Medical Records Management



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Medical Records Management



Table of Contents



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Guidelines of Medical Records

Content 1

Filing and Maintenance of Medical Records 1

Ownership of Records 3

Releasing Patient Information 3

Transferring the Medical Record Within County School Sites 4

HIPAA and “Family Education Rights and Privacy Act”(FERPA) 4

Forms and Documentation

Local Health Department Responsibilities 6

Legal Documentation Standards 6

Language Accessible Services/Use of Interpreters 16

Guidelines for Documentation When Using an Interpreter 17

SOAP Documentation 18

Authorization for Use and Disclosure of Patient Health Information

Authorization to Release Information (Who May Sign) 24

Exceptions to the Use of Written Release 24

Other Considerations 24

Coroner’s Cases 25

Additional Resources 26

HIPAA Final Omnibus Rule 27

Subpoenas and Court Orders

Types of Subpoenas 31

Court Order 32

Power to Issue 32

Responding to a Subpoena 32

Responsibility of Recipient 33

Contempt of Court 33

Deposition 33

Guidelines for Security of Subpoenaed Records 34

Appearance in Court 34

Procedure for Mailing Records to Court 35

Original Record to be Left in Court 36

Microfilmed Records in Court 36

Interrogatories 36

Waiver of Privilege 37

Procedures for Implementing the Records Retention & Disposal Schedule

Retention Time Period for Medical Records 38

Master Patient Index 38

Procedures for Archiving 38

Location of Inactive/Archived Records 39

Destruction of Medical Records 39
KDLA Local Health Department Records Retention Schedule Website 39
Guidelines for LHD Medication Plans 40
Medical Abbreviations 42

Symbols 72


MEDICAL RECORDS MANAGEMENT

Medical records shall be maintained in accordance with the following guidelines:



Content


  1. The medical record shall contain sufficient information to identify and assess the patient and furnish evidence on the course of the patient’s health/medical care.

  2. The record shall include accurate and legible documentation of any local health department activity involving or affecting the patient’s health to include but not be limited to assessment, tests, results, and treatment. Red or fluorescent allergy stickers may be displayed on the front of a medical record to alert the health care provider of a potential emergency that can interfere with a patient’s medical care or treatment. Allergies may also be written in red within a medical record.

  3. All medical records must be maintained in a standard format with entries and forms filed in chronological order with the most recent on top.

  4. Each form/document filed within the record shall include the patient’s name, identification number and clinic identifier. (The computer generated 1 or 2 label may be used.)

  5. Each entry in the record shall contain the date of service, description of service, provider’s signature and title.

NOTE: A service providers’ legend must be maintained which contains the signature, title of provider, provider’s initials and employee ID number. It is to be retained permanently and kept current of new certifications or license privileges. (See “Scope of Practice” in Administrative Reference (AR) Volume I, Personnel Section for instructions on updating license/certification of personnel.)


Filing and Maintenance of Medical Records


  1. Each patient receiving personal health services shall have a record initiated.

(Exception: anonymous HIV test/counseling patient.)

  1. The medical record shall be maintained in the health department (service delivery site) where services are delivered.

3. Medical records may be filed in alphabetical or numerical order.

4. A Master Patient Index shall be maintained permanently as a locator system for the records at each health center where the service was initiated/provided.

5. The Master Patient Index must be in alphabetical order by patient’s last name.

6. The patient index shall include the complete patient name, patient identification number, date of birth, gender, race, file number (if numeric system is used), father’s full name, mother’s full maiden name or legal guardian (if such information is necessary for identification of the patient), and location of record––if it is not in the active file.

7. All documentation regarding the patient (including the CH-2 Immunization/Master Record with documentation) shall be filed in one record (unit record) with the exception of patients of the licensed home health agencies and if the local health department (LHD) elects to maintain Health Access Nurturing Development Services (HANDS) records separately.

8. HANDS records may be maintained separately but LHDs are encouraged to integrate these records with the unit record.

9. Documentation of immunizations must be made on the CH-2 (cardstock weight paper) Immunization Record/Master Record.

10. Records for recipients of mass flu immunization clinics when only an influenza administration record is initiated and maintained are not required to be part of the index. They should be filed by year in alphabetical order by patient’s last name placed in a file drawer where they are secure and can be easily accessed.

11. Records for the KIDS Smile Program shall be kept as follows:


    1. If a child does not have a complete medical record and receives the dental varnish in the health department, the personal record for KIDS Smile shall be retained by the LHD in a folder marked KIDS Smile, 2004-2005 in alphabetical order, by patient name. These forms should be kept for fiscal year and not calendar year. For offsite Fluoride Varnish screenings and applications (schools, etc.), place the personal record for KIDS Smile and any related forms in a folder with the date (i.e. KIDS Smile 2004-2005) and keep in alphabetical order by the name of preschool/school or offsite location where the fluoride varnish was applied. Do not file these forms/records for offsite Fluoride Varnish screenings and application with the Patient Encounter Form (PEF) forms.

    2. When services are provided in the clinic, the personal record (screening, application of fluoride varnish, providing a preventive health message and referral to a dentist if necessary) shall be retained in the child’s medical record if such a record exists.

12. When the medical record is pulled from the active file for serving the patient or when working with the record, an “out guide” is to be used in the place of the record. The “out guide” identifies the location of the record and stays in the file until the folder/chart is filed back.

13. Medical records are to be returned to the centralized record section upon completion of services and/or before the facility is closed on evenings, weekends, or holidays.

14. Medical records shall be filed in a secure location that is locked during non-clinic hours to safeguard against loss, tampering, or use by unauthorized personnel. Care shall be given to assure that the area containing medical records is secured during clinic hours from patient or visitor access and that records are sufficiently distant from patient or visitor accessible areas to prevent viewing names or medical information. (For guidelines, see “Privacy and Security of Protected Health, Confidential and Sensitive Information Guidelines” in AR Volume I, Personnel Section.)

15. Medical records shall be retained in accordance with the Local Health Department Record Retention and Disposal Schedule.



Ownership of Records


1. The medical record is the property of the local health department. Records shall not be taken from the facility except by court order. This does not preclude the routing of copies of the patient’s records or portions thereof, including X-ray film, to physicians for consultation; or in those instances where delivery of services calls for it e.g., Home Health.

2. When the LHD provides services off-site, such as in a private physician’s office, clinic, or schools the documentation/record of these services is property of the LHD and shall be maintained separately/apart from the medical record of the contracted agency/physician(s).



Releasing Patient Information


  1. All medical records shall be regarded as confidential.




  1. Medical record information may be released only with the consent of the patient, parent or legal guardian of the patient, or as directed by law.

3. Immunization information may be shared, without authorization from the patient or the patient’s parent or guardian, if the patient is a minor, if the person or agency requesting the information provides health related or education services on behalf of the patient or has a public health interest or is an institution which requires evidence of immunizations pursuant to state law. Some of those entities that may report and exchange information under this exemption are: LHDs within and outside the state, childcare facilities, pre-schools, public and private schools and other providers outside of the LHD who are providing health care to the patients simultaneously or subsequently. See Administrative Regulation 902 KAR 2:055 for a complete list of entities that may report and exchange immunization information.


4. Patient information regarding Sexually Transmitted Diseases (STD), the HANDS program, mental health and drug and alcohol abuse shall be considered privileged information (protected health, confidential, personal or other sensitive information) and must be specifically authorized in the written release signed by the patient or legal guardian prior to the release of these records, unless other applicable laws apply.
5. Policies and procedures regarding releases of information shall be established and a designated custodian and a designee appointed to handle day-to-day occurrences.
6. The policies regarding the release of medical records shall be posted, according to the “Open Records” laws, in a conspicuous place for the public to see. Information regarding “Open Records” laws provided by the Kentucky Attorney General’s can be found on a document at the following link: http://ag.ky.gov/civil/orom/Documents/orom_outline.pdf
7. All matters relating to releasing information shall be referred to the designated custodian.
8. The policies shall address each type of information the custodian can release and the conditions under which the information shall be released.
9. In accordance with Kentucky Law, a patient who receives service from a local health department may have access to his/her medical record upon presentation of appropriate identification; however, the same law allows the health department up to three working days to decide if the request is appropriate.
10. Medical records shall be made available, when requested, for inspection by duly authorized representatives of the Kentucky Cabinet for Health and Family Services. Any refusal to honor an authorization for the release of information shall be documented and the reason stated.

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