12.67-Medical_Record_Management.doc

MEDICAL RECORD MANAGEMENT

POLICY NO. 12.67

Colorado Mental Health Institute at Pueblo

POLICY MANUAL

SECTION - MEDICAL RECORDS

POLICY NO.12.67 12.67

Effective Date: 9/10/14

TITLE:

MEDICAL RECORD MANAGEMENT MEDICAL RECORD MANAGEMENT

This is fillin "Type which policy this directive cancels."replaces policy 12.67, dated 10/12/11.

I.

macrobutton update DEFINITION/PURPOSE It is the policy of CMHIP to protect patient information from loss, unauthorized access, alteration or destruction.

The purpose of this policy is to define the process to protect patient information from loss, unauthorized access, alteration or destruction.

DEFINITIONS:

1.

Active Record: The record that is currently being used in the treatment of patients at CMHIP. Also known as “Open Record.” (There may be more than one admission episode in an Active Record.)

2.

Supplemental Record: Portions of the active medical record removed or “thinned” due to excess paper in the record.

Last Admission Record: The record of the patient’s last hospital stay.

4.

Closed Record: Record of a patient previously discharged from CMHIP.

5.

Authorized Persons: Persons who have a legitimate purpose for reviewing the medical record. A list of authorized persons is maintained in the Medical Records Department.

6.

Authorized Review: External or internal review of a medical record by an authorized person.

7.

Secure Location: Location for all or a portion of the medical record that is not accessible to unauthorized persons.

II.

ACCOUNTABILITY

Individuals responsible for implementing this policy include all treatment and support staff.

III.

PROCEDURE

A.

Active Record

1.

Storage: Active records are stored on the unit in a secure location when not in use by or under the supervision of staff.

2.

Access: If a record is removed from a secure location, an outguide card must be completed by authorized staff. The active chart must be returned to its storage location on the same day.

3.

Transfer: If the patient is transferred or discharged and readmitted to another unit within CMHIP, the active record accompanies the patient to the new unit.

4.

Nursing Audit: Nursing staff will perform a daily audit to ensure that all active records are returned to the unit on the same day. If an active record cannot be located within 24 hours, Department of Public Safety (DPS) and the Safety Risk Manager (SRM) will be notified that the record is lost and the Missing Document Acknowledgement (form 613) is initiated by the Medical Records Department as required per CMHIP policy 12.65, Incomplete and Missing Medical Records.

5.

Discharge: When the patient is discharged from a psychiatric unit, the medical record is sent to Medical Records Department within five (5) calendar days including Circle. If the patient is readmitted, this becomes the last admission record and is sent to the unit.

B.

Supplemental Record

1. Storage: A supplemental record is stored on the unit in a secure location when not in use by or under the supervision of staff.

2.

Access: If a supplemental record is removed from the unit, an outguide card must be completed by authorized staff. In addition to the date, name, and location where the record will be, the outguide card should indicate the patient’s name, and the volume number of the supplemental record being removed. A supplemental record must be returned to the unit on the same day.

3.

Transfer: If the patient is transferred or discharged and admitted to another unit within CMHIP, the supplemental record accompanies the patient to the new unit.

4.

Nursing Audit: Nursing staff will perform a daily audit of the outguided records to ensure that all outguided supplemental records are returned to the unit the same day. If a supplemental record cannot be located within 24 hours, DPS and the SRM will be notified that the supplemental record is lost and the Missing Document Acknowledgement (form 613) is initiated by the Medical Records Department and reported as required per the CMHIP policy 12.65, Incomplete and Missing Medical Records.

5.

Discharge: When the patient is discharged from the hospital, the supplemental record is sent along with the active record to the Medical Records Department within the time limits specified under A.5 above (5 calendar days).

C.

Last Admission Record

1.

Storage: Upon readmission, the last admission record is sent to the Admissions Department, which forwards the record to the unit along with the new chart. Last admission records are stored on the unit in a secure location when not in use by or under the supervision of staff.

2.

Access: The last admission record is kept on the unit until patient discharge or no more than six (6) months from the date of admission, whichever comes first. If a record is removed from the secure location on the unit, an outguide card must be completed by the authorized person which includes the signature of the responsible individual, the date, name, and location where the record will be, patient’s name, and the volume number of the record being removed. The last admission record must be returned to the unit on the same day. The last admission record is returned to the Medical Records Department six (6) months after admission or upon discharge. After that date, it becomes a closed record (see closed record access below). However, any incomplete last admission records will be returned to Medical Records on the 5th day after admission for all psychiatric units. Any last admission records not coded will be returned to Medical Records Department on the 5th day after admission.

3.

Transfer: If the patient is transferred or discharged and readmitted to another unit within CMHIP, the last admission record accompanies the patient to the new unit.

4.

Medical Records Audit: Medical Records Department staff will audit the location of the last admission records periodically by review of a sample number of records. If a last admission record cannot be located within 24 hours, DPS and the SRM will be notified that the record is lost and the Missing Document Acknowledgement (form 613) is initiated by Medical Records Department and reported per CMHIP policy 12.65, Incomplete and Missing Medical Records.

D.

Closed Record

1. Storage: Closed records are stored in a secure location when not in use by or under the supervision of staff. Access to the Medical Records Department is only available to authorized persons. After hours, keys to the Medical Record Department are only available to Medical Records, Admissions, nursing staff covering for Admissions, and Department of Public Safety employees. The Communication Center shall keep a log of all persons accessing Medical Records Department with this key.

2. Access: Staff are held accountable for closed records removed from the Medical Records Department by signing an outguide card. Closed records must be returned to the Medical Records Department within 30 calendar days. Except for sending the last admission record to the unit for a patient’s readmission, an incomplete closed record remains in the Medical Records Department for review so that it is accessible to all who need to complete it.

3. Audit: Medical Records Department staff will perform a daily audit to ensure that all records are returned to the Medical Records Department on the same day. If any records cannot be located within 24 hours, Department of Public Safety and the Safety Risk Manager will be notified that the record is lost and the Missing Document Acknowledgement (form 613) is initiated by Medical Records Department and reported as required per CMHIP policy 12.65, Incomplete and Missing Medical Records.

Birgit M. Fisher, PhD

Date

Interim Superintendent