In the past, managing medical records was simple. The patient’s information was recorded on paper charts kept in the office filing cabinets.
As medical technology and methods have evolved rapidly, the medical records and their management.
Nowadays, the majority of doctors are using electronic medical record (EMR) tools to keep track of their physical records in an electronic environment. With advancements in analytical and diagnostic tools, patients have more information available than ever before. In addition, following the passage of the Health Insurance Portability and Accountability Act (HIPAA), medical practitioners must stick to strict policies set by the federal government to safeguard the privacy of patients.
Medical professionals are a legal and ethical duty to safeguard the privacy of patients and to properly manage patient records. In the absence of this, it could cause medical errors or data breaches, which could cause expensive penalties.
Knowing the rules and principles regarding the management of medical records can assist organizations in ensuring compliance and safeguarding their patients.
What’s Medical Records Management?
Medical records management is the procedure and protocols for the management of patient data throughout the entire course of the data’s lifecycle. When an individual patient record is made, it has to be appropriately kept, protected, and kept. Once it is kept for the required duration (its duration of retention) it must be destroyed in a proper manner. There is a complicated set of regulations and rules regarding the management of medical records, and with good reason. If health records are not properly managed and manipulated, patients are put at risk.
The privacy of the patient is also in danger. Medical records contain sensitive personal data, and if mistakes happen, privacy is at risk. With the number of breaches involving healthcare data increasing, the trust of patients is waning. As per the recent survey, most patients are hesitant to disclose their entire medical history, citing concerns over privacy security.
A poor record management system also leaves doctors, hospitals, and other organizations vulnerable to expensive penalties and lawsuits, and criminal charges.
The Keys to Successful Medical Records Management
In today’s fast-changing medical industry, medical records management can be very demanding. But there are actions organizations can carry to safeguard patient privacy and ensure their organizations’ lawful compliance.
Establish Medical Records Management Procedures
In order to effectively keep track of medical data, a company must first define clearly the policies and procedures they follow to ensure security. The need for updates is due to changes in the organization. That is because it may alter the management or security of health information for patients.
Effective patient records management system programs are a collaboration between all departments. Executives at the top should solicit the input of every department that creates or manages records, making sure that every basis is covered when writing policies.
Label Record Records Effectively
To effectively monitor records of patients from their creation to destruction, businesses require exhaustive indexing and taxonomy that covers every kind of document handled. This ensures that records are kept to retention schedules and also makes searching more efficient, which saves time and money.
Automated Processes
By automatizing essential and lengthy procedures, central medical software will improve accuracy, ensure that the records are in good order, and protect patients.
Enhance Data Security
From creation to destruction, medical records must be protected. In use, electronic records must include a thorough audit trail, and paper records. It must be secured in a secure room that has restricted access. Records that are stored offsite must be stored in certified, climate-controlled locations. When they arrive at the fate of their valuable life, electronic and paper records must be destroyed in a secure manner.
