Medical Records Management



Download 0.9 Mb.
Page7/11
Date conversion05.12.2016
Size0.9 Mb.
1   2   3   4   5   6   7   8   9   10   11

PROCEDURES FOR IMPLEMENTING THE RECORDS RETENTION AND DISPOSAL SCHEDULE FOR

MEDICAL RECORDS



Retention Time Period for Medical Records


If the patient was less than 18 years of age on his/her last date of service, the record must be kept until he/she reaches age 18 plus 5 years, or 10 years whichever is the longer time period.*
If the patient was 18 years of age or older on his/her last date of service, the record must be kept for 10 years from the last date of service. *

* For all patients (without regard to age), the immunizations (other than influenza), positive Purified Protein Derivative (PPD)s and any patient record with documentation of Tuberculosis (TB) infection or disease treatment must be kept permanently.

Note: If information on completed/ recommended treatment regimen, allergies, and sensitivities, regarding TB, is extracted and entered on the permanent immunization/master record, the record may be destroyed when it reaches the assigned retention period.

Master Patient Index


The Master Patient Index is the locator system for the medical records and is to be kept permanently. It shall be all-inclusive to contain the name and location of all active, inactive and destroyed patient records. When the record is removed from the active file, a notation on the index shall indicate where the record is and if the record is reactivated, a notation is to be made. If the record meets the retention period and is destroyed, a note is to be included to indicate the record was destroyed and the date of destruction.

Procedures for Archiving


Following are procedures to use in archiving medical records in accordance with the December, 2001 Records Retention Schedule:

The medical records retention schedule is based on three factors:

(1) The last date of service; (2) patient’s age (minor – less than 18 years of age and adult – 18 years of age and older); and (3) type of service the patient has received, i.e., Immunizations and positive tuberculosis (TB) test and TB infection or disease treatment.

The record retention criteria necessitate the date of birth being included on the label of the folder.



  • When the patient has not received a service within the past five years, the record is considered inactive and may be removed from the active files.

  • In establishing the inactive files, consider the following:

  1. Minor patient records;

  2. Adult patient records; and

  3. Permanent records.

Location of Inactive/Archived Records


Local health departments are responsible for the storage of inactive/archived records. The records must be stored in an orderly, accessible manner and in a secure location. The State Archives Center may not be used for storing local health department records.

Inactive/ Archived Records and/or Reports may be retained in electronic formats to provide a better source of storage to local health departments. The access should be easy, fast, and readily available when needed. The inactive/archived records and/or reports should be maintained according to the records retention schedule and properly disposed of once the retention period has ended.


Destruction of Medical Records


If the medical record has met the required retention period, it should be destroyed. To destroy the record, it must be burned or shredded. A Records Destruction Certificate (Form PRD-50) is to be completed and mailed to the Department for Libraries and Archives, 300 Coffee Tree Road, Frankfort, Kentucky 40602. The PRD-50 forms may be obtained from the Department for Public Health Record Officer, Administration and Financial Management Division, phone number 502-564-7213. A copy of the Destruction Certificate is to be permanently maintained at the local health department.
LOCAL HEALTH DEPARTMENT RECORDS RETENTION SCHEDULE

See the link below for the most up-to-date KDLA Local Health Records Retention Schedule.


http://kdla.ky.gov/records/recretentionschedules/Documents/Local%20Records%20Schedules/LocalHealthDepartmentRecordsRetentionSchedule.pdf

GUIDELINES FOR LHD MEDICATION PLANS


I. Every Local Health Department should have in place a medication plan, in accordance with KRS 212.275 that:

  • Is developed in consultation with the Local Board of Health pharmacist or designee;

  • Is approved by the Local Board of Health;

  • Includes purchasing, storage, inventory, dispensing, and reporting of medication errors; and

  • Is consistent with the Department for Public Health, Board of Pharmacy and other relevant laws and guidelines.

  • Only additional in-house medications that are specific to the Local Health Department must be included in their Medication Policy. Medications listed throughout the CCSG need only be referenced in their local policy as “all medications listed in the CCSG.”

II. CHFS legal counsel has advised that LHDs prescribing drugs not in the CCSG assume responsibility specific to the service being provided and do so under local authority and individual licensees (physicians, nurse practitioners, etc.) without the specific endorsement by or liability to CHFS or DPH. The LHD also assumes responsibility for conforming to pharmacy and other relevant statutes.


III. Definitions and additional guidelines for nurses regarding medication prescribing, dispensing, delivering, and administering*:
A. Prescription means an authorization to obtain a prescription drug.

    1. This authorization can be given to a pharmacist via piece of paper or telephone call.

    2. An MD, PA, or an APRN (within their scope of licensed practice and collaborative agreements) may authorize a prescription.




      1. Dispense means to give a patient a drug to consume or use later.

      1. The drug must be packaged, labeled and recorded according to the Pharmacy Law.

      2. Dispensing is legal for RNs and APRNs only in LHDs following the CCSG and the DPH approved drug lists.

      3. Dispensing of sample drugs within their scope of practice is legal only for APRNs.

C. Administer means to put a drug into a patient’s body.



          1. This can occur by giving an injection, oral medication, applying a cream or ointment, or use of an inhaler.

2. Administration of a single dose is legal for LPNs, RNs, and APRNs upon the authorization of an MD or APRN.
D. Deliver means hand over a previously dispensed drug.

  1. LPNs and unlicensed personnel may deliver meds that have been properly dispensed.

        1. It is recommended that this be done in the LHD under the delegated authority of an APRN or RN.

        2. For DOT guidelines, see TB section in the CCSG.

* 1. Also included are other brands or generic forms of medications containing identical amounts of the same active drug ingredient in the same dosage form (this needs to be considered).

2. Dosages may be adjusted based on weight and age.

3. For DOT Guidelines, see TB section in the CCSG.

4. Before crushing or giving any medicaton mixed with food, check with the prescribing clinician for instructions.

MEDICAL ABBREVIATIONS


At present, the only approved medical abbreviations that are acceptable for LHD documentation are in this sectionand Marilyn Fuller Delong’s Medical Acronyms, Eponyms & Abbreviations, 3rd Edition or later. The following list has been compiled from sources that are nationally acceptable and are taken from documents that are published by such agencies as the Centers for Disease Control and Prevention, medical references, the MERCK Manual, and medical dictionaries such as Dorland’s Medical Dictionary. Each LHD should keep a log of non-medical abbreviations that are used in their agency, such as MCHS – Madison County High School, Tues. – Tuesday, CBH – Central Baptist Hospital, etc.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Symbols


2 times a day

BID

3 times a day

t.i.d.

4 times a day

QID

1st heart sound

S1

2nd heart sound

S2

3rd heart sound

S3

4th heart sound

S4

Ask, Advise, Assess, Assist, Arrange

5 A’s

A


a drop

gt

abdomen, abdominal

Abd

Abdominal pain, Chest pain, Headaches, Eye problems, Severe leg pain

ACHES

abnormal

Abn, ABNL

abortion

ab, AB

absent without leave

AWOL

absent, absence

abs

absolute bed rest

ABR

acceleration

accel

acceptable daily intake

ADI

according

acc

accumulation

accum

Acetylsalicylic acid (aspirin)

ASA

Acid Fast Bacilli

AFB

Acidophilus and Bifidum

A&B

Acquired Immunodeficiency Syndrome

AIDS

Acromioclavicular

AC

activated clotting time

ACT

activities of daily living

ADL

activity

act

Acute Lymphoblastic Leukemia

ALL

Acute Myeloid Leukemia

AML

Acute Otitis Media

AOM

Acute Respiratory Disease

ARD

Acute Respiratory Distress Syndrome

ARDS

adequate

adeq

to be administered

adhib

administered, administrator, admission

adm

Adrenocorticotropic hormone

ACTH

Adult Treatment Panel III

ATP III

Advanced Beneficiary Notice

ABN

Advanced Life Support

ALS

Advanced Practice Registered Nurse

APRN

advised

adv

Advisory Committee on Immunization Practices

ACIP

Advisory Opinion Statement

AOS

after (post)

post, p

after meals (post cibos)

pc

after surgery

Post-op

agglutinate, agglutination

agg, aggl

AIDS-Related Complex

ARC

Alanine Aminotransferase

ALT

alcohol

alc

alcohol like substance on breath

ALSOB

alcohol on breath

AOB

alcohol, tobacco, and other drugs

ATOD

Alcoholics Anonymous

AA

alert and oriented

A/O

alert and oriented to time, person, place, and date

A+Ox4

alive and well

A&W

Alpha-Fetoprotein

AFP

alternate

alt

Ampoule

amp

Amyotrophic Lateral Sclerosis

ALS

anatomy

anat

anatomy and physiology

A&P

annual family planning

AFP, ANF

anterior

ant

antibiotics

abx

antibody

Ab

Antibody to Hepatitis A Virus

anti-HAV

Antibody to Hepatitis B Core Antigen

anti-HBc

Antibody to Hepatitis B Surface Antigen

anti-HBs

Anticipatory Guidance

AG

Anticubital

AC

antigen, silver

Ag

Anti-Rabies Serum

ARS

apparent

appar

application, applied

appl

appropriate for gestational age

AGA

aqua – water

aq, aqu

Area Agency on Aging and Independent Living

AAAIL

Argininemia

ARG

arteriosclerosis

AS

artery

art

artificial

artif

as directed (modo praescripto)

emp, mp

as much as desired

qp, qv, qu

as needed (pro re nata)

prn

as soon as possible

ASAP

as tolerated

as tol

ascorbic acid

Vitamin C

Ask-Advise plus Refer

2A’s + R

Aspartate Aminotransferase

AST

aspirin

ASA

aspirin/caffeine

APC

asymptomatic

asx

at bedtime

hd, hs

Atherosclerotic Cardiovascular Disease

ACVD

Atrial Septal Defect

ASD

Atrioventricular

AV

atrophy

atr

Attention Deficit Disorder

ADD

Atypical Glandular Cells of Undetermined Significance

AGC

Atypical Squamous Cells – Cannot Exclude High-Grade Lesion

ASC-H

Atypical Squamous Cells of Undetermined Significance

ASC-US

auditory

AUD

auscultation

ausc, auscul

Auscultation and Palpation

A&P

auxillary

aux

axillary

Ax, ax

B


baby teeth

A-T

Bacille Calmette-Guerin Vaccine

BCG

back up method

BUM

backache

B/A

bacterial

bact

Bacterial Vaginosis

BV

bag of waters

BOW

balance

bal

barbiturates

barbs

barium

Ba

Bartholins, Urethral & Skenes gland

BUS

basal body temperature

BBT

basal cell cancer

BCC

basal energy expenditure

BEE

basal metabolic rate

BMR

battered child syndrome

BCS

battered woman syndrome

BWS

because of

B/O

bed rest

BR

before

ā

before dinner

ap

before meals

a.c.

before surgery

Pre-op

begin, began, beginning

beg

benign prostatic hypertrophy

BPH

between

bet

Bicarbonate

Bicarb, HCO3

Bi-chloroacetic acid

BCA

bilateral

bilat

bilateral breath sounds

BBS

Bilateral Otitis Media

BOM

Bilateral Salpingo-Oophorectomy

BSO

Bilateral Serous Otitis Media

BSOM

biopsy

Bx, bx

Biotinidase Deficiency

BIOT

birth control

BC

birth control clinic

BCC

birth control pills

BCP

birthmark

BMK

black box warning

BBW

blood

Bl, bld

blood alcohol

BA

blood alcohol level

BAL

Blood Assay for Mycobacterium Tuberculosis

BAMT

blood brain barrier

BBB

blood glucose

BG

blood lead level

BLL

blood pressure

BP

blood sugar

BS

blood sugar level

BSL

blood urea nitrogen

BUN

Blood volume

Q

body mass index

BMI

body surface area

BSA

body weight

BW

bone

os

bone mineral density

BMD

born

b

both ears, each ear

AU

bottle

bot

bowel movement

BM

bowel sounds normal

BSN

breakthrough bleeding

BB, BTB

Breast and Cervical Cancer Treatment Program

BCCTP

Breast Imaging Reporting and Data System

BI-RADSTM

breast self exam

BSE

Breastfeeding Woman

BF

breath

br

breath sounds bilateral

BSB

bright red blood

BRB

brought in by

BIB

buccal

B

By mouth (per os)

po

C


“cut down”, “annoyed”, “guilty”, and “eye-opener”

CAGE

calcium

Ca

calorie

cal

cancelled

canc

cancer, carcinoma

Ca, CA

Cancer Screening Education Materials

CSEM

capillary

cap

Capillary Blood Lead Level

CBLL

capsule

cap

carbohydrate

CH20, CHO, COH
1   2   3   4   5   6   7   8   9   10   11


The database is protected by copyright ©dentisty.org 2016
send message

    Main page