Records management is defined as the systematic life-cycle management of records that includes identification, collection, classification, storage, retrieval, and, eventually, disposition (Records Managment: Buisness Definition, 2010). There are many elements which fall under the management of patient records including but not limiting to; patient data maintenance, identifying, classifying, and storing records, and identifying information requiring capture.
Questions six thru twelve of the interview assignment from week four discuss similarities and differences between the circulation, tracking and security measures for records handling and storage within small, medium, and large facilities. Upon reviewing questions six of the interview assignment which states “If paper records: How many different locations are there in your department that patient files may be found? (For example, are there some temporary holding areas in addition to a permanent area? I can conclude that smaller offices which use paper filling system on average have less holding stations for medical records while medium facilities tend to have a few more holding and the majority of larger facilities use electronic medical records in which case this question does not apply. Smaller facilities likely have less holing stations than medium size facilities since they have less patient as well as less staff. In my opinion having a low number of holding stations where charts may be found helps to eliminate misplacing charts.
For instance, if there are only two holding areas for charts the likelihood of misplacing a chart is lesser than that of a facility which has five holding stations for charts that are not field. Question seven reads “If paper records: Is there a need to chart the circulation of files from one location to another, so that your staff knows where files are kept? ” Smaller facilities have less of a need for tracking of circulation of files. This is because in most cases these charts are in one of two holding stations.
There tends to be a greater need for charting the circulation of charts in medium sized facilities. This is likely due to the greater number of holding stations in medium sized facilities. In addition, some medium and larger facilities have more than one location. If a patients chart must be transferred to another office this information must be documented to keep track of the charts location. Question eight reads “What can cause the biggest problem for records management if it isn’t done right? While there are various issues in small, medium and large facilities which cause problems within the facility incorrect documentation is the biggest issue overall no matter the size of the facility. Incorrect documentation in a patients chart can lead to various issues such as law suits, incorrect administration of medication, incorrect diagnosis, incorrect billing, and a host of other issues. Information in a patients chart should remain as current as possible including demographics.
Policies on how frequent demographics are updated may vary due to specific policies of the facility. Question nine reads “What measures in terms of physical storage are taken to ensure the privacy of the medical record? ” Patient files are kept in a secure area in each size facility to assure the security of the. Question ten asks “What measures in terms of personal handling are taken to ensure the privacy of the medical record? ” Patient information is confidential and is not discussed in any manner other than in physician’s office or in examination room.
Patient’s files and situations are not open for discussion in any other manner Practice in abiding HIPAA standards. Also, staff must be careful not discuss patients in an open setting even when discussion is related to patient care. Question 11 reads “Do you have a policy or mechanism to reproduce a lost record? Loosing patients records can be problematic for many reasons. Patient’s records are confidential. Loosing patient records is a breach of HIPPA standards. Additionally, the loose of patient records interfere with patient treatment.
Shockingly many small and medium sized facilities do not have any current way of replicating lost patient records. Facilities which utilize an electronic medical records system have the ability to retrieve records because the system performs a back-up daily in case of system break down. Lastly, question twelve asks about procedures for handling charts of patients who no longer visit the facility. Overall most facilities typically have a time period in which they hold on to records before purging. Typically patients that have not been seen in three- four years are purged.