Expert Tips for Handling, Storing and Organizing Medical Records
Gallagher Healthcare :: Industry Insights
By Gallagher Healthcare | 6/28/2022
4 Tips for Properly Handling and Organizing Medical Records
Once upon a time, the only way to handle and organize medical records was with paper, pen, folders and lots of filing cabinets. Medical record retention options have increased as computer and internet technology have exploded over the past 30 years. Although traditional record-keeping methods still have merits, exploring your options is beneficial. Below, you'll find information on the importance of keeping medical records and how to optimize your record-keeping method.
Why Is It Important to Keep Medical Records?
The most important reason to keep medical records is to ensure optimal patient well-being and continuity of care. When you need to disclose patient information with other healthcare professionals, medical records ensure they provide your patient with the appropriate care. Still, the importance of medical record retention goes beyond patient care. Keeping medical records also helps you in the event of:
- Malpractice lawsuits
- Billing audits
- Licensing board complaints
- Peer review inquiries
- Governmental investigations
In malpractice lawsuits, the legal system relies on medical records in acquitting or convicting doctors of negligence accusations. Where there is little to no documentation, doctors have little to no defense. Depending on a general standard of care without proper documentation rarely convinces juries. In contrast, access to well-maintained patient records can dismiss shallow allegations.
Thus, proper documentation is doctors' sole option for proving they carried out patient treatment correctly during malpractice lawsuits, licensing board complaints or peer review inquiries. Further, record entries can also refresh a doctor's memory when revisiting an incident several years prior.
What Records Should You Keep?
What documents should you include in them? Anything relevant to patient care is worth documenting. Storing patient records generates financial expense, but it is often worth it in the long run. Important records to keep include:
- Discharge notes and summaries
- Referral notes
- Nurses' notes and provider notes
- Death summaries
- Inpatient files
- Diagnostic test results
- X-ray films
- ECG records
- Fetal monitoring strips
- Photos or videos
- Medical certificates
- Duplicate copies for lost documents
Records indirectly related to patient care can also serve as evidence in lawsuits, including accounts, staff service and administrative records.
Within those records, vital information includes:
- Dates of evaluations, operations, prescriptions, referrals, discharges and any other medical interaction with a patient.
- Instructions after discharge, including directions for taking medications, required physical care and urgent reporting if complications arise between discharge and follow-up.
- Relevant investigations.
- Patient medical history.
- Pre-, peri- and post-operative notes.
- Doctor's recommendations.
- Patient signatures for discharges and referrals.
- Patient progress or medication use.
- Informed consent documents.
For instance, if a patient is discharged against a doctor's advice but later files a malpractice lawsuit, proper documentation can acquit the doctor of negligence. In such cases, detailed notes documenting the doctor's recommendation against discharge are essential. Having the patient sign a document that acknowledges the risks of discharge against the doctor's advice is also critical in such cases.
How Long Should Medical Records Be Kept?
Each state has laws for minimum medical retention periods and appropriate methods of medical record destruction. West Virginia and Wyoming are the only states lacking legal requirements on medical record retention. Depending on several factors, the minimum medical retention period could be anywhere between two to 30 years after discharge, death or the last treatment date. Those factors include:
- The state you practice medicine in.
- Whether the patient is an adult or a minor.
- Either basic information or full medical records.
- If you practice in a hospital or private clinic.
- The type of documentation.
For example, Texas laws stipulate that doctors working in private clinics keep medical records of adult and minor patients for seven years after their last treatment or until a minor patient turns 21 — whichever date is later. Texas hospitals must keep adult and minor patient records for ten years after their last treatment or until the minor patient turns 20.
It's important to review medical record retention laws in your practicing state to ensure you're adhering to them.
The Risks of Poor Records Management
Poor records management poses risks for patients and physicians alike. Here are some risks that poor medical record management poses:
- Inhibits access to essential patient information: Medical facilities with poor records management endangers patients by hindering access to health information that could prove life-saving or life-changing.
- Lowers workplace efficiency: If staff are always looking for information that may or may not exist on record, the time they spend doing so diverts their attention from more productive tasks. It also signals a lack of structure and policy for patients.
- Increased risk of conflicting reports: Discrepancies in hospital records and information patients receive raise suspicion of tampering. Poor records management increases the risk of these discrepancies occurring. When record-keeping discrepancies appear in malpractice cases, patients typically get the benefit of the doubt.
- Billing error potential: Disorganized medical records may lead to billing errors, which can cause several headaches if the Centers for Medicare and Medicaid Services perform a billing audit.
How to Handle and Organize Medical Records
The days of thick paper charts and endless storage space needs are growing dim as electronic medical records dominate the scene. Still, a robust medical record system remains essential to ensure optimal patient care and workplace efficiency and to reduce lawsuit risks. To that end, here are some tips for handling and organizing medical records.
1. Put Away Older Records
Records have a life cycle. The stages of this cycle are:
- Creation: This stage involves starting a medical record for a new patient.
- Use and modification: Once the record is in the system, nurses and doctors review and modify it for treatment purposes and as the patient's care plan unfolds.
- Maintenance and protection: This stage involves routine protection measures to ensure the information is neither destroyed nor tampered with until the minimum medical retention period passes.
After these three stages, the final stage is either disposal or preservation. This stage occurs after the minimum medical retention period passes. At this point, you have to decide if you want to archive the record or destroy the information. Some documents must be kept indefinitely. To prevent disorganized record systems, construct digital or physical storage spaces dedicated to archiving older records. Doing so will ensure easy access to current and archived records with minimal clutter, optimizing patient care and workplace efficiency.
2. Make Thorough Notes
Thorough notes are essential for optimal patient care and protection against malpractice accusations. A well-organized record system with insufficient patient information will not offer the necessary protection. You may find specific files quickly, but that has limited value if the file has inconsistent, outdated or incomplete information. A well-organized record system with thorough notes is a strong defense and optimizes patient care.
3. Keep Copies of Records
Both digital and paper records are vulnerable to loss or accidental destruction, whether due to a data breach or fire. Thus, it pays to make record copies to prevent lost documents. Store the copies in a delegated area separate from the others.
4. Modernize Your Filing Systems
Although electronic medical records aren't perfect, they're far more efficient than the old paper and box file system. Electronic medical records allow providers to track data over time much easier. Often, such tracking is automated, making it much simpler for providers to track how patients respond to treatment. Whereas paper records need copious physical storage space, electronic medical records only need an encrypted hard drive that holds many bytes.
Learn More About Malpractice Insurance
Besides organizing and optimizing your medical record system, it pays to have a safety net against malpractice accusations with malpractice insurance. Learn more about how malpractice insurance can help you with Gallagher Malpractice today!