a paper chart.
Billing types will be different for different family members, so uncheck the box "same for all" when changing billing types. The other billing types that do not require charts are as follows.
-Interested (Any potential customer. We don't enter them in the computer unless we have to attach notes to them)
-Guardian (For next of kin and also for pet owners)
-Vendor (Someone we do business with who is not a potential customer)
-Misc (For example, staff, or anyone else who does not fit one of the above categories)
This billing type is soon to be phased in:
-Member
We use Smead 14931 folders with 2-hole fasteners. Empty charts are already sitting on top of the filing cabinet.
Left Side
Charts start out preloaded on the left 2-hole fastener with:
Chain of Custody and Document of Disposition
These documents are loaded in the left 2-hole fastener, with Patient Chart Contents on top.
Documents of Gift / Authorization and Preservation Agreement also go on the left side. All of these documents are also scanned into the Images module for patients in storage. None of these documents are scanned for members not in storage.
Confidentiality is strictly enforced for those who request it. In these cases, a "confidential" card will be in front of all the documents on the left, indicating that they are never to be scanned to the shared network folders. Confidential charts are also stored in a safe instead of the fireproof cabinet, whether for patients or members. Only management has access to these confidential charts, and staff is never allowed to see them under any circumstance. To back up the confidential charts, management scans the documents and stores them in an organized directory on an Apricorn hardware encrypted hard drive, which is then stored off site. This is a totally separate backup from the normal software backup.
Right Side
The right 2-hole fastener is for hard copy printouts from the software, with the oldest documents in the back, and the most recent in the front. The documents on the right side are not divided into parts for the different kinds of documents. Always enter Progress Notes and other ordinary chart documents first into the computer, and then print for hardcopy. There is no process established yet for frequency of printout for hard copy, and it's currently done as needed.
Many documents will be added to the patient chart from outside sources. Scan into the Images module of the patient. After scanning, attach a note: "PatNum:###, scanned, file" to the paper and turn it in to management to be added to the right side of the chart.
Computer Folders
There is a folder on the network at \\Storage\Patients. Inside this shared folder is a separate folder for each patient in storage. These folders are for complex documents that do not fit well into the Images module. Examples might be spreadsheets, graphs, subfolders for photos, etc.
Simpler documents that might be considered part of the chart should go in the Images module. Do this by copy/pasting using Windows into the appropriate AtoZ folder. Then, open the images module for that patient from within Open Dental to see the file pop in. Do not change the name of the file in Windows after that, or it will recognize it as a second file in the Images module.
There is also a folder within Patients called "Not In Storage". This is used to hold complex information about potiential patients.
Sensitive documents such as surgical photos do not belong on the network. They are stored separately by management on a private hard drive and backed up separately.
New Charts
Process new membership paperwork using the "NewChartChecklist.xls", located in the Storage\My folder. Print out the checklist and start doing the items from the top down.
Computer Entry Slips
Computers are provided in all administrative and clinical areas, but there are still times when a computer may not be immediately accessible to enter a chart note. In that case, a Computer Entry Slip may be used. As soon as reasonable, a computer entry should be made based on the slip.