Paper medical records are being replaced by electronic files.
The maintenance and destruction of medical records are regulated by federal and state law. Concerns over privacy issues, record accuracy and accessibility fuel regulations to protect patients. Strict policies monitor and facilitate the release of important and accurate medical data for treatment purposes as needed. Laws require that accurate medical records be accessible for litigation purposes and for physicians treating patients. Court orders are the only legal way to move original medical records off-site.
Records Retention Policy
Health care providers and institutions are writing policies and procedures to address records retention and destruction policies as a safeguard against litigation, fines and penalties. Because record retention and destruction guidelines vary among regulators, it is best to interpret conflicting regulations in favor of retaining the information for longer periods of time to be safe. Policies should contain detailed information for the maintenance, access and destruction of medical records.
Maintenance
Strict maintenance policies and procedures are required for managing medical records. Legal standards mandate that a medical record be maintained for every patient who is examined, evaluated or treated. These rules include patients treated in the emergency room, inpatients and outpatients. Both paper files and electronic records are considered medical records subject to legal maintenance policies. Electronic files from various sources are consolidated into one electronic medical record. Access to medical records is limited by law to protect a patient's privacy. According to medical records standards, approved personnel are the only individuals allowed to make medical entries in a patient's record. Medical entries are expected to be completed in a timely fashion and to include the date, time and signature of the authorized recorder. Anyone accessing medical records should log them in and out so they can be tracked at all times.
Record Destruction
Destruction policies relate to the appropriate time to destroy records and also the means used. Eliminating old medical records protects a patient's privacy. Paper and electronic records require different methods of disposal. Electronic records must be erased permanently so that they can never be recovered. Many organizations turn to paper shredding companies to eliminate paper files.
Penalties for Noncompliance
Organizations that disregard state and federal laws regulating medical record maintenance and destruction risk incurring harsh penalties and other nonmonetary sanctions. Health care institutions that cannot prove they provided appropriate medical care because the medical records are unavailable are likely to lose in court against malpractice claims. As a losing party in a court case, a health care provider will often have to pay court costs in addition to damages awarded the plaintiff.
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