Medical records are filled with personal information regarding the patient’s health and other sensitive data, granting some of the highest levels of protection under the law.
Doctor-patient privilege has been a long-standing legal concept and in most states, serves as a law protecting medical record privacy.
Medical charts, health records, and medical records are terms that, to an extent, are used interchangeably, and describe a system of documenting an individual’s medical history and care over time within one healthcare professional’s jurisdiction. During care, the health professional will enter notes and other information to record the administration of therapies and drugs.
Accurate and thorough records are required of healthcare professionals in order to remain certified or licensed to practice.
Contents of Medical Records
Medical records contain the medical history of a patient to allow health professionals to more easily provide care based on their medical history.
It’s a central repository for documented information from professionals/providers on a patient’s care and can be used to aid in the future planning of the patient’s care.
Traditional records can include notes about admissions, progress notes, operative notes, postpartum notes, delivery notes, and notes about the patient’s discharge from the facility.
Personal records combine these features and portability allowing patients to take their records and share them with other health providers and systems but keeping their patients safe from medical identity theft.
Along with the medical history of the patient, medical records are also used to identify patients. These records, along with any that are electronically stored, contain the patient’s proper identification. Additional information included in the record will depend upon the individual person’s medical history.
Medical providers write the contents in the medical records and up until recently, the patient could not control what it contained. However, patients can now review their records and voice any objections regarding the accuracy of entries recorded.
A Note on Patient Privacy
Although there is such a thing as patient confidentiality, medical records have not always been kept so private. HIPAA, passed by Congress in 1996, requires the confidential handling and the privacy of protected health information.
HIPAA also provides millions of workers in America with the ability to continue their insurance coverage by transferring it should they lose or change their job while simultaneously reducing abuse and fraud in regards to healthcare.
Privacy regulations in HIPAA require that healthcare organizations, providers, and business associates, not only develop procedures ensuring the security and confidentiality of health information that is protected upon transferring, receiving, handling, or sharing, but they must strictly follow these protocols.
All protected health information, whether it’s oral, on paper, or electronic, is protected by HIPAA. HIPAA also requires that only information that is necessary in conducting business should be shared or used.
Medical Record Storage Options
Since 2014, electronic health records (EHR) have been required to be in “meaningful use” as stated in the American Recovery and Reinvestment Act of 2014. There are penalties if these requirements are not met.
The switch to a digital filing system for EHRs allows for more efficiency and security with the management of patient information. If your healthcare practice hasn’t made the switch to EHRs already, you’ll want to do so very soon.
In conjunction with a digital filing system comes offsite storage services. For certain files and records that have a required retention period in physical form, offsite storage services are a perfectly reliable way to keep those documents safe. With climate-control, 24 hour surveillance, and fast document retrieval options, storing your documents off site not only keeps your patient’s information safe from data breach and identity theft, but also saves space normally wasted on storage in your workplace.
Backfile and Day-Forward Scanning
Backfile scanning allows you to convert your archived files in bulk. You choose which files are converted to digital based on necessity, making the process fast and efficient.
Day-forward scanning gives you the flexibility to access paper files and transition between your old document management system to a secure and convenient EHR System.
Optical Character Recognition and Data Extraction
Optical Character Recognition (OCR) and data extraction services ensure all your patient records have accurate information and can be modified or edited quickly and easily. OCR gives you the ability to search and index every aspect of your files with a quick keyword search.
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