Medical Record Lifecycle Management

Medical Record Lifecycle

• The medical record lifecycle includes records creation, usage, maintenance/distribution, and termination.
• There are three stages:
  • Active Records are actively used and easily accessible.
  • Semi-Active Records are seldom used and suitable for off-site storage.
  • Inactive Records are no longer regularly referenced and stored in a less accessible place.

Lifecycle of Medical Record Management

• Creation involves gathering essential patient information during initial encounters.
• Use, Distribution, Maintenance ensures continuity of care and minimizes risks.
• Retention addresses recommended retention periods based on patient age and various conditions.
• Termination and Disposal includes proper arrangements for disposing of paper and electronic records.
• Safeguarding and Security involves risk assessment and protection from physical damage and cyberthreats.

Medical Records Storage

• Factors for an effective filing system are reduced physical effort, accessibility, simplicity, cost effectiveness, expandability, and a tracer system.
• There are three primary storage options widely used in the healthcare industry:
  • Physician's Practice (In-House)
  • Electronic Health Records (EHR)
  • Off-Site Storage for Medical Records

Best Practices for Storing and Sharing Records

• Implement best practices for secure medical record storage which include:
  • Storing records in a secure location
  • Regular electronic record backups
  • Using HIPAA-compliant methods for document sharing
  • Implementing access controls
  • Training employees on record-keeping policies

Appraising Records

• Records appraisal is analyzing records to determine administrative, fiscal, historical, legal, or other archival value.
• The purpose is to determine how long, in what format, and under what conditions a record series is preserved.
• Based on the inventory, records are either permanently preserved or disposed of when no longer required.

Records Retention

• Appraisal has many benefits like records retention schedules
• A records retention schedule contains the records retention periods for all the records identified.
• Records retention is retaining medical records for a certain period according to its value and the organization should have a documented record retention and disposal program to secure the legal and financial records
• Adult healthcare records must be kept for 8 years after treatment or death
• Child healthcare records must be kept until the patient is 25
• Maternity records must be kept for 25yrs after birth
• Records related to a mentally disordered patient, keep for 20 years after last treatment or eight years after death.

Disposal of Medical Records

• An organization's retention schedule and information management policy will establish when records are disposed and if paper or electronic records are about to be involved in litigation preserve under holding until resolved
• Medical offices need to dispose of information after approval and do so compliantly
• Records must be destroyed carefully to maintain patient confidentiality and protect records against unauthorized use
• Practices have secure destruction bins
• The service includes that offer destruction provide certificates
• For electronic records, ensure to completely delete files and refer to IT services
• Some countries legislations state that you must keep a register that includes the patient's name, covered dates and dates of destruction