Department of Health and Human Services (HHS). The United States government has taken a special interest in ensuring this responsibility through the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as well as the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) which bolstered HIPAA’s rules with stronger civil and criminal enforcement. For individuals to entrust healthcare professionals with this information, these records must be handled with the utmost care. They are also deeply personal stores of information that may include patients’ names, birth dates, private medical conditions, and payment information. In this way, better medical records management leads to better outcomes.īut medical records are not simply resources to be used in the facilitation of better healthcare. Physicians can only provide the best possible care for patients when they have access to all the information they need about their current condition and other pertinent considerations such as family history. The foremost benefit of effective handling of medical records is self-evident. While this mainly referred to the handling of paper documents in decades past, the explosive growth of electronic health records now means nearly 4 in 5 office-based physicians and more than 9 in 10 non-federal acute care hospitals now use digital medical records management systems.
It includes the storage of key information such as patient encounter documentation and physician notes as well as periphery documentation such as personally identifiable payment statements. Medical records management is the process, structure, and discipline of recording, storing, retrieving, and eventually disposing of documentation related to the health of patients. This guide will walk you through the essentials you need to know to begin working toward more effective and safe medical records management, including an introduction to special concerns related to HIPAA and potentially helpful electronic medical records management software. Setting up the proper management of medical records for your healthcare business will depend on your particular role in the healthcare system, how many people you serve, and where you’re physically located. Keeping all this information on hand in a way that is both helpful and legally compliant often requires a carefully crafted medical records management system. That goes for specialized knowledge acquired across years of training, of course, but also the specific knowledge of patients’ medical histories, current status, and the symptoms of any ailments those patients may be suffering from. Knowledge is an essential resource for healthcare professionals.
Learn the elements of effective and compliant management of medical records
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