Records Controls HCR 210 April 21, 2013 Records Controls Small, medium, and large facilities take many security measures to protect their business and clients. In an effort to keep patient records safe there are secure file rooms, password protected computers, doors that require access codes or key cards, among other things. If records were not secured, medical facilities would run the risk of confidential material getting into the wrong hands. There are differences and similarities in the way each size facility handles medical records. The handling of medical records includes security measures, tracking, and circulation.
All size facilities use similar security measures when using an electronic filing system. Most facilities use passwords and access codes to access the information. Passwords and access codes are only given to certain staff members, not the entire staff. Limiting the number of people with access to records can cut down on the possibility of the information falling into the wrong hands. In the case of some small facilities, only one person has the access code/password to the system. Many small facilities still prefer to use paper records, which can be positive or negative.
Small facilities usually only have two or three physicians to see all the patients. This allows each physician to work on a smaller scale and makes record keeping easier. Patient records are typically kept in one location and any new information is kept in a separate area until it can be anchored within the patient record. Most medium-sized facilities have made the move to electronic records. New records are often kept in secured locations until they can be scanned into the computer system. Records can be accessed via password protected computers.
Large facilities have made the same move as medium-sized facilities. All electronic records are kept in secured areas with limited access and loose information is kept secured until it is scanned into the computer. Tracking patient records can be a major task for any sized facility. It is imperative that the information within each patient record is current with the latest test results, new ailments, and physician observations. In facilities where paper records are a thing of the past, the staff uses a variety of record tracking software to capture and store the initial paperwork.
Tracking software maintains and updates contact information for the patients and their physicians; individual patient records can contain links to images from the radiology lab and other tests, making it easier to access. Facilities using paper filing systems must do all this by hand. Organizing circulation within any facility is important to keep track of who has each record. Facilities using paper systems often rely on routing slips or a sign-out sheet to note the name of the person taking the record, where it is going, and the time and date the record is moved.
It is much easier using electronic systems in this aspect. When a staff member logs into the computer system, it makes a notation of the user, time, and date. Taking note of who has the record is, again, important to keep it within the facility and out of the hands of people who could use the information for identity theft and fraud. The main reason for the differences between the facilities is simple: volume. Each size facility is only capable of handling a certain patient load. Smaller facilities are able to keep paper records because they only handle a few patients when compared with medium and large facilities.
Handling paper records can be more time consuming, but is easier for smaller facilities that use an alphabetical or numeric system to organize files. Medium and large facilities may use a combination of paper and electronic records. Keeping electronic records is easier for medium and large facilities simply because of the number of patient records that are handled on a daily basis. Medium and large facilities can handle hundreds of patient records a day and they require a more efficient way to track, handle, and secure records.
Each facility has its own way to record and store information. Procedures are put in place to protect the patient and the integrity of the facility itself. Each facility has a legal obligation to the patients they see. When the staff at any size facility fails to follow the set procedures it can cause havoc within the facility: patient records could be lost, accidentally destroyed, or stolen. Lost and stolen records could put patient information at risk and force the facility to recreate the record(s) or face the possibility of legal action from the patient.
If there is no backup in place some records could be lost forever, meaning that years of carefully compiled information is lost. As you can see, there are many differences and similarities in how different sized facilities handles records, including security, tracking, and circulation. It is important that each size facility has procedures in place to monitor patient records at all time because it could create complications for the facility and the patients served by the facility.