This past week I had the chance to work a little bit with the hospital's system as well as do my own analysis. I was tasked with updating patient information in their electronic system, such as updating insurance information as well as inputting dates.
I conducted analysis on federal and state records retention regulations. I found out that the federal government has set many different retention schedules for several different types of medical documents. Some documents are meant to be kept for three years, while others should be retained for five years. Documents related to Veterans Affairs must be kept for a good 75 years before being destroyed.
Each state government has their own specific records retention regulations as well. Arizona specifically requires patient documents to be retained for six years after treatment by a healthcare providor before being destroyed.
Hi Shabab,
ReplyDeleteIt looks like they use some software to enter the basic information about the patients. How much (percentage)of the patient information and medical records is stored in the computer? As far as reading your ideas looks like you are following four major ideas.
1. Creation of software or data entry port for medical records
2. Utilization of the information
3. Maintenance of the information
4. Destruction of the information as per the guidelines.
The hospital doesn't have an exact percentage of how much of the records is actually stored in the computer system. Yes, those are some of the things I am discussing.
DeleteI have few questions too.
ReplyDelete• Are you thinking about creating a new software? Or scanning and saving the records as a password protected PDF document? Do you think this method can store the radiology films, pathology slides etc?
• Is this accessible only by the hospital staff? Do you think individual patient can access their medical information by creating a user name and password?
• You mentioned that documents are stored anywhere from three to 75 years. Who is in-charge of maintenance and destruction? Are the patients notified when their information will be destroyed?
• I think identifying the records is an important step in the successful maintenance of filing system. What are your thoughts on active an inactive records? If a patient comes in for short term period…gets cured and doesn’t need the treatment again, what do hospital do to their records?
Creating a new software is definitely something I will suggest. The main problem at the moment is that many of the data programs are not actually linked, so doctors must often waste time gathering information from several different programs. A software that links these programs together would remove one of the largest obstacles to switching over to electronic record keeping. They should be able to store films and slides, as those are considered records as well.
DeleteAs far as I know, the information is only accessible to hospital staff, but patients can request the information. However, I do not believe they can create their own username and password.
At the hospital I work at, the research and grants department is responsible for the destroying the records. I am actually not sure if patients are notified when their information is destroyed, so I will ask and let you know!
Even if the patient doesn't need the treatment again, the records must still be kept for the time period specified by the government.
Hi Shabab. It seems like this is a really important document. I am always amazed at the record keeping of some hospitals, and how smoothly they process all the documents.I look forward to reading more as you delve deeper into this topic.
ReplyDeleteThanks for showing interest!
DeleteShabab, your project came up with a patient today! She needed to retrieve paperwork from 1999 on her kidneys and she was having a difficult time because the information she needed was not in an electronic format. So I'm assuming wherever she got her testing done has not switched to the electronic format therefore making it difficult for patients and their new doctors to receive past medical records. It would be easier for patients to be able keep their own records. Is there any talk about that happening?
ReplyDeleteActually, all hospitals have a mix of electronic and manual record keeping. The issue is the entire system being electronic. If her information wasn't in an electronic format, it must have been some of the information that hasn't been scanned in yet. That's one of the problems I will be discussing: The time and money it takes for workers to scan in all the documents.
DeleteSo far in the analysis I have conducted, I have not yet come across this idea. But I will be sure to ask the people I am working with and will follow up with you on that!