Medical Record Management Practices

This assignment delves into the crucial aspects of managing patient medical records. It covers topics like archiving procedures, legal requirements for record-keeping, the importance of accurate information in patient records, storage facilities for inactive records, and secure disposal methods. Understanding these practices is vital for ensuring patient privacy, facilitating communication among healthcare professionals, and complying with legal regulations.

Management of Patient’s Records
Archive Records
Process of removing the
patient’s file from the main
filing system and storing
them in a separate storage
place
Important procedure to
assure that there is enough
space for the new files and
the flow of information.
Files should be archived at a
regular basis.
Retention of records
Keeping the medical records
of the patient is a vital part of
the healthcare.
The nurses should also be
aware of the legal
requirements of the practices
required in the record-
keeping.
Medicare and Veteran
Affairs Documentation
Medical records are
also an important
source of
communication
between the medical
nurses.
It is important to
ensure that the health
care records of the
patients should an
accurate information
regarding the
treatment, planning
and the delivery of the
healthcare services.
The patient’s record
should be written with
the involvement of
both patient and the
medical practitioner
and provide a clear
evidence of the care
planned, decisions
made and the event
shared.
Closure of a health care facility
The archived files are not
destroyed and are available
whenever required.
If the patient returns to the
healthcare facility, these
records can be restored
(Read & Ginn, 2010).

Storage facilities
The inactive or old medical
records are identified and
kept in a separate filing
system as they are keeping
too much space.
It includes electronic system
and separate filing system.
These files should be
maintained in the same
manner as the personal
records
It is important to keep a
record where the information
stored and the data at which
the information is transferred
to the patients (Adam, 2007).
Disposal
When a medical practice is
complete, the medical record
belonging to different
patients are needed to be
disposed.
The records obtained during
the treatment of the patient
can be kept, archived or
disposed. It is important to
set specific criteria so that
the patient’s record.
It is important to manage the
records of the patients so
that other practitioners can
take advice for the treatment
of other patients.
It is important to dispose of
the records in a confidential
manner, so that no
information is leaked from
the organization.
References
Adam, A. (2007). Implementing
Electronic Document and
Record Management
Systems. CRC Press.
Krueger, J. (2013). Cases on
Electronic Records and
Resource Management
Implementation in Diverse
Environments. IGI Global.
Read, J., & Ginn, L. (2010). Records
Management. Cengage
Learning.