When someone needs to be hospitalized, there are some procedures that are needed to be followed. Only after completing those formalities, the treatment is proceeded with. Various medical tests and checkups are undertaken after that and the hospital keeps a proper and systematic record of these important details and documents.
Just as there is an exceptional staff in the hospital for every task, similarly, there is a team for the management of medical records. Their job involves collecting all the reports, documents, doctors’ prescriptions, medicine, tests etc., of each patient individually, which is kept for future reference.
But we all have seen that maintaining massive records of patients is tedious, unreliable and risky for the hospital department. For this, new technology is introduced that aids medical records management.
According to medical ethics, the personal details of any patient are essential. And they are not shared with anyone without the permission of the patients, even if they are relatives of the patients. These are confidential documents that need to stay safe. And that is why there are specific rules that hospitals follow when it comes to medical records management. To understand better, you can read as follows.
Rules of medical records management
To manage any patient’s medical records, the staff has to follow several rules so that there is no loss of any kind to the patients.
- No records are shared with anyone without the permission of the patients.
- If the patient dies, then reports are given only to selective people in the patients’ blood relations.
- Medical records are shared only if there is a solid reason; records are not disclosed otherwise.
- If the reports are to be transferred from the first doctor to the second doctor, the medical officers’ permission and the reason are given only after verifying.
- The work of records management is done only by the selected staff; any other medical officer or staff cannot use it without permission; it is against the rules. With this, action can be taken against that person.
- These records are managed for a specific time only; then, they are destroyed forever to keep them confidential.
For medical records management, the assigned person is given that type of training under experts, and the trained personnel is then appointed for this work. All the laws of medical ethics are taught to them so that the reports are not disclosed even on the burden of any senior officer. Violating the rules can be a cause for trouble in hospitals.
The problem of records management –
For every solution generated, there was once a problem. Similarly, medical records management was also an issue for a long time. Some problems persist, but many have been deterred after the efficient management techniques to handle the records of the patients.
- Updating outdated medical forms requires re-adding the old records in the new format.
- Old records have to be stored in the right place not to get spoiled.
- Unwanted records have to be destroyed from time to time.
- The records in paper format affect the atmosphere, so many times the papers get torn, ink splits, insects are applied, or for some reason, they catch moisture. In this case, making a copy of original documents with their hands is essential.
- If the records of many years ago have been made inactive, they have to be activated when the time comes.
After introducing technology, things have changed a lot and mainly for good. There has always been a need for computerized documents for long-lasting reports. Otherwise, there were torn papers and half-visible doctor prescriptions.
For how long do these records have to be managed?
The time of records management depends on the age of the patients.
1) Records of patients above 18 years are kept for three years.
2) Records of patients aged 15 or less are also maintained for three years, i.e. until they attain 18 years.
3) The records of developmentally disabled patients are maintained for their lives until their treatments or checkups are started.
4) The records of cancer patients are also maintained as long as the hospital is started; they are never destroyed.
Medical records management is a critical process. It helps to get much information about the life of the patient. Managing these records helps the patients in their best treatment. It also helps the doctors suggest the right exercises and diet for the future. Therefore, it is vital that they are written correctly, and there are no errors of any kind in them.