Record control 1

Record Control

Lisa Rosier

HCR/210

August 13, 2010

Madelene Williams
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Medical records are necessary to enable a medical facility to have all of a persons

information to be in one place, and easily accessible. Keeping track of these records can be a

difficult task, especially trying to keep up with the records are at all times, making sure they are

kept confidential so that the Health Information Portability and Accountability Act (HIPAA )

guidelines are met and ensuring that privacy is not compromised at any point in time.

All medical facilities have their own way of accomplishing these tasks, but there are

differences and similarities among all sizes of facility. No matter what size the facility is each

has a responsibility to control the records in the facility and ensure the patients privacy.

Small, medium and large facilities each have different places where the files are kept for

example, filing cabinets and locked rooms. The numbers of different places vary and can be one

location, like in a filing cabinet or many places, like a cabinet, physician’s desk, and locked

rooms. Access to these files by limited to staff of the facility. Controlling access helps if there is

an issue with missing files there are only a few people who could have moved them, therefore

making it easier to track them down.

When another department needs a record, obtaining that record is often done in different ways,

depending on the nature of the request, for example if a record is necessary during a non-

emergency situation, personnel from the requesting department will be sent to retrieve the record

(Green & Bowie, 2005, p. 217).

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Each facility adopts their own unique way to do this, but the main focus of circulation and

tracking is to make sure files can be found at all times and are put back in the appropriate

location and above all, patient privacy is always a top priority.

Tracking a file sometimes can be difficult if there is a miscommunication issue or the file

was taken by one department then given to another without proper documentation about where

the file went. To help avoid these issues there are a number of ways to help the staff keep track

of the record. One example would be for the requesting department to use a sign in- sign out

sheet. means that whoever requests the file will sign it out then when the file returns they sign

it This back in, much like signing a child in and out of school.

During the absence of the file an out guide(a folder with information about the records

location) is put in the place the record should be, this outguide would have a copy of the request

for the records and also any new files that need to be put into the record when it returns to the

department (Green & Bowie, 2005, p. 214).

Protecting the patient’s right to privacy is very important when handling medical records.

HIPAA (Health insurance portability and Accountability act) requires that all patient files are

kept private at all times. To help ensure these guidelines are kept each facility must have a

security plan. Some facilities such as those who service only a small number of patients can keep

these files in locked filing cabinets or in a filing drawer that can be lock when there is no one in
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the department. Larger facilities may choose to use a large closet to house the files or store them

on shelving behind the check in counter, out of the reach of unauthorized persons.

Some facilities have no privacy issue because their records are electronic and can be accessed

by a select group of personnel. For instance if the electronic record is accessed the person who

accesses it will have to sign in with a security password. By using this password they are leaving

information on the computer about who last accessed the file. This information would be

valuable in the event of a compromised file. Paper records are the most threatened when it

concerns security so keeping them locked up is very important to ensure privacy for the patient

even after the patient is no longer a visitor to the facility his or her privacy is still important.

Storing the files of past patients can last from three years to as many as 10 depending on the

policy adopted by the facility. Small facilities tend to keep their records for around three years.

They are kept in an on-site locked facility for a set number of years and then destroyed.

Larger facilities keep dead(the records of past patients who no longer visit the facility)

records on-site for a number of years then transfer them to an offsite facility for a few years

before destroying them. The method used to destroy the record depends on the type of record,

for example paper records be incinerated or destroyed with the use of acid.(Green &

Bowie, 2005, p.98)
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Patient medical records are private and should be kept that way. No matter what way different

facilities choose, this is a top priority by all facilities. By making sure that records are filed

correctly, tracked properly and returned to the correct department and destroyed properly when

they are no longer needed are all ways to keep the contents private and avoid lawsuits. By

following guidelines set by the government and those implemented by individual facilities

privacy should not be in question.

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REFERENCES

Green, M.A., & Bowie, M. (2005). Essentials of Health Information Management. Clifton Park,
N.Y: Thomas Delmar Learning