Best practices for managing medical records

Managing medical records was quite simple not so long ago. Paper charts containing patient information were kept in office filing cabinets. With advancements in technology and medicine, this approach has also evolved.  

Today, electronic medical records (EMR) systems are used by more than 99% of general practitioners and pharmacies to handle physical information in a digital setting. More patient information is available than ever thanks to improvements in diagnostic and analytical techniques. 

Medical personnel are required by law and ethics to keep patient records and patient information securely. If this isn’t done, there could be medical errors and data breaches, both of which could result in heavy fines. 

Understanding the guiding principles and regulations for managing medical records can assist companies in staying in compliance and safeguarding their patients. 

What is the management of medical records? 

Medical records management is the term used to describe a set of practises and guidelines in charge of controlling patient data during the whole data lifetime. A patient record must be properly saved, protected, and maintained ever when it is first produced. The record must be appropriately destroyed once it has been kept for the required amount of time (its retention period). Medical record administration is governed by a complicated system of laws and norms, and for good reason. Patients are put at danger when medical records are improperly managed. 

Hospitals, medical offices, and other service providers are also at risk of facing expensive penalties, legal action, and criminal accusations due to poor record-keeping. 

Policy and procedures for medical records 

The Privacy Act was established in 1988 to guarantee the management of medical records and safeguard patients’ private information. It includes policies for the following records management processes among others. 

Security for medical records and storage practices for medical records 

Despite The Privacy Act granting organisations some latitude in designing systems that suit their sizes and requirements, it does stipulate several common security measures. Organizations must: in order to retain compliance: 

  • Determine potential security dangers and take active precautions against them. 
  • All employees should receive medical record security training. 
  • Restricting access to locations where documents are kept or available 
  • Implement equipment, programs and procedures to keep an eye on access 

Access and Release of Medical Records 

A patient or the patient’s appointed representative has the right to access records under The Privacy Act. Only with consent may a provider or insurer send a patient’s medical records. 

Retention Schedule 

In Australia, the Privacy Act is a national legislation. The complexity and vast range of requirements depend on the state, record, and institution in question. 

Destruction of Data 

Data destruction is the process of getting rid of information so that it can’t be utilised fraudulently or illegally. Paper records must be destroyed using one of the following methods: shredding or burning. Using overwriting software or magnetic ways of erasing computer hard drives, electronic data must be erased. 

Keys to Medical Records Management Success 

Medical records administration might be difficult in the continuously evolving healthcare industry of today. Organizations can, however, take certain measures to safeguard patient privacy and uphold compliance. 

Create procedures for the management of medical records 

An institution must first specify its security policies and processes in detail if it is to manage medical records successfully. Updates are necessary in response to organisational changes that can impact how patient health information is handled or secured. 

Programs for managing medical records that are effective involve the whole company. When formulating procedures, senior-level executives should seek feedback from every division that produces or manages records to ensure that all bases are covered. 

Create thorough employee training programs 

Some breaches happen as a result of sophisticated hacking, while others happen because inexperienced staff improperly handle private health records. Companies need to provide training to any employee who deals with medical records at any point in the data lifecycle. 

Label Records Effectively

Organizations require a thorough classification and indexing system that covers every type of record handled in order to efficiently monitor patient records from generation to deletion. By improving searching efficiency, this ensures adherence to retention plans while also saving time and money. 

Streamline Procedures 

The responsibility of ensuring compliance with intricate state and federal legislation is challenging, and the medical industry leaves minimal tolerance for human mistake. A unified medical records management systems can increase accuracy, ensure consistency, and safeguard patients by automating necessary and time-consuming activities. 

Strengthen Data Security 

Patient records must be protected from creation through destruction. Paper records should be securely locked in a room with limited access, while electronic records should have a thorough audit trail while they are in use. Offsite storage of records should take place in accredited, climate-controlled facilities. Paper and electronic records should be securely destroyed at the end of their useful lives. 

Conduct self-audits 

Organizations should implement performance and compliance monitoring, as well as recurring self audits, to assure compliance. 

The Management of Medical Records into the Future 

A more sophisticated method of managing medical records is now required due to developments in technology and healthcare. Patients and healthcare providers are at danger when health records are not secure. 

Fortunately, there are various actions that businesses may take to safeguard their customers and themselves. Providers can stay compliant and avoid expensive fines and legal action by adopting a proactive approach to document security and making an investment in a centralised, complete medical records management systems.