Medical Record Assignment 1. How does the process for beginning a patient medica
ID: 123424 • Letter: M
Question
Medical Record Assignment
1. How does the process for beginning a patient medical record begin? How are mistakes that are recorded in the record corrected?
2. How does your facility store medical records? Are there different procedures for active records vs. inactive?
3. How long does your facility keep medical records and radiographs? What are some exceptions as governed by your state regulations?
4. How does your facility regulate fax transmissions of patient information?
5. How does your facility manage electronic files and access to such records?
6. Have there been any breaches of confidentiality noticed or reported at your facility? If so, then why? How could this have been prevented?
7. Do you undergo any formal training related to the handling and storage of patient medical records and confidentiality?
Explanation / Answer
1. Patient record is nothing but the one book of search and research. Patient take admission in hospital and after treatment he go but there may some problem come in future like adverse drug reaction or any non compliance. So health care people to maintained this record for future purpose. There is no proper method at the beginning to store document. They are not separated as per disease and criticality issue.
2. My facility store records online as well as offline. Online are those records which are highly confidential and offline record is nothing but the short term treatment record. Yes there is different procedure to store active and inactive records. Active are stored in area which is easily available as compare to inactive.
3. Online records are kept throughout the life of patient and offline for 5 years. State also regulate this procedure.
4. If patient data needed at other site, we required written consent from his family via mail or application plus why it is need from other organisation. After that our senior management sign require to send fax.
5. Electronic records are highly prevented in our hospital. We assign password and user ID to each and every employee but there is privileges groups there to access information. One time wrong password block your ID.
6. Initially we face problem about confidentiality but make strict rules not to share your ID and password for the login. We prepare different group to access information.
7. Yes. Every two month we are providing training to our employee including me. It is refresher training and to prevent any leakage of information.