1. 13 Managing Medical Records Lesson 3:
Releasing, Retaining, and Storing Medical Records

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. MUSTS for Performing Transcription
Ensure accuracy
Ensure confidentiality
Ensure professionalism

16. 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

17. 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

18. 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

19. 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

20. 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

21. Questions? 21