Safety and Security of Medical Records

Introduction

The hospital organisation and its individual employees jointly share the responsibility for the best possible care of the patient. To fulfill this obligation, the hospital and the employees are both charged with certain reciprocal ethical obligations to safeguard confidential information regarding patients and the hospital; to avoid gossip and criticizing the hospital in public; to develop a spirit of mutual friendliness with fellow workers, and to be courteous to the public. The hospital therefore is responsible for providing adequate safety and security to prevent access to patient's medical record by unauthorized persons or protecting the records from nature from the time the record is initiated.

Safety for staff

• Safety factors are an important consideration in the filing area and safety rules should be conspicuously posted
• The prevention of falls is of prime importance, particularly when staffs are working with the upper shelves in open-shelf units. Skid proof ladders and step type steel stools are a wise investment
• Filing shelves and other mechanical equipment devices should be well erected to avoid accidents.
• There may be either pullout shelves in the record-storage unit or carts of some type to assist in processing records within the filing area
• Adequate lighting reduces eyestrain. Proper conditioning of the air with regard to temperature, humidity and dust control is essential for fire prevention and employee productivity
• Necessary safety measures should be taken for the welfare of both the departmental staff and visitors to the department

Preservation of records

Protective covers for medical records

In order to keep the contents of medical record documentation intact and to protect the sheets from tearing and from the effects of repeated handling, medical records should have protective covers. Some that are popular are chart covers, file folders, and record folders are common options.

• Record folders may be purchased with preprinted numbers on the cover, which provides a neat and legible appearance.
• The patient's name as well as the hospital number should appear on the folder or cover
• A sequential list of years printed horizontally on the front right-hand side of the folder allows for checking the year of most recent registration and makes purging inactive records an easy process

Selection of paper and ink

The medical records which are needed to be preserved either for a long duration, say for more than 10 years, or permanently, the selection of paper or ink plays an important role in the preservation.

Ambience of records room

• Exposing the records to a hot and dry climate, stagnant air, direct sunlight or heat, accumulation of dust and dampness, leads to deterioration. Hence, arrangements for proper cross-ventilation and provision for an adequate number of electric fans/air-conditioners and exhaust fans should be made to ensure good air circulation
• Regular dusting of records with the help of vacuum cleaners is also necessary to keep them clean and tidy

Protection from insect attack

• Prevention of infestation of records by insects can be done by periodical checking of the floors and walls and attending to minor defects, using insecticidal powders or sprays and naphthalene. While using liquids, care should be taken to see that records on shelves are not directly sprayed upon, as it may stain or damage the record
• During fumigation of record rooms, only those fumigants, which do not have any deleterious effect on paper and other record materials, should be used
• Filing racks should not be kept in close contact with damp walls to avoid damage by silverfish. The rack should be installed at least 5" away from the wall. Since wooden shelves attract white ants, closed steel racks are preferred for filing medical records

Safety measures against fire in records room

• The entire medical record department, especially the filing area of records and X-rays, should be protected from fire
• Important documents such as medico legal cases should be preserved in "fire-proof" cabinets
• All electrical cords should be covered to avoid short-circuiting. Smoking, lighting of matchsticks, carrying of an open flame, and storage of chemicals should be prohibited in the record room. All electric wires should run through conduit and windows and ventilators should be fitted with wire-net frames
• An adequate number of fire extinguishers should also be fixed in all convenient locations

Temperature and humidity control

• Temperature and relative humidity of the atmosphere above 32° Celsius results in the growth and propagation of pests like hookworms, silverfish, cockroaches, termites, and a variety of funguses commonly known as mildew. The temperature most suitable for proper preservation of paper and other record materials ranges between 22-25°celcius
• Regulation of temperature and humidity in the above range is only possible with the help of an elaborate air-conditioning plant
• Heavy dust particles are also eliminated in the airway system. Direct sunlight should also be minimized as it damages the records
• All endeavors for proper preservation and storage will however be in vain if care is not observed in handling the records

Security of medical records

The policies on disclosure of the contents of medical record must begin with a set of basic principles. These basic principles relate to the uniqueness of medical record: confidentiality, accessibility and hospital security. Medical records of the hospital maintained for the benefit of the patient, the doctor, and the hospital are regarded as the property of the hospital.

Confidentiality and disclosure

• The patient has the right to expect that records pertaining to his care will be treated as confidential, and the hospital has the responsibility to safeguard his records against unauthorised disclosure
• Subject to applicable legal provisions, the hospital may restrict removal of medical records from the shelves or from its premises, determine who may have access to their contents, and sort the information that may be disclosed

Accessibility

• Medical records should be used within the hospital only by authorised personnel on a need-to-know basis
• Responsibility for disclosure of medical record information by the hospital, with or without the authorisation of the patient should be delegated to hospital administrator who recognises the occasional situations that require the advice of a doctor or the hospital lawyer
• The hospital shall provide security to safeguard medical records and establish internal policies to provide for their proper use as needed to carry out functions within the hospital
• Access to the medical record without the written permission of the patient depends on the reason for the request

Hospital security

• It is the responsibility of the hospital administrator to establish and implement security measures that reasonably safeguard both the medical records and its informational content, whether in hard copy or in computerized form, against loss, damage, alteration and, unauthorised disclosure
• All employees of the hospital must be made aware of their responsibility in maintaining the confidentiality of medical record information and of the disciplinary actions that may be taken for unauthorised disclosures of patient identifiable information

Patient's authorisation

• Use of a patient's previous medical record, both inpatient and outpatient, by doctor and other hospital doctors involved in the care on that patient at the institution maintaining the record does not require the patient's signed authorisation because consent to such use is not mandatory
• Disclosure of medical information in the event of direct referral or transfer of patient to another institution does not require patient's signed authorisation. I n that event it becomes necessary to disclose the contents of the record of that institution
• Written authorisations from the patient may be necessary under some regulatory requirements. One of the purposes of a well drawn authorisation for disclosure of medical record information is to indicate to the patient or the lawyer acting on his behalf, what subject matter is being authorised to be disclosed to the person or organisation that will receive the information

Study and research programs

• The rules of the hospital shall define the extent to which doctors and other professional staff in good standing are privileged to use the medical records for study and research and shall describe circumstances that require patient authorisation for such use
• Anyone using the medical records for study and research must also share the responsibility for protecting the confidentiality of medical records, ensuring availability of medical records for patient care purpose at all times

Policies on external disclosure

• Without the authorisation of the patient, access to the medical record should be provided only on a need to know basis, including the necessity for external or internal administrative tasks
• Disclosure of medical records content can be done only by the hospital administrator
• The hospital should establish its own policies for disclosure of medical record information to meet various requests from outside such as insurance companies, corporate companies having tie-up with the hospital and, outside agencies authorized to receive information
• The hospital authorities should also include the establishment charges for furnishing copies of medical records

Summary

The hospital medical record is not merely a collection of papers recounting the tale of the patient's sojourn under the care of his physician in a hospital. It is an in-patient document and is frequently used in the court. It can serve a protection to the hospital, physician and patient only when it clearly shows the treatment given to the patient, by whom and when. Medical record is compiled, preserved and protected from unauthorized inspection for the benefit of the patient, doctor, hospital and its employees. Plenty of data are entered in medical records. To some it may mean a waste of paper. But, it is obvious that each statement made in the hospital medical record is a relevant fact which can be produced as evidence in a court of law. The hospital therefore is responsible for providing adequate safety and security to prevent access to patient's medical record by unauthorised persons or protecting the records from nature from the time the record is initiated.

Key points to remember

• Safety factors are an important consideration in the filing area and safety rules should be conspicuously posted.
• Proper conditioning of the air with regard to temperature, humidity and dust control is essential for fire prevention and employee productivity.
• To protect the sheets from tearing and from the effects of repeated handling, medical records should have protective covers.
• Important documents such as the ones related to medico legal cases should be preserved in "fire-proof" cabinets.
• All officers and employees of the hospital must be aware of their responsibility in maintaining the confidentiality of medical record information and of the disciplinary actions that may be taken for unauthorised disclosures of patient identifiable information.
• The hospital should establish its own policies for disclosure of medical record information to meet various requests from outside such as individual persons, outside agencies, or organizations authorized to receive information.
• The hospital should maintain either the original or copies of the patient's disclosure authorisation, which should be made available for examination by the patient

Student exercise

Answer the following

1. Discuss the safety measures to be taken in the interests of the patient and the hospital.
2. Explain in detail about the preservation of medical records.
3. Devise medical record policies and procedures for the release of confidential patient information to patients and their authorised representatives, third party agencies and insurance companies.
4. Discuss the procedure to be followed while disclosing the contents of medical record document to another hospital where the patient is taking treatment.