Medical records management is the part of records management that relates to the operation of a healthcare set up. It is the field of administration that is accountable for all records throughout their life span from birth, receipt, preservation, and use to removal.
Every so often referred to as health information management (HIM) or health records information management (HRIM), medical records management can encompass everything and all about a practice and a patient, comprising but not restricted to a patient’s account, clinical outcomes, diagnostic test results, pre- and postoperative care, patient growth, and treatments.
The essence of quality health delivery is not just providing efficient and maintainable care to the patients but also appropriate maintenance of records, handy in the shortest time. If precise, decipherable and updated medical records of the patients are not obtainable, it is very difficult for the care providers to agree on the treatment plan.
It is understood that the patient medical record is the chief source of information regarding patient care. The medical record is valuable whenever suggestions are required to protect the service provider on patient care. The customer medium is mainly dependent on the medical records, whenever there is a medical negligence incident filed. This is the only record for the doctors to ascertain that the patient care was approved out as per procedure, during such disagreements. The insurance companies also need a precise medical record for clearance of claims. Improper/incomplete record keeping may lead to serious penalties to the service provider and the patients.
Purpose of medical records
The first and primary purpose of preservation of medical records is to visibly lay the path way of treatment in order to simplify a methodical and ‘on the track’ action to the patients. As the doctors keep moving from one patient to another, it is not humanly possible to remember the particulars of all patients. The latest data, along with the case account of the patient, will allow the facility providers to work out midterm alterations, if any, and to continue the already laid out treatment plan. This is a good communication tool for referring, treating, going to doctors and other care providers. This is the only dependable evidence to verify that a methodical care has been provided by the doctor and hospital, in the court of law. The medical records will be valuable for taking many health statistics of the hospital for analysis and development. These statistical data are not only useful for hospitals but also to government agencies for many uses. These records are also useful for patients’ orientation after release and helpful to them as a defensive tool, in case of any curative negligence. Traditionally, the records were conserved physically but now it is getting transferred to electronic systems.
Risks of Unmanaged Medical Records
Not having informal access to possibly life-saving or life-changing health info is a significant risk that unmanaged medical records give. A lack of organization with regard to record keeping can also pose a legal risk. Additionally, when staff are continuously struggling to find possessions, patients might view the absence of management and strategy as a signal that a practice is behind the times.
Disorganization can also lead to a loss of efficiency, repetition of efforts, or a failure to complete essential tasks. Billing mistakes could arise as a consequence of poor records that eventually cost the practice money. Paper records also necessitate a physical storage area and can occasionally result in practices needing to obtain additional office space, which can be costly.
Unfortunately, many medical amenities do not see medical records management as an important or necessary function. As a result, they do not provide training or arrangement to create a well-organized and acquiescent policy.
Retention guidelines
There is no single guideline demonstrating how long a medical record needs to be conserved by hospitals in India. Some states have guidelines, while some of them do not. All hospitals have customised code of behaviour for the preservation of medical records. In general OPD records are kept for three years, while IPD and medico legal records are kept for 10 years in corporate hospitals. This is also in line with Directorate General of Health Services (DGHS) guidelines for Central Government Hospitals vide ref no: 10-3/68-MH dated 31-8-68. In case a court case is pending on a record, the above rule does not apply. The records need to be preserved beyond the stipulated time period. To permit the opportunities of any appeal, the records need to be kept at least two years after the most recent court decision. The Medical Council (MCI) of India has given course of action that individual doctors should preserve the in-patient records for three years from the date of beginning of treatment. It also guides to make documents obtainable to patients or authorised person within 72 hours. The Consumer Protection act 1986 fixes a time restriction of two to three years for filing a suit, from the date of treatment. This period may get relaxed by the court, in a suitable case.
Careers and Training in Medical Records Management
Many medical providers make the error of presuming that anyone can handle medical records management. This is not the situation: It is a specified and methodical field. In some administrations, there are health information technicians who are accountable for accumulating and organizing medical records while upholding privacy and safety. There are also health information managers who deal more with the general health information administration structure than the day-to-day data record. Each organization has diverse titles and job accounts with varied salary and certification necessities. As with any expert type of work, training, certifications, and professional organizations are obtainable. Several schools also deal programs in information management with specialty trails in medical records.
