A Guide to Medical Records Management

Medical records serve the needs of patients for present and future health treatment, as well as for insurance, employment, and other purposes. Physicians have an ethical duty towards the management of medical records and release of information services, in keeping with their professional responsibilities to protect the privacy of patients’ personal information.

Health information on patients is handled and organized in a way that makes it easy for medical professionals to access it and use it in healthcare workflows. When someone enters a clinic or medical facility for the first time, a record of that patient is produced. This entails maintaining privacy and integrity while also updating, altering, and coordinating with other providers. Maintaining health records is crucial because the information they contain influences how doctors treat patients.

Today, electronic medical records (EMR) systems are used by more than 85% of doctors to handle physical information in a digital setting. Additionally, since the Health Insurance Portability and Accountability Act (HIPAA) was passed, medical professionals are now required to follow stringent government regulations to protect patient privacy.

The Features of a Good Medical Records Management System

Any healthcare provider’s main goal is to give the patient the finest possible care, starting with the welcome and continuing through diagnosis and treatment. However, it is vitally important to keep track of all the details and occurrences relevant to each patient and to document them for recordkeeping and future use.

Medical records management, also known as health information management (HIM) or health records information management (HRIM), is the process of managing all the information related to a practice or a patient, including but not limited to the patient’s history, clinical findings, diagnostic test results, pre-and postoperative care, patient progress, and medications.

The following are the features of an ideal medical records management system:

• Quick and simple access for prompt retrieval
• Accurate labeling and organization through proper setup
• Adequate checks and balances to guarantee the privacy, reliability, and accuracy of the records being created and managed
• Data security to prevent data loss, alteration, and illegal use
• Adhering to all legal requirements
• Secure and thorough disposal techniques.

The Policy Environment Around Medical Records Management

HIPAA was established in 1996 with the goals of modernizing medical records administration and safeguarding patient data. It includes guidelines for certain records management practices, such as the following:

Storage and Security of Medical Records

• Organizations must identify and proactively protect against anticipated security threats in order to maintain compliance.
• All employees should receive medical record security training.
• Access should be restricted to locations where documents are kept or available
• Suitable equipment, programs, and procedures must be implemented to keep an eye on access

Records Access and Release of Information

A patient’s right to access records is protected under HIPAA, as is the right of the patient’s appointed representative. Only with consent may a provider or insurer send a patient’s medical records. The Fair and Accurate Credit Transaction Act (FACTA), which was passed in 2003, adds another level of consumer protection in relation to the disclosure of medical records. FACTA severely limits the sharing of medical records with affiliates by providers and insurance companies to lower the risk of consumer fraud and identity theft.

Retention Timelines

Most of the time, HIPAA prevails above any state legislation that might be relevant to medical records. HIPAA largely cedes control over record keeping to the states, though. The complexity and vast range of requirements depend on the state, record, and institution in question. In Florida, for instance, hospitals must preserve patient records for seven years while doctors must keep them for five. Providers in Nevada are required to keep records for five years, or until patients who are minors turn 23.

Destruction of Medical Records Data

Data destruction is the process of getting rid of information so that it can’t be utilized fraudulently or illegally. Both HIPAA and FACTA have strict procedures for data deletion. Paper records must be destroyed using one of the following methods: shredding, pulverizing, burning, or pulping. Using overwriting software or magnetic ways to destroy computer hard drives, electronic information must be erased.

How can Organizations Ensure Best Practices in Medical Records Management?

Medical records management might be difficult in the continuously evolving healthcare industry of today. And yet, unmanaged medical records pose a serious risk of not having simple access to potentially lifesaving or life-changing health information. Besides legal risks, it could also lead to patients thinking that your practice is out of date if there are no rules or structures in place.

Even for records that people don’t commonly use, optimized medical records management enhances record location and tracking. In the event of a calamity or a legal obligation, it can also preserve important historical information about a medical facility. A records management system can also make it simple to distribute or transfer information between offices. It may reduce the risk of lawsuits, reduce operational expenses, and increase staff productivity, mobility, and efficiency.

• Make sure the practice or establishment has a clear policy that forbids unauthorized workers from accessing patient medical records.
• Consider medical factors when deciding how long to store documents.
• Make the medical record accessible upon request or with the consent of the patient or a representative with authority, to the new doctor, or as otherwise required by law.
• Charge (if any) a fair price to cover the record’s transfer expenses.
• Keep records that weren’t given to the patient’s current doctor in the right place.
• Inform the patient of how to access the saved record, as well as how long it will be accessible.
• Outsource a medical records management expert like MRO Corp to handle all your operations with ease!

The HIM department at MRO Corp can help streamline the flow of clinical data throughout the healthcare ecosystem by standardizing business workflow to enable information release, managed care contract negotiations, audits, and government and commercial evaluations. You may successfully manage the flow of clinical data with MRO as a partner using cutting-edge services and technology that are at the forefront of the industry.