Accountability Related to Patient Medical Record


POLICY:
 
It is our policy to maintain a clinical record system from 
which information can be promptly retrieved.  Clinical 
records are legible, documented accurately in a timely 
manner, and readily accessible to health care providers.  
Patient rights to privacy, and the security of health care 
information as delineated by the HIPAA legislation, are of 
paramount importance in permitting access to the patient 
medical record.
 
Designated staff members have the responsibility to control 
access to the medical records and, under the direction of 
appropriate management staff, maintain the medical record.  
All staff members with access to these records have received 
appropriate patient privacy training.
 
PROCEDURE:
 
1.  An individual record whether paper or electronic is
    prepared for every patient and events of patient visits
    and procedures are documented into the chart.
 
2.  All diagnostic test reports and dictated reports will be 
    included in the patient's chart within 48 hours of being read by the responsible physician.
 
4.  Access to patient charts is allowed only on a 'Need to  
    See' basis during hours of operation.
 
5.  All PAPER charts shall be assessed from a quality
    process standpoint before re-filing or closing, to 
    include:
 A.  Completion of any tasks requested via notes attached 
        to the outside of the chart; documentation of action 
        in chart; appropriate disposition of note; i.e., 
        file, return to originator, discard.
    B.  Checking of legibility of typed name on chart label.
 
6.  All medical records shall be stored securely, with no
    possibility of public access, consistent with
    HIPAA regulations. Should it be discovered that there
    has been a breach to any individual's private health 
    care information, all requirements regarding the breach 
    and individual notification will be followed. 
 
7.  A subpoena will be needed to remove/access the patient
    chart when legal matters are involved.
 
    When there is a need to remove or allow access to a
    chart from the  organization, either to take to the
    hospital for surgery, or to a satellite office, the     
    following procedure shall occur:  A list will be made of 
    charts being removed, by whom, that day.  The charts 
    will be carried in a brief case or other suitable 
    container that locks.  They will not be left in any 
    vehicle at any time.  Should the individual transporting 
    the charts, not return to the main facility,   the 
    charts will be removed from the vehicle and kept in the 
    house, locked  in the brief case or container.  
 
    Medical records may be copied/duplicated only with the 
    appropriate authorization from the patient.
8.  Any employee falsifying or intentionally changing 
    information included in the patient's chart is subject 
    to disciplinary action, including termination.
 
Electronic Medical Records (EMR)
This organization is entirely an electronic record keeping 
system or close to it as of early 2015.
 
As with all issues relating to computer use; the system is 
password protected and staff should only sign in using their 
password; never sharing passwords with others.  There is also 
an electronic signature system for authenticating records. 
Computers utilized to access patient medical records will 
have an appropriate 'time out' session which is automatic on 
the computer to reduce unauthorized access.  
 
Because this organization utilizes EMR, the following is in 
place should there be an interruption; whether scheduled or 
unscheduled of the information systems either due to a power 
outage or other problems with the system.
 
We will return to paper charts, with all documentation being done on paper and when

EMR is availabe, the information will be scanned or entered into the EMR.


This organization's electronic system is backed up via cloud.
 

Approved By Governing Board    
PR.6
Control #19.4
GUPTA GASTRO