Your medical records are potentially the most important documents that your practice maintains, so creating guidelines around how they’ll be created, stored and handled can help you remain compliant.
To develop guidelines for your medical records, check out four essential steps that your practice can’t afford to ignore.
1. Your Medical Record Policy Should Be in Writing
All practices should develop a written policy defining the medical record needs and identifying where the records physically exist. The primary considerations during this process should always be the needs for immediate and long-term patient care, as well as the legal and regulatory requirements for maintaining compliant medical records.
Maintaining policies in writing will not only be important so you can refer back to them and update them as needed from a compliance perspective, but it’s also essential for staff education. When new employees join your practice or inquire about medical records, you’ll have a written policy to share with them, which you can update over time as needed.
2. Involve a Health Information Committee
A health information committee comprised of patient care team members and administrative staff should be assembled to help guide this process. The patient care team members can identify the clinical record details that are important for positive patient care, while the administrative team can incorporate the features that are essential to compliance, claims processing, billing, storage, legal compliance, stage regulations, medical association rules, and other issues.
3. Identify Clinically Meaningful and Required Information
When you’re drafting your policy, the team should determine what information is considered clinically meaningful, as well as which line items are required by insurers and the law. Suggested steps during this process include:
- Identifying relevant regulations, standards and laws. For instance, does your state medical association require you to have a specific chief complaint at the top of the record, or can it be anywhere?
- Determining which elements support the patient’s illness or injury, treatment decisions and other patient care issues. If one provider performs an initial visit and another provider at the practice takes over follow-up care, can the second clinician easily see what was determined and done, and what the next steps are? If not, the record needs help.
- Addressing medical record retention requirements according to local, state, federal and insurance-specific guidelines. This may mean talking to an attorney about whether state medical record retention guidelines trump local or federal guidelines.
- Considering how the data in the record will be produced. Will clinicians write down the data? Will basic information carry over in an electronic record from previous visits? Is the doctor using a scribe? If so, what are insurers’ rules about scribes? These are the questions you must ask.
- Classifying how and where all records will be physically kept, and what security measures will go into place to keep them protected. For example, if your state requires you to maintain paper records for 10 years, have you considered whether you have enough storage space available? If not, your guidelines should spell out where paper records will go, how secure that place is, and whether it’s accessible for quick record retrieval when needed.
4. Review Your Policies, Records Regularly
Because the importance of compliant, thorough and easy to read medical records is so high, you should review your medical record guidelines frequently and update them as needed. Involve the original team (including administrative, clinical and legal team members) every time you make an update to the policy, and keep a record of any updates you make, along with the date. That way, you can demonstrate the reasons behind these changes to show how dedicated your practice has been to its medical record guideline requirements.
Medical records are integral to your practice, so you can’t afford to make mistakes. Let attorneys Daphne Kackloudis and Ashley Watson walk you through the specifics of medical record best practices during their one-hour online training session, “Avoid Medical Record Destruction Mistakes and $50,000 Fines.”
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