13 Managing Medical Records Lesson 3: Releasing, Retaining, and Storing Medical Records

Lesson Objectives Lesson Objectives Upon completion of this lesson, students should be able to … Define and spell the terms to learn for this chapter. Explain quality assurance. Discuss ownership of the medical record. Know the medical record’s statute of limitations. 2

Quality Assurance Program Goal is to improve quality of care Implementation requires developing patient-centered criteria One method to document problem areas is the use of incident reports 3

Purpose of an Incident Report Report should be completed whenever there is an unusual occurrence, such as a fall, error in medication dispensing, needlesticks, fire, or patient complaint Purpose is to document exactly what happened with the goal of preventing another episode Details on completing an incident report are usually included in every office’s procedure manual

Interventions to Ensure Quality of Patient Care The Joint Commission Occupational Safety and Health Administration (OSHA) Health Insurance Portability and Accountability Act (HIPAA) Let’s take a closer look at each one of these! 5

The Joint Commission Private, nongovernmental agency Establishes guidelines to address quality of care provided by hospitals and health care agencies Conducts surveys and accreditation programs to ensure institutions are following guidelines for accreditation Works with facilities to correct deficiencies 6

OSHA Federal agency established in 1970 Purpose is to ensure safe work environments for employees Sets basic safety standards that all institutions must follow Violators of OSHA standards pay fines In 1992 OSHA set a mandate that all health care employers provide protection from Hepatitis B to all employees 7

HIPAA Contains privacy provisions that apply to health information For those institutions that transmit health information electronically the following rules must be followed: Safeguards to protect integrity and confidentiality of health information Train personnel in how to protect the confidentially of health information Policies and procedures that provide protective measures for the security and confidentiality of information 8

Authorizing Release of Records Physician owns the medical record Patient has the legal right to access the record To authorize release a release form must be signed by the patient, parent, legal guardian, or agent 9

Protected Information Substance abuse treatment records HIV/AIDS information Mental health records 10

Disclosure Without Consent Instances when medical records can be released without consent include: When records are needed by health care workers for the care of the patient For qualified individuals who perform tasks such as data processing, medical record transcription, and microfilming 11

Disclosure Without Consent Instances when medical records can be released without consent include: Government agencies who investigate or regulate health issues such as child abuse and communicable diseases Lawyers and parties involved in a law suit related to the patient’s medical condition 12

Protecting Patient Privacy For a video about protecting patient privacy click here, go to MyHealthProfessionsKit.com, or insert the DVD-ROM found in the back of your book. 13

Options for Storing Medical Records The medical office building Another office or building near to the medical office A business that specializes in housing records 14

MUSTS for Performing Transcription Ensure accuracy Ensure confidentiality Ensure professionalism

Skills of a Medical Transcriptionist Excellent typing Knowledge of medical terminology Desire for accuracy and efficiency Ability to understand words Know where and how to apply words Have proper English grammar skills including understanding of etymology, phonetics, synonyms, acronyms, antonyms, homonyms, and eponyms

Ownership of X-rays X-rays are the property of the medical facility that performed the X-rays Physicians are able to loan their films to referring physicians for further examination but the patient must sign a release The films must always be returned to the original facility Sometimes patients can obtain a duplicate copy of film for a fee

Ownership of Medical Records If a patient requests to view their own medical record, access must be allowed unless the physician determines it may be detrimental Prior to allowing the patient to view their record, the MA must first check with the physician or office manager for approval Never leave the patient alone with their record

Guidelines for Retaining Medical Records To be absolutely safe, medical records should be retained forever Legal statues to keep records and documents vary by state The standard set by most states for keeping records is 2-7 years after the last treatment, or seven years after the patient reaches the age of majority The AMA recommends keeping records for 10 years 19

Issues Addressed in a Medical Record Destruction Policy Length of time records are kept Where records will be kept Person responsible for deciding what to keep and what to destroy Method used for documenting destruction of records Method of disposal 20

Questions? 21