Healthcare Medical Record Policies

Health Care Medical Record Policies

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Health Care Medical Record Policies Part I

The Healthcare environment is an indispensable requirement for every human life. The medical technology deals with procedures and instrumentation which are designed for the principle purpose providing the public with quality health care. Therefore, the medical record plays as a powerful tool which enables the treating physician to keep track of the medical history of their patients and recognize patterns or problems which might assist in determining the course of healthcare provided (Sharpe, C. C. 1999).

The purpose for the medical records therefore is to describe the constituents of the electronic and paper medical record in order to provide support to the patient’s diagnosis while justifying treatment, care and other services provided.  The medical record has to be maintained for each and every patient served by the healthcare facility, where with varying automation levels, some records could be maintained in paper format while others electronically. It is crucial that every medical facility has in place a formalized for maintaining their records since all the records have to be organized systematically and readily accessible.

Policy:

Every medical record entry, inclusive of electronic and handwritten/ paper records, must be completed, timed, dated and legitimate/ legible also authenticated by the individual in charge for evaluating and providing the offered services in consistency to policies and procedures of the hospital/ medical facility.

The Content of the Medical Record

The medical record content which contains electronic and written documentations should be able to allow the physician/ professional account for major source of information and support for their medical decision making.

  • The medical record contains patient demographic information such as: name, date of birth, their address, sex, their legal status, ethnicity and race, communication and language needs, and any representative legally authorized.
  • The medical record contains patient’s clinical information like; purposes for treatment, their original condition and/or diagnosis and diagnosis established in their course of treatment, medication prescribed/ ordered, any allergies or undesirable drug reaction to medication or food, medication administered and prescribed when patient is discharged and treatment goals among other clinical information.
  • In order to provide treatment and care, the medical record contains; any documentation on communication with the patient (e.g. mail, phone calls), advance directives, information generated by patient, informed consent prior permission.

A key constituent of the maintenance of medical records is handling of corrections, amendments and any deletions. Any individual documenting the medical records has to have authority or be credentialed to document following the policies defined by the facility. The individuals should have competence and be trained in the facility’s essential practices and legal standards of documentation.

  • Entries must be made immediately in the event of a confirmed observation. It’s crucial for timely input of patients’ medical records and each entry inclusive of day, month year and time associated with it.
  • It is thus illegal and unethical to pre- or back-date any entry. Dating should be done for the accurate time and date of inputting the entry.
  • Each entry has to be linked to the residence in practice, providing their name and medical record number, and authenticated by the medical author, that is, it should not be edited and signed by any other individual other than the author.

When making corrections to a paper medical record, accepted principles are accomplished through the use of one like strike through to allow future reference of the original content. It’s important that the author of this alteration dates and signs his/her revision. Electronic health records medical records on the other hand require more consideration. Records originated from electronic records with corrections or amendments have to specifically make out any delays, corrections or amendment while also providing a dependable means for vividly recognizing the original content, including the authorship and date for every modification on the records.

Health Care Medical Record Policies Part II

Ownership of the medical record

The medical records (electronic or paper documents) are to be possessed/owned by its author (practitioner or physician) and not by the patients. Alternatively, the medical record’s information belongs to the patient and therefore should be accessible by the patient or their legal representative upon their request (Heller, M. E., et al 2009). Although the practitioner or physician still has the overall say to avoid any access to specific pieces of information, particularly information which contain likelihood of causing substantial harm to either the patient or any other person. 

A patient has a legal right to seek court protection in case of wrongful use of the physician’s discretion having their own initiative for challenging the physician to denial of access. The original medical records cannot be removed from the medical facility, except when authorized by a court order or when required by law. Therefore, the medical personnel and other professionals in the healthcare facility are accountable for documenting the medical records within the proper and mandatory time frame in their support of patient care.

Policies/procedures for the release of records

Physicians and practitioners have constantly encountered immense complexities whenever they want to release medical records in response to Health Insurance Portability and Accountability Act (HIPPA) of 1996. So as to uphold confidentiality of patients and conform to government regulations, the following procedure and policies will ensure that confidential medical records’ are transferred according to all essential guidelines when released.

Health Care Medical Records will only be released upon the patient’s written request. This request has to be followed in accordance to Uniform Health Care Information Act 70.02 RCW (Washington (State). 1970). The Medical Healthcare facility shall only release records which were generated the facility’s practitioners/ physicians and preserved within the facility. Records from other facilities will not be released.

The requirements to be met for valid authorization in order for medical records release are; Written document signed and dated by the patient, which exclusively recognizes the patient, healthcare provider (practitioner/ physician) making this disclosure and exclusively provides information to be released. The document provides name, contact information, and affiliated institute of the individual/ entity who would be the recipient of this information. Before processing the request, the patient’s Identification has to be verified by the information provided in order to verify the appropriateness of information appealed for release. The request is then completed if its content meets the facility’s requirements. If not the application is returned to the requestor together with a description explaining need for more information needed.

Ways to maintain confidentiality

 In harmony to the Confidentiality of Medical Information Act (CMIA) (California Civil Code Sections 56-56.37, n.d.) and Information Practice Act attending to security and privacy of medical information the confidentiality of medical information in the facility shall be reserved. The following controls and principles should be executed in every location of the medical records within the healthcare facility.

  • Only the individuals having authorization/permission by the director shall have access to the information.
  • The service provider must date and sign the information recorded like consent to service, diagnose, and treat and any follow up prior to storage of the information.
  • The medical information records shall be put in a locked room or files while the electronic records protected by passwords when not in use.
  • Each of the medical facility shall be reviewed yearly on their record management practices to guarantee filing, storage and utility of the medical records in a conduct which provides standard confidentiality.
  • Back-up of the medical records electronic data shall be reserved in a secure off-site locality.

References

California Civil Code Sections 56-56.37(n.d.) Confidentiality of Medical Information Act (CMIA). Retrieved from http://www.ucdmc.ucdavis.edu/compliance/pdf/Confidentiality%20of%20Medical%20Information%20Act%20(CMIA).pdf

Heller, M. E., & Veach, L. M. (2009). Clinical medical assisting: A professional, field smart approach to the workplace. Clifton Park, N.Y: Delmar Learning.

Sharpe, C. C. (1999). Medical records review and analysis. Westport, Conn: Auburn House.

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Washington (State). (1970). Washington appellate reports. Olympia, WA: Court of Appeals. Retrieved from http://apps.leg.wa.gov/rcw/default.aspx?cite=70.02

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