Record Retention Policy for an Acute Care Facility, Research Paper Example

Health information management is an essential aspect of the modern-day healthcare industry. As healthcare institutions continue to process more patients, they are continually faced with the challenge of retaining patient information for as long as the information may be perceived to be useful. With the usefulness of this information being subject to opinion, there is need for healthcare institutions to develop policies and procedures that detail the retention of healthcare records.

Healthcare Information Retention Policy

The healthcare institution, as a public sector agency that holds personal information must guarantee:

1. That information pertaining to patient record will be kept only for the duration which it is perceived to be legally useful. Information will only be retained for the purpose for which it was intended for the duration of period that is prescribed in law.
2. Healthcare record must remain in readable and retrievable state for the duration of time which it is perceived to be legally useful. All records must be accessible when required within the time prescribed for in the law.
3. Health care record will be stored in all versions, including all previous versions. All versions of the document that are different by date will be maintained. All alternate media, such as Polaroid pictures and data strips will be maintained.
4. All metadata that is captured will be maintained. Information such as dates shall be maintained for the chronological organization of data. This is useful in determining the records that are retained and those to be purged from the system.
5. Records from other facilities associated with the institutions healthcare records will be maintained. All patients’ records pertaining to the institution’s patients, retrieved from other healthcare institutions shall be maintained.
6. Electronic records will remain accessible regardless of hardware and/or software changes. All data shall either be converted to the more modern technology, or the old technology shall be retained for the purpose of reading and maintaining such healthcare records. This will also include adequate backups.
7. Healthcare record that are perceived to be obsolete will be disposed of in a secure manner in adherence with the healthcare information retention and disposal requirements. By implementing such security safeguards, the information if protected from loss, modification, use, disclosure or unauthorized access.

Procedures for Purging

In order to maintain an efficient information system, healthcare institutions have to be able to apple the healthcare information retention policy to identify healthcare records that may be deemed as obsolete, or no longer legally useful.

• Healthcare record employ the discharge date as the cutoff date for inactive records.
• Unit records are employed in the records management system and this has to be taken into consideration when purging records.
• Multiple discharge dates from a single healthcare record are maintained by purging only those records whose entries are deemed as inactive as per the policy.
• Paper records shall be burnt, shredded or pulped in order to be purged.
• Metadata (such as date and method of destruction, as well as a description of records destroyed) on the destruction of health records shall e documented.

In conclusion, as information management in the healthcare industry shifts towards EHR information systems, there is need for the creation of policies and procedures that guide how information is managed and retained. The policies highlight the framework that is employed in the retention of information in the health institution.