Infographic taken from the paper titled, “Driving patient’s records management process on the healthcare service delivery using records life cycle as a tunnel towards quality patients care” by Prof Ngoako Solomon Marutha
Good medical record management is paramount to the success of a healthcare facility, as these records provide the foundation for continuity of care. Furthermore, a well managed record system allows for better risk mitigation, reduction in redundancy and promotes timely access to care.
According to the Medical Protection Society, medical records in South Africa are governed by three record management standards, namely:
ISO standard ISO/IEC 27002: 2005 — which contains information on security issues such as staff responsibilities and training, premises, business continuity, protocols and procedures, email and internet usage policies and remote access. This standard has been approved for use in South Africa as SANS 27002:2008.
ISO 27799: 2008 — Health Informatics: Information Security Management in Health — which contains all the relevant guidance in ISO/IEC 27002 as it relates to the healthcare sector.
Section 19 of the Protection of Personal Information Act 4 of 2013 — appropriate, reasonable technical and organizational steps to prevent loss, damage or the unauthorised destruction of personal information or the unlawful access to or processing of information.
Lets take a closer look at the lifecycle of Medical Record Management
Creation: At the core of the medical record lifecycle lies its creation. Data capturers, Medical clerks and Healthcare professionals gather essential information during initial encounters, laying the foundation for comprehensive patient records. In this crucial phase, capturing accurate and detailed data provides the framework to build out a patient’s health journey.
Use, Distribution, Maintainance: Effective records management is vital for the continuity of care and mitigating the risk of adverse incidents. The aim is to create a well-organised and accessible record system that is intuitive and not cumbersome. In addition, it should address challenges such as information quality, permissions and access, misinformation, and misfiling; with the establishment of a records management policy, including designated personnel responsible for regular policy review and adherence to legislative requirements.
Retention: Guidelines for record retention are provided by the Health Professions Council of South Africa (HPCSA), addressing the recommended retention periods for various types of records. Factors such as patient age, mental impairment, occupational illness or accidents, and slow-developing diseases are considered, along with the balance between cost, space, and potential usefulness in legal, academic, or research contexts.
Termination and Disposal: An efficient records management system includes proper arrangements for the disposal of both paper and electronic dormant records. Guidelines should be in place for identifying records due for disposal, signing disposal authorisations, and maintaining a register of destroyed records. Confidentiality agreements with outside contractors and certifications of destruction for patient-identifiable information should be in place.
Safeguarding and Security: Risk assessment measures are needed for protecting paper records from moisture, fire, and insects. Proper storage facilities, fire alarms, and regular inspections should be conducted. For electronic records, regular backups and off-site storage is encouraged, along with precautions against physical (fire and water) damage and cyberthreats when necessary.
In conclusion, the medical record lifecycle entails careful capturing, management, retention, and disposal of health information. By appreciating the significance of accurate records, adhering to retention guidelines, and implementing secure disposal practices, healthcare providers can ensure the continuity of care, protect patient privacy, and contribute to the overall quality of healthcare services
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