Accountability Related to Patient Medical Record
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
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.
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
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