Information is power, and medical records provide very crucial information and data needed during medical diagnostic procedures. Medical records ensure that there is continuity of care provided to patients. Effective, elaborate and comprehensive medical records ensure that caregivers and medical practitioners can easily track past patient information without necessarily relying on personal memories. On a different note, archived records also serve various legal purposes; for instance, they can be used as evidence to support given claim, or even as a basis for filing a lawsuit. Medical records can take various forms, including but not limited to:
- Handwritten notes
- Reports from laboratory
- Computerised records
- Communications between health practitioners
- Imaging records from x-rays and other treatment equipment.
- Video recordings
- Printouts from monitoring equipment
- Correspondence between doctors and patients.
Patients have right to their records; therefore, it is the duty of the hospital to make sure that they practice safe and secure record keeping. The question that arises is: what are the best practices of archiving medical records? And are they economical? Owing to the number of records generated in heath care facilities, an efficient information storage system is required. Hospital records have immensely contributed towards the emergence of the ‘big data’ concept, whereby a lot of data is generated daily. As a result, it is pertinent for IT department in hospitals come up with innovative ways of handling the through a resilient medical records archiving solution. In a healthcare setting, medical records are crucial in providing the patient medical history; hence, they must be securely stored and must be retrievable whenever they are needed.
Properly archived medical records provide the basis through which doctors and other medical practitioners enrich their diagnostics and understanding of a clinical problem. Doctors are able to refer to a previous case, analyze it and infer the merits and demerits of the solution and the possible implication on the current situation. They are able to make better judgment and provide a well-thought and evidence-based intervention. Serious medical breakthroughs have been made with the help of stored records by studying of pattern of occurrence of certain diseases or other medical phenomenon and drawing a conclusion from them. When doing medical research, student use stored information as secondary data and sometimes as the primary source of information.
Archiving also aids in the provision of quality care in hospitals, hence promoting better health outcomes for the patents. Easy retrieval of medical records enhances doctors’ ability to provide efficient and fast treatment. For every patient, the healthcare professionals have to keep a written medical record; this can be done using physical files or in using an electronic health record system. An electronic health record system makes it more convenient for the doctors to get this information as quick as possible. When emergency cases happen in the hospital that requires immediate attention, the only way the available doctors at the scene can handle the case is based on how quickly they retrieve the information needed. Therefore, file archiving solution for medical records should be provided at all cost. One of the best ways of sharing and using medical records is by improved internal communication in the health facility. Hospital management should facilitate doctors and nurses with proper and effective internal communication system.
Different Techniques of Archiving Medical Records
Digitization of medical records: it is easy to archive electronic medical records. With the help of appropriate medical records archiving software, it is easy to securely store the files for a long period. File archiving solution providers suggest that effective medical records archiving solution should at minimum do the following:
- Use a comprehensive data analysis method and create a report.
- Use a centralized remote file management to make it easy to update and access.
- Do automation of the file storage system engine with efficient and effective relevant commands.
- Optimize storage system with file de-duplication system with single instance storage.
Grouping data storages into different enhance data movement while still maintaining its integrity. Tiering data also helps reduce total storage cost. When tiering, the data that is very variable, valid, reliable, often accessed, crucial and has secretive information is stored in tier one. Then the financial and other data files that are rarely used are stored in tier two. Finally, tier three contain data that is less classified and which is supposed to be in public domain or which is event-driven. The illustration below shows the cost factor and efficiency in each tier.
- Tier 1-this level is expensive but has high performance
- Tier 2-it is less costly however it is very slow as compared to tier one
- Tier 3- it is the cheapest and readily available
On a different noted, there are very helpful off the shelf software that enhances record keeping and management. With the present day technology, information management systems remain the best and most effective way of managing records. With automated health record keeping, it is easy to analyze data and gain critical insights that can aid in making an informed clinical decision .
For handwritten notes, it would be advisable for the archiving room to be well equipped and able to resist a wide array of adversities. Additionally, there is the need to scan and store as a soft copy as a backup in case of loss.
The chosen file storage systems should exhibit the following characterizes:
- Efficiency: The system should depict aptness, accuracy and high throughput in the storage and retrieval of the relevant record.
- The records should be organized in a logical manner, and in a form that is easy to decipher. Both patients and doctors should be able to understand it easily. Transparency improves the level of confidence in doctors and other medical practitioners, and it makes patients trust doctors with their confidential personal information.
- Storage system should guarantee maximum security to private and confidential information of the patients. For electronic file storage systems, the data should be highly encrypted and access privileges granted only to the relevant individuals. For physical filing systems, access to the storage facility should be managed to limit any unauthorized access.
- Data integrity. Doctors should be able to verify data retrieved is the one that was actually entered, so the system should be able to produce legitimate and accurate information at all time without any form of alteration.
Challenges of Provision Of Medical Storage Facility
Although a medical archiving system is a very important component in ensuring efficiency in a healthcare setting, various challenges are probable. Firstly, archiving is a costly venture. Initial installation cost although high can be managed by proper utilization of fund by the management. Secondly, this system requires constant maintenance to avoid breakdown which could be catastrophic for the hospital. As a result, the need to work with highly trained and qualified personnel is a requirement. Non-compliance with the stringent standard of archiving medical records can be solved by the willingness of the staff to comply with the rule and regulation and constant reminder that standards should be followed at all time and make it hospital policy to observe those rules.
Rules and Guidelines for Archiving Medical Records
To ensure safe, effective and reliable medical records archiving solution is arrived at, the following guidelines can be utilized to make sure that the medical records capture relevant information:
- The medical records should contain adequate information to identify and assess the patients and provide proof on the course of patient’s health care.
- The records should include accurate and legible documentation of any local health department activity involving or affecting the patient’s health. Data needed should include but not limited to assessment, tests, results, and treatment.
- All medical records must be maintained in a standard format with entries and forms filed in chronological order with most current on top.
- Each and every form or document filed within the record shall include the patient’s name, identification number and clinic identifier.
- Each entry in the records shall contain the date of service and description number.
- Documentation should be done in accordance to with the public Health Practice Reference (PHPR) documentation guidelines.