MOAS1201- Basic Records Management

archive
to remove a file from active status and store it in a secondary location or on a secondary medium.
Echart
electronic chart
EHR
Electronic health record; an accumulation of essential information from an individual’s electronic medical records that is accessed electronically at different points of service for purposes of client care.
EMR
Electronic medical record; a legal health record in digital format. It contains the client’s health information collected by one or a group of providers in one location. It is a portion of an EHR.
Health information custodian
a person, persons,or organization who has the responsibility for safekeeping and controlling personal health information in connection with the powers and duties performed.
First step in the life cycle of a record
Creation. A record originates when a client registers for health services from a specific provider. Specific data required for the creation of a record includes: name, address, telephone number, date of birth, health insurance number, next of kin, insurance information and employer information.
Second step in the life cycle of a record
Maintenance. includes organization of records through some sort of filing system so that they are easily accessible.
Third step in the life cycle of a record.
Provision. Protection of privacy of the record. This includes making sure that access to the record is limited to a need-to-know basis (client’s circle of care) and preventing unlawful access.
Lock Box
refers to a segment(s) of information within a client chart that the client has specifically asked the doctor to keep confidential- between client and physician. If the physician feel that this information should be revealed to assist in care, the physician must obtain consent from the client before doing so.
Fourth step in the life cycle of a record.
Disposition. keeping the client’s health record active, as long as the client is alive and has the potential to seek treatment.
Purging
periodically going through patient records and getting rid of duplicate and irrelevant information, often to save space and time.
Examples of filing systems
alphabetical, numeric, consecutive numeric, terminal digit, color coding
Centralized Storage
designation to one location in which to house all records
Decentralized storage
allowing parts of the patient record to reside in areas outside Health Information Services.