Records Management Principles for Community HealthPresentation Transcript
Records Management for Staff and Clinicians Nicole Stanzer Area Health Information Manager Updated April 2011
What is a health care record
Storage and Retention
Access and Security
Use and Disclosure of Health Information
The Hybrid Record
What is a health care record?
A health care record is a documented account of a patient’s/client’s health evaluation, diagnosis, illness, treatment, care, progress and health outcome that provides a means of communication for all health care personnel during each visit or stay at a health service.
Maintaining good health records and practices will ensure:
a means of planning continuity of patient care,
a means of communication regarding episodes of illnesses for all health care professionals,
Availability of data for research, study and evaluation
Adhering to legislative requirements
All staff are responsible for:
Accessing only the health care records and electronic information of patients they are treating or require to access in the completion of their duties
Maintaining the security of health care records in their location
Ensuring health care records are always available for patient care
Ensuring patients’ confidentiality is maintained and kept
Ensuring health care records are not removed from the Health Service without approval
Ensuring that health care records are protected from un-authorised use and access
Ensuring that health records are not destroyed without authority
Responsibility and Accountability
Clinical staff are responsible for
Ensuring there is appropriate documentation in the health care record at each entry including date, time, printed name, signature and designation.
Being aware of the accepted Source of Truth for the sections of the record for which they are responsible
Ensuring health care records are always available for patient care and not locked in offices unable to be accessed by other staff or removed from the hospital grounds
Ensuring patients’ confidentiality is maintained and kept
Health Care personnel who provide a person with care, assessment, diagnosis, management and/or professional advice are responsible for legibly documenting and dating this activity in the person’s health care record.
Always make entries into clinical notes, charts etc as the event occurs or as soon as possible after the event.
What is good documentation?
Blue or black pen only
Print name, sign, date and designation
Accurate and specific
Things to remember
Never obliterate a mistake
Poor documentation can provide the foundation for a disciplinary complaint against a clinician and can lead to disciplinary action.
Please always use approved abbreviations.
Do not make an entry for anyone else, especially nursing procedures or care performed or provided by another nurse .
Record Covers and Forms
The name of the health care service should be incorporated on the record cover and any forms.
Each form must include the patient’s name, MRN (or identification number), DOB. The details may be represented by a label.
Exemptions to this standard exist for services such as sexual assault and child protection.
Every page must have patient identification
Record Covers and Forms
New State Record Cover for Community Health is available through ePOD (Salmat)
A total of 81 State Forms are currently available for ordering and MUST be used as per policy directive 2009_072 ‘State Health Forms’.
All community health forms must be approved and contain a barcode to ensure they can be scanned into the eMR.
Contact Forms Manager Patricia Van Ritten on 02 4320 3123 for further forms info
There should be only one record for a patient. This ensures there is a medical history available for the patient upon their next visit.
If a record goes missing a temporary record may be created. If the original file is found this temporary file cover is destroyed and all notes are integrated back into the original file.
It is your responsibility to conduct a thorough search of your premises for the original record before creating a temporary record.
If a duplicate record is created by mistake there must be a process established for their reconciliation and linkage. The physical file must be merged and the electronic record merged. Contact the Statewide Service Desk on 1800 XXX XXX and speak with the eMR team for assistance.
Currently the following health care records are stored separately to the general health care record:
Child Protection Services
PANOC (Physical Abuse and Neglect of Children)
Sexual Assault Services
Drug and Alcohol Services
Sexual Health Services
These records must be linked to the general health care record through the creation of a media type of “Confidential file” in the medical record tracking system
Satellite health care records should meet the same standards as the general health care record.
Health Specific Legislation
Governs public and private sectors
Applies to personal health information
Privacy- Health Records and Information Privacy Act 2002 (HRIPA)
Collection of personal health information
Use & Disclosure
Patient Access & Amendment
Breach of privacy laws by organisation: Payment of up to $40,000 to the injured party
Corrupt disclosure by individual: Fine of up to $11,000 and/or 2 years imprisonment
Personal health information must be collected for a lawful purpose
Information collected must be relevant , not excessive, accurate and not intrusive.
Collection must be directly from individual concerned, unless this is unreasonable or impracticable .
Use and Disclosure
The ‘ primary purpose’ of why the information was collected
When using personal health information, all reasonable steps must be taken to ensure that it is:
up to date
not misleading Reference : Privacy Manual, Section 10
Sending records by fax
locate fax machines in secure location
use speed dial if possible to ensure the correct fax number
include privacy notice on fax cover sheets (Privacy Manual, Appendix 4)
establish caller has legitimate grounds to access the information, eg. is known to be patient’s GP, is known to be patient’s relative, etc.
do not leave personal health information on voice mail. Only provide caller’s name and/ or name of health service, if appropriate.
Email security Generally secure within NSW Healthnet only
ensure accuracy of email address
only include personal health information necessary for the purpose
outside NSW Healthnet exercise caution
request that recipient sends first email
Where a person lacks capacity, an authorised representative can make decisions on their behalf
Authorised representatives are:
a power of attorney
a guardian, or ‘person responsible’ as defined in the Guardianship Act
if under 18, the authorised parent or guardian spouse, carer, or close relative Reference : Privacy Manual, Section 5.6
Patient Access and Amendment
Patients have a right to access their personal health information in the medical record
Patients have a right to obtain copies of their medical record
In certain circumstances the health record may be required for patient care. If this is the case the relevant section of the record should be sent as per the Privacy Manual.
Contact HIS for advice
Alicia Duffy, HIS Manager 9926 8585
Elizabeth Bush, Medico-legal Manager 9926 8584
Staff Accessing Records
There are strict rules around staff accessing a person’s health record.
Staff may only access a person’s health care record where this is directly related to their area of work and when access is essential to enable them to fulfil their duties.
Staff not involved in the provision of care to the patient/client or maintenance of the record, cannot access them
Availability of Records
Health Care records need to be available at the point of care. To ensure this occurs, health records should be stored in a secure but accessible central location and not kept in individual offices, locked cabinets or on desks.
Leaving records on your desk presents a possible access issue and fire hazard.
A marking out system (or tracking) must be instituted to ensure the location of the record is known at any time to facilitate access to the record.
No record should be moved from its home location without the following details being recorded either electronically or manually:
Health Care Record ID details (MRN or CRN) and Patient Name
Destination/Location of the record
Person responsible for/in possession of the record
Contact number so the record can be requested to be returned if needed
Date record was moved.
Where access to an electronic tracking system is available, receiving staff should update the location of the record on the system .
Removal of health care records from the Health Service
Generally, health care records must not be removed from the Health Service except under the direction of a subpoena, warrant, coronial summons or order of the Director General.
Health care records in the patient’s home
Part of the health care record may be left in the patient’s home for the purpose of ongoing patient care when being treated on a regular basis in the home, eg APAC & Community Nursing.
These records must be returned and linked to the main hospital or community health care record on discharge from the service.
Staff involved in the patient’s care in the home are responsible for ensuring the health care record is collected from the patient’s home within 1 week of discharge.
Record Retention and Disposal
Health care records are required to be stored for specified periods as determined by the State Records Act 1988.
Most health records have a minimum retention period of 7 years however records of a teaching hospital must be kept a minimum of 15 years and sexual assault/records of minors must be kept significantly longer.
Health care records must only be disposed of in a confidential manner using confidential locked bins or shredding/pulping. A register of what records have been destroyed must be kept.
The ‘Hybrid’ Record
When a record is stored in both paper and electronic form it is referred to as being in a hybrid state. NSLHN now has a hybrid record. Cerner eMR and the paper record are considered one record.
Source of Truth
When patient information is solely available in electronic format, the Source of Truth is the electronic system which holds that information.
When patient information is solely available in paper format, the Source of Truth is to be interpreted from the paper records alone.
When paper records are scanned, their imaged version is the Source of Truth and the paper is destroyed.
Printing should be kept to a minimum
In the event an electronic document is printed and a hand written clinical notation is added to this document, both the electronic document and the hand written notation must be kept.
Any electronic Source of Truth document which has been printed should be destroyed once the document is no longer required, unless there is a hand written clinical notation added to this document.
To ensure a complete record is maintained for each patient/client. All loose sheets created about a patient/client should be filed into the health care record as soon as practicable after presentation.
These sheets should be sent for scanning ASAP after the patient presentation.
Ensure documentation standards are adhered to (for those writing in the medical record)
To ensure records are available for patient care
Comply with Health Records and Information Privacy Act 2002
Ensure each page is identified and sent for scanning promptly
Ensure records are managed appropriately, stored correctly and kept secure.