Show
Good medical record keeping is a very important aspect of managing a practice and part of your job as a practice manager is to put systems in place to ensure quality patient care and to keep their personal health information secure and confidential. What is a medical record?A 'medical record' is a general term for all of the information collated about a patient for the purpose of treating that patient, including:
Medical records should include the following information:
Medical records should also comply with any relevant legislation for record keeping. Who owns the medical record?In a private medical practice, the ownership of the medical records depends on the structure of the practice in which the doctor works. It is advisable for doctors to clarify ownership of the medical records at the beginning of a contract to avoid any disputes when the doctor leaves the practice as to whether copies of the medical records can be taken with the doctor. Subpoenas or summonses seeking production of medical records for legal proceedings should be addressed to the owner of the records. How should medical records be stored?Medical records may be kept in electronic or paper format, or a combination of both. Where a ‘hybrid’ of paper and electronic records is used, a system is required to cross reference the records for each patient. Electronic records need to be kept in a form that allows them to be printed out as required. You should also ensure that appropriate secure back-up of electronic records are maintained. How long should medical records be kept?Medical records should be retained for as long as required by relevant Australian, state or territory government legislation. Generally, this means that inactive individual patient medical records should be kept until the patient has reached the age of 25 years or for a minimum of seven years from the time of last contact – whichever is the longer. Disposal of paper-based medical recordsDisposing of paper copies of notes that have been transferred or scanned into the electronic records is allowed as long as the disposal is done in a manner which preserves confidentiality and complies with legislative requirements. In New South Wales, a register of all records that have been destroyed should be kept. Whilst this is not a requirement in other states, it would be considered good practice to keep a record in other states as well. Keeping medical records secureOrganisations that hold health information must take reasonable steps to protect the information from loss and unauthorised use or disclosure. To ensure that electronic records are kept safe from damage, loss or theft, complete back-up of the computer record should be performed on a regular basis. Back-up may be automated to a remote data storage facility or by using external hard drives that are used on a rotating system. If using external hard drives ensure the back-up discs stored off-site. Computers should be password protected and the passwords changed on a regular basis. Seek advice from an IT specialist regarding protection against unauthorised access, amendment of records, computer viruses, firewalls and quality of resolution of scanned documents. See: RACGP Computer and information security standards(CISS) Access to medical recordsAt common law, a patient does not have a right of access to his or her medical records. However, under privacy legislation, patients have a right to request access to their records. Access must be provided subject to any limitations and procedures set out in the legislation. Access around medical records is covered under legislation in Victoria (Victorian Health Records Act 2001) and New South Wales (NSW Health Records and Information Privacy Act ) Patients must make a written request for access to their records or to request a transfer of their records. A copy of the request should be kept in the patient’s medical record. If a patient wishes to transfer to another doctor, the new practitioner is entitled to a treatment summary or a copy of the records. The transfer date and location of transferred records should be maintained in a register, and the transfer date added to record. Files may be transferred using paper, CD or secure electronic means. A reasonable cost can be charged for providing copies of medical records. eHealth recordsSince July 2012, Australians have had the option of registering for a personally controlled electronic health record (PCEHR). This patient-controlled record is kept completely separate from the patient’s electronic medical record.The fact that a patient may have a PCEHR does not alter the doctor’s obligation to maintain a medical record for the patient. Note: Remember the PCEHR is a summary document and does not replace the full electronic medical record (EMR) held at the medical practice. Access to, and disclosure of, information in the PCEHR is subject to the PCEHR Act 2012 (Commonwealth) and associated rules and regulations. Organisations registered with the PCEHR system should be aware of their obligations under the legislation. The Office of the Australian Information Commissioner (OAIC) regulates the handling of information under the PCEHR system. It recommends that health care providers should: Develop processes for handling e-health records and ensure staff are adequately trained to follow them. Tellyour patients about what information you intend to add to and access from their e-health records and explain what you will do with the information. Ensure that you do not collect more information from an e-health records than is necessary. Collect, use and disclose information in a patient’s e-health record only for the limited and authorised purpose allowed under the e-health records system. Know how the e-health record system can be used in an emergency situation. Improve your practicePlease use the Medical Record checklist as a starting point.
Next pageTelehealth
What conditions should be present in the storage area for paper medical records?2: The Paper Medical Document Storage Basics. Storing all paper medical records away from any heat source like an HVA, fireplace, space heater, etc.. Storing records away from a source of water, dampness, and humidity. ... . Making sure the temperature stays between 65 and 75 degrees Fahrenheit year-round.. What is a guideline for the storage of backup copies of electronic medical records?What is a guideline for the storage of backup copies of electronic medical records? If possible, they should be stored off site in a secure location.
Which of the following are ways to maintain medical records security?Which of the following are ways to maintain medical record security? 1) Lock the file room. 2) Give keys to all staff members.. To allow unlimited access to medical records.. To keep medical equipment safe from theft.. To maintain medical record security.. To keep everyone but the provider from accessing records.. How long should the medical records of minors be retained and why?Records should be kept to 10 years after the patient turns 18 years old. Per CMA, “in no event should a minor's record be destroyed until at least one year after the minor reaches the age of 18.” Records of pregnant women should be retained at least until the child reaches the age of maturity.
|