Document Storage for Medical Practices and Other Healthcare Institutions
The medical record is a powerful instrument that gives the treating physician the ability to track the medical history of the patient and identify patterns and other problems which may assist in determining the course of treatment.
The major aim of the medical record is to improve the quality of health care administered to a patient. It is therefore a living document which details the chronological story of patients and facilitates each encounter or meeting with the health professionals that are involved in their care.
Document management for a medical practice is therefore very important. In fact, it could be the difference between life and death for some patients. The various documents which are usually handled in a healthcare facility include patient records, laboratory reports, hospital records, research reports, MRIs and CT scans, X-Rays and more. Such documents need to be kept in a safe and secure site so as to ensure physical and logical integrity as well as confidentiality, which is an absolute necessity.
Therefore, physicians, working with record managers, must ensure that the appropriate record management protocols which regulate access to documents are put in place. Access should be contingent on role, responsibilities and authority of the users. At the very least, these protocols should ensure that medical records, whether in paper or electronic form, are easily and readily available and producible when required.
Clear steps must be taken to protect all documents from theft, misplacement/loss, unauthorized disclosure, copying, alteration and disposal. This requirement should apply on all the information stored on site, regardless of whether it is in the control of the physician or not. What is reasonable in terms of the record management protocols largely depends on the risks and dangers to which the data is exposed, the sensitivity off the information and to what extent that information can be linked or associated with an individual.
Physicians and record managers are encouraged to stay abreast of the latest developments in industry standards as well as government regulations to ensure they are fully compliant.
It is inevitable that sharing of medical information among established physicians and healthcare organizations will have to take place at one point or another. Data sharing agreements and procedures must therefore be adequately outlined in the records management policy. This is of great importance for doctors and medical practitioners who share records with other facilities or those that permit multiple health workers to make entries into a given record. It is the responsibility of the physicians to be fully aware of people within this chain who can access such records.
Those that have accessibility rights much be bound by strong confidentiality agreements. When it comes to electronic systems, a functional audit trail must be in place to record anyone who has accessed a given document and what modifications, entries or edits have been made over time.
Encryption mechanisms must be put in place for Electronic Medical Records (EMRs). Strong encryption is especially important if information has to be shared over insecure networks and various devices. If information has to be communicated via mails, email encryption must be available.
Maintaining integrity of information
All medical records and data has to be stored in restricted access areas such as locked filing cabinets which cannot be burglarized, tampered with or damaged by fire. This is for the purpose of protecting information from damage and loss of integrity. Some files contain an almost lifelong account of a patient’s medical story. Misplacement or damage would be a big, big loss.
Electronic records need to be backed up regularly to ensure redundancy. The backup copies should be stored in a separate location from where the parent data is stored. One must also remember that medical information is very private, sensitive and confidential. All the necessary measures must be taken to ensure it stays that way.