Medical records management was simple not too long ago. Patient information was handwritten, recorded on paper charts, and filed in office cabinets for safekeeping. This was before the digital revolution took over and changed how we do things forever.
According to the Centers for Disease Control and Protection, close to 90%of physicians use electronic medical records (EMR) systems to maintain and safeguard patient history and information.
With the enactment of the Health Insurance and Portability and Accountability Act (HIPAA), medical providers were mandated to adhere to strict federal guidelines to protect patient information. With HIPAA in place, health practitioners have an ethical obligation to manage records to safeguard patient information adequately, which has also become a legal requirement.
What Is Medical Records Management?
Medical records management is a system of procedures and protocols determining how patient information is handled. It starts when a patient record is created and how it is stored, secured, and maintained until the record must be destroyed. There is a strict code that governs medical records management appropriately so that when health records are mismanaged, patients’ lives are put in unnecessary peril.
According to a study by John Hopkins University, medical errors are the third leading cause of death in the United States after heart disease and cancer. Poor management of health records can lead to medication errors, missed diagnoses, and treatment lapses that can ultimately be fatal.
Medical records contain highly sensitive personal information. When these are not properly managed, they can be vulnerable to data breaches. As such, more and more patients are unwilling to share their complete medical histories for fear of risking their privacy.
Why Is Medical Records Management Important?
Proper record management means that a comprehensive knowledge of a patient’s medical history can be retrieved if and when it is needed. How up-to-date and well-kept medical records are can spell the difference between life and death in case of emergencies when physicians need to make quick medical decisions. Proper medical records management saves lives.
Keys to Proper Medical Records Management
HIPAA was enacted in 1996 to modernize medical records management and safeguard patient information. Enumerated below are the guidelines that health facilities can follow to be HIPAA compliant for proper medical records management.
1. Implement clearly defined medical records management procedures
Medical facilities must clearly define their policies and procedures for collecting, filing, and storing medical records. These policies and procedures should be written and retained for six years.
It will take the dedication of the entire organization for a medical records management program to be successful. Every department that generates or handles records should be monitored so that information is safeguarded at every step.
2. Provide comprehensive staff training for medical records management
Sensitive health records in the hands of undertrained medical personnel are accidents waiting to happen. HIPAA requires health facilities to provide sufficient training to all employees that handle health records one way or another.
3. Initiate clear labeling systems
A comprehensive classification and indexing system for health records are necessary to maintain and protect patient records from creation to destruction. Efficient labeling systems enable adherence to retention schedules and make retrieval efficient both time and cost-wise.
4. Invest in automation
Health facilities should automate essential tasks where there is no room for human error. The same goes for time-consuming processes if done manually. Automation makes for a more centralized medical records management program, thus improving accuracy and consistency in protecting patient information.
5. Establish effective data security protocols
Patient records must be secure from creation to destruction. Paper records should be secured in a room with limited access, and electronic records should have a detailed audit trail. Facilities used for the storage of medical records should be climate-controlled. NAID-certified methods should be used to destroy paper and electronic records for proper disposal.
6. Schedule periodic self-audits
Health facilities should subject themselves to periodic self-audits to know if their efforts at data security are up to HIPAA standards. They must institute performance and compliance monitoring to check for compliance and avoid penalties.
Final Thoughts
Advancements in technology and medicine put a pressing need for better medical records management. It is acknowledged that when health records are at risk, so too are health providers and their patients.
Health facilities and organizations need to be diligent in safeguarding health records by adopting comprehensive medical records management programs that are HIPAA compliant and avoid lawsuits and litigation.
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