The Medical Record Lifecycle

A journey through your health story

Infographic taken from the paper titled, “Driving patient’s records management process on the healthcare service delivery using records life cycle as a tunnel towards quality patients care” by Prof Ngoako Solomon Marutha

Understanding the Importance of Medical Record Management in Healthcare

Good medical record management is crucial for the success of any healthcare facility. Think of these records as the backbone of continuity of care. When they’re organised and accurate, healthcare providers can offer timely and informed treatment, which is essential for patient health. Plus, a well-managed record system helps reduce risks, cuts down on unnecessary duplication, and ensures that patients receive care when they need it.

What Standards Govern Medical Record Management in South Africa?

According to the Medical Protection Society, South African medical records must adhere to the following legislature, namely:

1. Protection of Personal Information Act (POPIA) 4 of 2013 — This act lays out the necessary steps to protect personal information from unauthorized access, loss, or destruction. It’s mainly concerned with keeping patient data safe and secure. Working hand in hand the Promotion of Access to Information Act (PAIA),

… and in the public sector…

1. The National Archives and Records Service of South Africa Act 43 of 1996 — This act details the how public entities to set up the necessary infrastructure, policies, strategies, procedures and systems to ensure that public records, in all formats, are managed in an integrated manner.

In addition, medical records must also adhere to 5 key international standards:

1. ISO 15489 — This is the international Records Management Standard. It establishes the principles for creating, capturing, and managing records.
2. ISO 23081 — Specifically governs the metadata for records.
3. ISO 15801 — Relates to electronic document management systems. Ensuring systems stores authentic, reliable and usable/readable electronic information
4. ISO 27002— This standard covers information security issues, including staff responsibilities, training, business continuity, and how to handle remote access.
5. ISO 27799 — This one focuses specifically on health informatics, providing guidelines for managing information security in healthcare settings.

What Is the Lifecycle of Medical Record Management?

The lifecycle of medical record management is broken down into five key stages:

1. Creation

The journey begins with the creation of medical records. During a patient’s first visit, data capturers, medical clerks, and healthcare professionals collect crucial information. Capturing accurate and detailed data here is vital, it sets the stage for a complete record of the patient’s health journey.

2. Use, Distribution, and Maintenance

Once records are created, effective management is essential for continuity of care and minimising risks. The goal is to have a well-organised, user-friendly record system that makes it easy for healthcare providers to access the information they need. Tackling challenges like information quality, access permissions, and misinformation requires a solid records management policy. It’s important to have designated people responsible for reviewing and updating these policies regularly to ensure compliance with legal standards.

3. Retention

The Health Professions Council of South Africa (HPCSA) offers guidelines on how long different types of records should be kept. These recommendations consider factors like the patient’s age and specific health conditions. It’s all about striking a balance between cost, available space, and the potential usefulness of records in legal or research contexts.

4. Termination and Disposal

A well thought-out records management system also includes protocols for disposing of old records, whether they’re paper or electronic. It’s essential to have clear guidelines for identifying records that are ready for disposal, getting the necessary authorisations, and keeping a register of destroyed records. Don’t forget to establish confidentiality agreements with any outside contractors and ensure proper destruction of patient-identifiable information.

5. Safeguarding and Security

Protecting records from risks is another important aspect. For paper records, measures should be taken against moisture, fire, and pests. Regular inspections and proper storage facilities are essential. When it comes to electronic records, regular backups and off-site storage are recommended to guard against cyber threats and physical damage.

Interesting to Note

In South Africa, there is no dedicated regulatory body for Health Information Systems (HIS). Instead, several organisations jointly oversee health information, but their core business isn’t HIS. This is similar to not having an equivalent to AHIMA (United States) in the country.

This lack of a dedicated regulator can make maintaining oversight difficult for a few reasons:

• Monitoring Health Needs and Service Coverage: Without a dedicated body to track health information, understanding what communities need can be tough. This can make it difficult to provide adequate care.
• Efficient Resource Allocation and Equal Access to Care: A good HIS is essential for distributing resources. Without a clear regulator, there may be clustering of services, meaning some people may not have the same access to healthcare services.
• Measuring Progress Towards Universal Health Care Goals: Reliable data is crucial for checking how well we are doing in achieving UHC through the National Health Insurance. The lack of a regulator can make it hard to evaluate health outcomes accurately.
• Setting Standards for Health Information Systems and Data Quality: Without established standards, data management and reporting can be inconsistent.
• Regulating Health Information Technology Vendors and Applications: Without specific regulations, there may be a wide range of quality in health IT solutions on the market.
• Ensuring Different Systems Can Work Together: A lack of oversight for standards (such as HL7) can create barriers, making it difficult for different health information systems to communicate.

Conclusion

In closing, managing the lifecycle of medical records involves steps in capturing, maintaining, retaining, and disposing of health information. By recognising the importance of accurate records and adhering to retention guidelines, healthcare providers can promote continuity of care, protect patient privacy, and enhance the overall quality of healthcare services.

However, the absence of dedicated regulatory bodies for Health Information Systems in South Africa may presents challenges that could impact these efforts. Without adequate oversight, issues such as inconsistent data quality, lack of interoperability, and inadequate patient privacy protections may arise. Addressing these gaps is crucial for both effective health information management and for achieving universal health coverage.

Frequently Asked Questions

1. Why is medical record management important?
   It’s important for maintaining continuity of care and ensuring that patients receive safe and accurate treatment. Good record management also helps healthcare providers comply with legal regulations, reducing the risk of errors.
2. What are the risks of poor medical record management?
   When records are poorly managed, it can lead to misinformation, delayed treatments, legal issues, and compromised patient privacy. It can also result in wasted resources and system inefficiencies.
3. How long should medical records be retained?
   The retention period varies based on regulations and individual patient circumstances. The HPCSA provides guidelines that consider factors like age and specific health conditions.
4. What are the best practices for disposing of medical records?
   Best practices include getting necessary authorisations for disposal, keeping a register of destroyed records, and ensuring confidentiality through agreements with verified contractors.

Final Thoughts

Effective medical record management not only protects patient privacy but also significantly enhances the quality and efficiency of healthcare delivery. By prioritising accurate data management and compliance with established standards, healthcare facilities can improve patient outcomes and overall operational effectiveness.

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