Archive and Destruction of Patient Records

Transcription

1 Archive and Destructin f Patient Recrds If yu have run ut f rm t stre paper recrds yu may need t archive the riginal dcuments. A cmprehensive archive prcess, with written plicies and prcedures will help yu meet yur prfessinal standards and legislative requirements. A physician wh clses a medical practice is respnsible fr the secure strage and dispsitin f the patient recrds frm that medical practice. This applies if the physician manages the strage f the recrds himself and when he cntracts with anther physician r service prvider. Yu may have inactive patient recrds patients may have deceased, left yur practice, r simply have nt returned t the practice fr a length f time. The Health Infrmatin Act makes infrmatin security prvisins requiring custdians t prtect individually identifying health infrmatin in their custdy r cntrl by making reasnable security arrangements t prtect against unauthrized access, cllectin, use, disclsure, r destructin. These same prcedures apply t ther types f imprtant recrds in yur practice emplyee, accunting, business cntracts, fr example that requires secure safeguards. Whatever the reasn that yu have decided that yu need t archive yur recrds, the fllwing are key pints fr yur cnsideratin. Inventry: Whether yu plan t mve, archive, r transfer the patient files t anther custdian, yu need t knw what patient recrds yu currently have. Prepare an inventry r listing f all patient recrds that yu have initiated during yur practice. This can ften be generated frm existing data surces like yur billing r EMR system s central patient index. The inventry shuld include, at minimum, the fllwing infrmatin: Patient s first and last name Date f birth First and last visit date Primary physician s name See the sample prcedure Archive and Destructin f Patient Recrds and its frms t help yu recrd yur inventry. Recrds Retentin: Determine which, if any, recrds have met the minimum recrds retentin plicy and which culd be securely destryed. The Alberta Cllege f Physicians and Surgens Retentin Schedule states that chart destructin may ccur 10 years after the end f the year in which the INFORMATION MANAGERS LTD., Edmntn, AB, Website: Infrmatinmanagers.ca; inf@infrmatinmanagers.ca Page 1 f 6

2 last visit was recrded and at the end f the 20th year fllwing birth fr recrds f minrs wh are n lnger patients whichever cmes later. (CPSA Standard 21, sectin 9). Nte: smetimes it seems that it is easier t keep recrds frever rather than destry them after the retentin perids and legislative requirements are met. Hwever, remember that yu may be required t prduce r prvide access t recrds fr as lng yu cntinue t have custdy f recrds. Destructin: Ensure that yu have recrded which recrds have been destryed, the methd f destructin, and the date and signature f the persn respnsible fr the destructin. See the disclsure lg frm in the sample prcedure Archive and Destructin f Patient Recrds. Infrmatin Manager: If a physician clsing his/her medical practice is unable t prvide nging management f patient medical recrds, either persnally r thrugh a clleague, they shuld be put int cmmercial strage fr custdy, transfer as necessary, and destructin when that is apprpriate. The abve steps t create an inventry f patient recrds apply here, t. When a dctr leaves a grup practice, there shuld be a satisfactry arrangement made fr transfer f apprpriate recrds; the patients shuld nt be left with the respnsibility f btaining them. If yu utsurce the wrk f archiving yur recrds, the vendr will likely be cnsidered an infrmatin manager (as defined by Health Infrmatin Act) r a business assciate in ther legislatin. An Infrmatin Management Agreement (IMA) is a legislative requirement f the Health Infrmatin Act. Sectin 66(2) requires that the agreement be in writing; sectin 7.2 f the Health Infrmatin Regulatin specifies the details f the agreement. Patient Access: The infrmatin in a medical recrd belngs t and must be prvided t the patient when it is requested. In the event f clsing a medical practice yu can anticipate that there will be many requests t access recrds. Review (and revise if necessary) yur written plicies and prcedures t ensure that yu have an efficient prcess that accurately dcuments the request. The custdian has the right t charge a fee fr access requests as defined by Health Infrmatin Act s 67 and Health Infrmatin Regulatin, s 9, 10, 11, and 12. The basic fee f $25 may be applied (r waived by the custdian). Additinal fees may be charged fr prducing a cpy f a recrd. See Health Infrmatin Regulatin Schedule. (fr example, phtcpies $0.25 per page after the first 25 pages, prducing a recrd frm an electrnic recrd $10 per ¼ hur) INFORMATION MANAGERS LTD., Edmntn, AB, Website: Infrmatinmanagers.ca; inf@infrmatinmanagers.ca Page 2 f 6

3 Reminders: 1. This archive and destructin lg is maintained permanently by the Clinic Manager n behalf f the custdian(s). 2. Archive and destructin can be dne at tw separate stages. Yu may archive (r thin ut) paper recrds fr a transitin perid and recrd the archived recrds in the lg. When the recrds meet retentin perids (and the practice makes apprpriate decisins) the archive lg can be used again as destructin lg. 3. Prir t implementing, ensure that yu have reviewed and dcumented yur recrds retentin requirements with related prfessinal clleges and legislatin. This dcument management tip is intended t help yu alng yur jurney by guiding yu thrugh a series f questins and prviding resurces t get started. It is expected that yu will review and refine these dcuments t meet yur needs. Related Infrmatin Managers Ltd resurces: Dcument Management Tip: Scan and Shred Quality Assurance r - Quality Assurance Dcument Imaging (Scan) t EMR Dcument Management Tip: Clsing (r Mving) a Physician Practice Practice Management Nugget Webinar: Archive and Shred Oh My! Resurces and References: Alberta Health and Wellness. Health Infrmatin Guidelines and Practices Manual, Cllege f Physicians and Surgens f Alberta. CPSA Standards f Practice, Standard 20, Standard 21, 22, January 1, Retrieved May ce_cnslidated_versin.pdf Fluke, Nigel. Tips When Preparing t Clse a Practice. Physician Achievement Review (PAR), Retrieved May 2012 frm Infrmatin Managers. Data Sharing Agreement Outline fr Physician Grup Practices - Fr Discussin, Archive and Destructin Lg, Office f the Infrmatin and Privacy Cmmissiner. OIPC Order H Retrieved May Rzvsky, Lrne E. Canadian Healthcare Frms & Plicies, LexisNexis Octber INFORMATION MANAGERS LTD., Edmntn, AB, Website: Infrmatinmanagers.ca; inf@infrmatinmanagers.ca Page 3 f 6

4 Cntact Us: Jean L. Eatn, B Admin, CHIM INFORMATION MANAGERS LTD. Cell: Fax: jean@infrmatinmanagers.ca Infrmatin Managers prvides a wrkshp series n Privacy, Cnfidentiality, and Security fr Medical Offices fr clinics by webinar, public wrkshps and custmized n-site wrkshps t private practices. Infrmatin Managers It's the elephant in the rm: yur practice depends n yur recrd management, and the privacy and prtectin f all kinds f cnfidential infrmatin. But smetimes taking care f this elephant can be a challenge. We're here t help. Infrmatin Managers specializes in health infrmatin management, plicies & prcedures, recrds management, clinic management practice efficiency and wrkflw cnsultatin as well as privacy and security in the Health Care sectr. We give yu the cnfidence t take care f the elephant in the rm. This publicatin prvides general guidance fr a medical ffice in Alberta. Cnsultatin with yur infrmatin systems, health recrds, and privacy ffice is recmmended. Fr additinal assistance, cntact Infrmatin Managers Ltd. INFORMATION MANAGERS LTD., Edmntn, AB, Website: Infrmatinmanagers.ca; inf@infrmatinmanagers.ca Page 4 f 6

5 Prcedure # : Archive and Destructin f Patient Recrds Start Date: Revisin Date : Apprved By: Date: Purpse: Scpe: Prerequisites: Materials Needed: Recrd patient recrds which have been purged and destryed All riginal patient recrds Must meet retentin requirements Outdated, inactive patient recrds Perfrmed by: 1. Identify patient recrds that are eligible t be purged and destryed. a. Retentin Schedule: The Alberta Cllege f Physicians and Surgens Retentin Schedule states that chart destructin may ccur 10 years after the end f the year in which the last visit was recrded and at the end f the 20th year fllwing birth fr recrds f minrs wh are n lnger patients whichever cmes later. (CPSA Standard 21, sectin 9)If purging recrds in 2014, i. Last visit must be 2004 r earlier and ii. Patient s date f birth must be 1994 r earlier If recrds have patient demgraphic sheet at the frnt f the chart, 2. Review patient recrd t ensure that each page in the recrd belngs t the same patient. 3. Ensure patient demgraphic sheet has (at minimum) the fllwing: a. First and last name (circle in felt marker) b. Date f birth (circle in felt marker) 4. Remve patient demgraphic sheet 5. In additin, recrd (in felt marker at bttm f page): a. The first and last visit date b. The primary physician c. Date purged, initials f staff, and hw recrd was destryed (this culd be pre-printed n cmputer generated labels fr cnsistency and efficiency) 6. Maintain patient demgraphic sheets, in alphabetical rder by last name, in binder (lcatin details) 7. Lk up patients and append a nte in the central patient index and add date f destructin. a. Cnsider if patient was nt previusly in central patient index, shuld it be entered at this time? b. If recrds d nt have patient demgraphic sheet at the frnt f the chart, recrd the patient infrmatin in a separate dcument (sample attached). T make retrieval f infrmatin easier, this culd be entered int an excel spreadsheet.

6 Archive and Destructin f Patient Recrds Lg Last Name First Name Other Name Date f Birth (spell mnth) First visit date Last visit date Primary physician Date purged Initials f Staff Hw destryed Retentin Perid: Permanent CLINIC NAME Page