Good medical records management is not only a very important aspect of running a medical practice or hospital records department, but it is also an integral measure to ensuring adherence to the compliance of various state and federal governance’s relating to the storage, management and retrieval of medical records.
Records management should be a priority for all health departments and medical departments. Across all states, medical businesses that hold health information must take reasonable steps to protect medical records from misuse and loss through unauthorized access, modification or disclosure.
Document storage and retention in medical records management
The length of time records should be maintained varies in each state and healthcare providers should be aware of their local legal requirements. The general framework for storage and retention is:
- A medical record must be kept for at least 7 years from the date of the last entry in the record if the patient is an adult
- For children, the record must be kept until the child attains the age of 25 years.
Utilising the strength and reliability of a professional information management partner is the perfect way to ensure that you have all of your document storage systems appropriately covered. Compu-Stor have developed a robust information management solution that facilitates a superior level of document storage and retrieval. Our CIMS information management solution delivers efficient and time-sensitive access to information, allowing healthcare practices and teams to more efficiently organise, access and preserve information.
The use of CIMS is easily adapted and maintained, with simple access to every document and detail readily available to multiple users via PC, smartphone or tablet.
Document destruction in medical records management
Brisbane’s Princess Alexandra Hospital recently announced it was the first QLD hospital going 100% digital, meaning all records and information will be stored straight to a digital records management system, instead of a paper-based one. As part of the move to a fully digitised system, the destruction of existing paper-based records needs to be handled in a highly sensitive manner.
Disposing of paper copies of notes that have been transferred into the electronic format is allowed under AMA and RACGP guidelines 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 is required to be kept. Whilst this is not a requirement in other states, it is considered good practice to keep a record of destroyed documents, regardless of their origin.
RACGP Medical Record Management Guidelines
The RACGP Computer and Information Security Standards (CISS) provides information and recommendations that will help educate general practices about contemporary security issues in order to help protect them from potential threats and loss of sensitive data.
CISS provides general practice with a framework for evaluating risks, guidance and solutions to improve competency and capacity in computer and information security. The most recent edition includes additional information to support GPs and their practice teams as they develop policies that relate to participation with the Personally Controlled Electronic Health Record (PCEHR).
RACGP CISS can be downloaded from the RACGP website.
Compu-Stor have over 30 years’ experience in working with hospitals, private medical practices, medical groups and medical centres to deliver efficient records management and document storage programs that help manage healthcare records.
We can help your healthcare business build a robust records management system that completely fulfils your functionality, accessibility and compliance requirements.