Term: Medical Records Management

Description:

Definition
Records Management is the field of management responsible for the efficient and systematic control of the creation, receipt, maintenance, use and disposition of records, including processes for capturing and maintaining evidence of and information about business activities and transactions in the form of records.

There are needs to store paper and electronic records; automating, capturing, storing, and disseminating these records is important. A record policy must include a policy, standards and management. It must be broad enough to meet standards for compliance, to be legal admissibility, to be secure and private and must be capable of demonstrating this compliance. Records management is typically the domain of librarians, archivists and govt. bureaucrats.

Some types of records that need to be managed in healthcare are paper records (regular, facsimiles, laser printed, dot-matrix), x-ray images (scans, dental images, etc.), and electronic (email, various file formats, databases).

Medical Records Management Issues
Some issues of record management are the rising costs related to storage of paper and electronic information. There are risks incurred by a lack of paper and electronic records management. Records management may not be viewed as a critical function. Records are not seen as assets and there is no clear policy or procedure. Functional silos inhibit flow of information or there is a lack of training, tools and guidance for end users.

Paper records take up space and are visible. Electronic records, however, are not visible. There is a problem of employees functioning without training, rules, procedures, or a standardized organizational structure and make decisions about what records to create, keep, or destroy as they manage their email and computer files. Sometimes decisions are made without legal view. Most employees keep almost all documents and email they create and/or receive and have devised their own personal filing systems.

Medical Records Management Benefits
Some records management benefits are they preserve a historical record and protects vital information. There is protection of information that supports effective decision making. Medical records management reduces operating costs by promoting effective use of storage. There is an improvement of efficiency and productivity. It controls creation and growth of records. It ensures regulatory compliance. It also minimizes risk of litigation and ensures audits and compliance.

Some of the functions of records management include capturing, storing and disseminating medical records. The capturing of medical records includes the specific information as well as the metadata and retention period of the record. The metadata includes the unique id of the record, the time that the record was created, author, etc. In order to successfully store the medical record, it must be classified correctly to assist in retrieval. The record must be consistent, secure, provide authorized access, and provide accountable management. The dissemination of the record includes the method, tracking and two factor security: authentication and authorization.

Accurate estimates of the quantity of obsolete or redundant data being stored are difficult to make. Records that are retained unnecessarily increase the costs associated with producing records to comply with requests for open records or for litigation. The cost of migrating records to other media or to other formats as changes take place in technology is supportable only for records of value. All data that is stored is backed up regardless of value. Because data is backed up by “mirroring”, any useless data is kept in two places doubling its negative impact. In the event of disaster, a larger amount of data slows the restoration

Risks of Unmanaged Medical Records
Loss of valuable information
Users may be deleting records that should be kept or keeping records that should not be kept.
Risk of the loss of significant organizational records that can’t be found or are not accessible to other employees.

Legal liability
Records, regardless of medium, that are not preserved or disposed of in accordance with the records retention schedule can have adverse effects in a legal environment. An organization must show a rationale for handling of its records, or it can be held liable.

Negative public perception
The reputation of our organization is based on providing good information and therefore, it is vital that we have in place a program that will show our responsible handling of our records. Without such a program, there is a danger of negative public perceptions.

Inability to locate information
Efficiency issues
Inability to complete work
Duplication of efforts

Unnecessary retention of information
Duplicate. obsolete, or valueless records may be kept if electronic records are not systematically managed.
A record remains public information even after the expiration of the retention period for that record. If a record (convenience copy of a record – whatever the format) has not been destroyed, it is still subject to the Public Information Act.

Noncompliance
Without a clear structure and methodology to follow, it is very easy for any person to be noncompliant with the possibility of exposure for the organization. Courts do look to see if proper procedures are in place.


Applications:

Example
POLICY NO. MR-14
RECORDS RETENTION REQUIREMENTS

1. PROCEDURES


Business records:
o Encounter Forms – 3 years
o End of Day Reports – 2 years
o Mail Batch Records – 2 years
o Supply Requisitions – 1 year
o Licenses (all federal, state and local) – 4 years

Clinical Records
o 10 years from last date of service. This applies to pediatric and deceased records. Provider charts from prior to joining the practice can be destroyed with that provider’s permission or after 5 years if the physician cannot be contacted, unless also seen at FPRP.

o Note: you must maintain a log, which contains patient name, date of birth and date and manner of destruction, of all records destroyed. See Policy 10-24 for destruction guidelines. This log should be kept indefinitely.

X-Ray:
o Films – 10 years
o Logs – 7 years from last entry
o Inspection – 3 years
o Misadministration records – 20 years
o Training & License Records – Expiration/termination of license plus 1 year

Lab Related:
o Point of Care Test Results – 3 years
o Control Test Results – 2 years
o Proficiency Testing – 2 years
o Test Requisitions – 2 years
o Controlled Substances (drugs dispensed, administered, order, inventory records) – 3 years
o Temperature Logs – 2 years
o Autoclave Sterility Results – 1 year

Miscellaneous:
o Policy Statements & Directives – While in effect and 7 years after superseded
o Telephone Message Pads – 5 years
o Physician on Call Records – 3 years
o Bio-Medical Waste Management Records – 3 years
o Records of Employee Signatures, Initials, ID Codes – 10 years
o Personal Action Records – 2 years
o Staff Attendance Logs – Calendar Year plus 2 years

Adopted: 01/08


Web Resources:

http://en.wikipedia.org/wiki/Records_management

http://en.wikipedia.org/wiki/Medical_record


Related Terminology:

Electronic Medical Record
Document Management
Record Management

Citations/References:

Dr. Randeree’s Records Management Slides

Records Management Policy of Tallahassee Memorial Hospital