A Comparative Study of Laws and Procedures Pertaining to the Medical Records Retention in Selected Countries - Zdravlje, medicina, lijecenje, zdravstveni portal

A Comparative Study of Laws and Procedures Pertaining to the Medical Records Retention in Selected Countries

A Comparative Study of Laws and Procedures Pertaining to the Medical Records Retention in Selected Countries

Nahid Tavakoli, Sakineh Saghaiannejad, Mohammad Reza Habibi

Acta Inform Med. 2012; 20(3): 174-179

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Abstract

Introduction: The health record serves several purposes and must be retained to meet those purposes. These varied purposes influence how long health records must be kept, or their retention period. Aim: Present study aimed to recognize laws and procedures pertaining to retention of health records in selected countries and provide a proposed guideline for Iran. Methods: This was an applied and descriptive-comparative research on laws and procedures pertaining to retention of medical records in USA, United Kingdom, Australia and Iran that performed in 2011. The data were collected via library sources, websites, and consultation with specialists in and out of the country. The validity of the data was confirmed by experts. Finally, the recommendations were provided for medical record retention in Iran. Results: The study revealed that, there are complete and transparent record retention schedules in selected counties so that retention situation for adults, minors, emergency, outpatients and deaths records is clearly recommended. But in Iran, either there aren’t specific laws and procedures for medical record or they are unspecified. Conclusion: The lack of a complete, transparent and update medical record retention schedule in Iran, lead to confusion for hospitals. Some of hospitals maintain medical records more than of determined retention period and some of them destruct them before expiring of essential retention period. In order to optimize the situation of health records retention in Iran, it is necessary to review, correction and correction and completion of medical records retention schedule on the provided recommendations for kinds of medical record.

REFERENCES

1. Latour K, Eichenwald Sh. Health Information Management Concepts, Principles and Practice. USA: AHIMA; 2002: 204.

2. Skurka M. Health Information Management Principles and Organization for Health Record Services. USA: AHA Press, 1998: 157-158.

3. Sadoughi F, Ahmadi M, Asadi F, Jalalifard B. Health Information Management of a Strategic Resource. Tehran: vajepardaz; 2003: 352.

4. Education Module for Health Record Practice. 2005: 24-25. available at: www.ifhro.org/ed_modules/Education_Module3.doc

5. Abdelhak M, Gostick S, Hanken M, Jacobs E. Health Information Management of Strategic Resource. second edition. USA: WB Sunders Company, 2001: 198.

6. McWay D. Legal Aspects of Health Information Management. Second Edition. USA: Thampson Delmar Learning, 2002: 78: 75-76.

7. Medical Record Manual: A Guide for Developing Coutries. 2001: [24].wavailable at: www.wpro.who.int.

8. Arabzadeh A, Azizi A, Alimadadi E. Storage And Retrieval System. In: Health Information Management. Iran: TOHIDE GHOM; 1999: 173.

9. Davis N, Lacour M. Inroduction to Health Information Technology. USA: WB Saunders Company, 2002: 155.

10. Mennillo A. Retention and destruction of medical records. Medical Insurance Group Australia Bulletin. 2006; 1. [cited 2006 August]. Available at: www.miga.com.au.

11. Department of Health. Record Management : National Health Services Code of Practice, Part1. London; 2008: 1-78. Available at: www.dh.gov.uk/ publications

12. Corn M. Archiving the Phenome: Clinical Records Deserve Long-term Preservation. Journal of American Medical Informatics Association 2009 jan-feb; 16(1): 1-6. Available at: http://www.ncbi.nlm.nih.gov.

13. Tavakoli N. Investigation of retention and destruction process of medical record and provide guidelines in hospitals in Isfahan [In Persian]. Isfahan University of Medical Science, Faculty of Medical Informatics & Management, 2007.

14. Ebadifar F, Hajavi A, Maidani Z. A Comparative Study of Medical Record Standards in Selected Countries. Management and Medical Information Journal. 2004; 7(17): 37-41. [Article in Persian]

15. Green MA. Jo Bowie M. Essentials of Health Information Management: Principles and Practices. USA: Thampson Delmar Learning; 2005: 96.

16. AHIMA. Practice Brief: Retention of Health Information (updated). 2002: 1-6 available at: http://library.ahima.org.

17. Department of Health. Record Management: National Health Services Code of Practice Part2. London; 2008:9-66. Available at: www.dh.gov.uk/

18. The General Retention and Disposal Authority (GDA17)- Public Health Services: Patient/Client Records. MAY 2004 Sydney: 228. Australia; State Records Authority of New South Wales. Available at: www.records.nsw.gov.au/recordkeeping/

19. National Documents Organization of Iran, approved retention schedule for medical record by The National Archive council of Iran, 2003.

20. Guidelines for destruction and scanning paper medical records, Isfahan Province Medical Records Committee, University of Medical Sciences, Isfahan, 2009.

21. Destruction Guidelines in Hormozgan university. available at: http:/him.hums.ac.ir/emha_dastorolamal.pdf.‍‍‌ [2011 sep 22] .

22. Thompson L. Record Retention Practices among the Nation’s “Most Weird” Hospitals. Journal Perspectives in Health Information Management 2008; 5:8.

23. Tabibi S, Ebadi F. Azar F, Safdari R, Hajavi A, Meidani. Health Information Management Standard. Tehran: Ebadifar; 2004: 164.

24. Ministry of Health and Medical Education, Standard Guidelines and criteria for evaluation of public hospitals. Tehran: Ministry of Health, Treatment Evaluation Office; 1996.

25. Daniali A. Study on medical record filing unit in educational hospitals in Shiraz University of Medical Science [Thesis]. Iran University of Medical Sciences, School of Management and Medical Information; 1998.

26. Huffman E. Medical Record Management. Ninth Edition. USA: Physicians Record Company, 1990: 321.

27. Patient Information Retention and Disposal Schedule Version 3, 2008. Information Management and Reporting Department of Health, Western Australia. Available at: www.docpdf.info/.

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