If you need to move paper records that contain protected health information, use procedures that minimize incidental disclosure. Never leave them lying around and always use caution when handling such documents.

A patient has the right to access his or her medical record. However, a physician can refuse to make the record available in certain situations.

Definition

Medical records are the personal and confidential documents of a patient. They are used to manage the patient’s health care, and they should not be given to third parties without the consent of the patient. Nevertheless, there are certain exceptions to this rule that allow the hospital to give information about the patient to another entity.

Clinic Record / Shadow File: Documentation that is not part of the Legal Medical Record but still contains important patient information. Examples include protocols/clinical pathways, best practice alerts and test results.

Correcting Errors in the Medical Record: All documentation must have a method for tracking corrections to ensure that the original entry is viewable and that the person making the change is identified. Also, a signature must be affixed only to authenticated entries, and the method of authentication must comply with UC___ electronic signature standards.

Keeping the Record Open on a Temporary Absence: Organization policies should define how transfers between levels of care like from NF to SNF will be handled. Closing the record after a transfer makes it difficult to reconcile the admission date, discharge date and financial records with the health record.

Extent

Federal law does not require records to remain open upon discharge for temporary absence. Closing the record on the discharge date keeps the admission and discharge dates consistent with the financial and health records. It also minimizes time spent on readmitting and reassessing the resident when the information prior to the temporary absence is available in the new record. Policies should define a maximum amount of time to keep the record open. Payers such as Medicaid may set bed hold guidelines to follow in developing policies for keeping records open.

Purpose

Managing medical records is a complex task as a patient moves between providers and modalities of care. Information needs to move with the patient and remain accessible to all parties involved in their care. Physicians have a responsibility to keep their patients informed of their records and to provide copies or transfer information as requested by the patient or their authorized representative.

One option for long term care facilities to use is to close the record upon discharge for a temporary absence. This is consistent with most state and payer guidelines. It minimizes the time involved in readmitting and reassessing the resident upon return. This method also keeps the admission and discharge dates consistent with the financial and health records.

When closed records are requested the archivist can provide a copy of the record (if possible without risking further damage) or transcript of the entry. Often requests are made by people who have an interest in an individual.

Limitations

A physician who practices medicine via telemedicine must be able to access any records that document the delivery of health care services. It is a violation of medical board and commission rules for physicians to be denied access to such information.

Long term care facilities should develop policies that determine when a record will be closed. Generally, a change of level of care such as a move from NF to SNF should not close the record since the information is still applicable.

Closing the record upon a temporary absence allows for consistency with admission/discharge dates, financial records and the health record. This will minimize the time in readmitting and reassessing the resident. Information prior to the temporary absence should be brought forward and placed in the new record.

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