The Healthcare Professional's Guide to Medical Records Management

Learn the elements of effective and compliant management of medical records

Knowledge is an essential resource for healthcare professionals. That goes for specialized knowledge acquired across years of training, of course, but also the specific knowledge of patients’ medical histories, current status, and the symptoms of any ailments those patients may be suffering from. Keeping all this information on hand in a way that is both helpful and legally compliant often requires a carefully crafted medical records management system.

Setting up the proper management of medical records for your healthcare business will depend on your particular role in the healthcare system, how many people you serve, and where you’re physically located. This guide will walk you through the essentials you need to know to begin working toward more effective and safe medical records management, including an introduction to special concerns related to HIPAA and potentially helpful electronic medical records management software.

Read our guide to business information management systems to find the practices, tools, and software you need to keep your business’ essential info accessible.

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What is medical records management?

Medical records management is the process, structure, and discipline of recording, storing, retrieving, and eventually disposing of documentation related to the health of patients. It includes the storage of key information such as patient encounter documentation and physician notes as well as periphery documentation such as personally identifiable payment statements.

While this mainly referred to the handling of paper documents in decades past, the explosive growth of electronic health records now means nearly 4 in 5 office-based physicians and more than 9 in 10 non-federal acute care hospitals now use digital medical records management systems.

The foremost benefit of effective handling of medical records is self-evident. Physicians can only provide the best possible care for patients when they have access to all the information they need about their current condition and other pertinent considerations such as family history. In this way, better medical records management leads to better outcomes.

But medical records are not simply resources to be used in the facilitation of better healthcare. They are also deeply personal stores of information that may include patients’ names, birth dates, private medical conditions, and payment information. For individuals to entrust healthcare professionals with this information, these records must be handled with the utmost care.

The United States government has taken a special interest in ensuring this responsibility through the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as well as the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) which bolstered HIPAA’s rules with stronger civil and criminal enforcement. Both are administered by the U.S. Department of Health and Human Services (HHS). The Centers for Medicare & Medicaid Services’ Medicare Promoting Interoperability Program also prioritizes providers creating data that can be meaningfully shared where needed to improve patient access and outcomes.

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How does HIPAA impact the management of medical records?

HIPAA governs the usage of individuals’ medical records and other individually identifiable health information, which the act collectively refers to as protected health information (PHI). This information could be anything that relates to:

  • An individual’s past, present, or future physical or mental health conditions.
  • The provision of healthcare to an individual.
  • The payment for said healthcare.

Through its Privacy Rule and Security Rule, HIPAA mandates which materials constitute PHI, who may be permitted to access it and when, and how healthcare organizations should safeguard that information.

The U.S. Office of Civil Rights enforces HIPAA compliance through regular audits and by investigating complaints from individuals. Failure to comply can be costly; since the HIPAA Privacy Rule went into effect in 2003, OCR has settled or imposed civil money penalties in 130 cases for a total of more than $134 million. Violations can also result in imprisonment of up to 10 years.

Here are some resources to help you ensure your medical records management system is HIPAA compliant.

HIPAA medical records management requirements for security

The HIPAA Security Rule applies to electronic protected health information (e-PHI), which is any PHI an organization creates, receives, maintains, or transmits electronically. Healthcare organizations must ensure the confidentiality, integrity, and availability of e-PHI, identify and protect against reasonably anticipated threats to the e-PHI, protect against reasonably anticipated improper usage and disclosure to the e-PHI, and ensure compliance by their workforce to these rules.

The HHS does not impose specific solutions businesses must put on their electronic medical records management system. Instead, it directs organizations to hew to the stipulations above while considering their size, infrastructure, potential risks, and similar concerns.

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HIPAA medical records management requirements for retention and destruction

HIPAA also takes a more hands-off approach to specifications for how long PHI must be retained and when it should be destroyed. The act largely leaves these regulations up to individual states, which may require documents to be retained for 5 to 11 years following patient discharge. Individual practitioners and hospitals also have different requirements.

HIPAA also does not mandate specific requirements for disposing of PHI, though it does offer some recommended methods including shredding, burning, or pulping of paper records, and clearing, purging, or outright destroying electronic media storage.

How to implement electronic health records management

Rather than starting from scratch in building compliant medical records management software, your organization will likely benefit from capitalizing on the groundwork laid by established healthcare document management software. And whether you already have large stores of paper medical records to process for more efficient storage, or are simply looking to keep up with the most effective medical records management processes possible, your medical business will need the right document digitization devices to bring all of your information in line.

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Built to purpose for the most demanding document handling jobs, fi and SP scanners are capable of processing tens of thousands of pages per day at the highest levels of accuracy. Their intuitive integration capabilities with all existing work suites minimize time-to-value for businesses looking to invest in tools that will pay dividends for years to come. Click here to learn more or shop our entire production scanner line.

Note: Information and external links are provided for your convenience and for educational purposes only, and shall not be construed, or relied upon, as legal advice. PFU America, Inc. makes no representations about the contents, features, or specifications on such third-party sites, software, and/or offerings (collectively “Third-Party Offerings”) and shall not be responsible for any loss or damage that may arise from your use of such Third-Party Offerings. Please consult with a licensed attorney regarding your specific situation as regulations may be subject to change.

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