Medical Records Management

Medical record management, also known as health information management, focuses on the accumulation and care of the health records of each patient cared for at a medical practice. This is a highly sensitive aspect of medical practice management due to the confidential nature of the information. Additionally, workers in medical record management must be extremely conscientious, as errors or accidental omissions can dramatically affect insurance reimbursement and factor into potential malpractice litigation.

Medical records employees assemble patient health information. This includes each patient’s medical history, symptoms, examination findings, test results, and treatment. The information is culled and organized into a singular file for use at all future patient visits to the medical practice facility. The information serves as a tool for clinical providers in understanding the patient’s state of health as well as a source for billing and coding specialists in submitting claims for payment. The information may also be provided to statisticians for use in medical studies such as in cancer research, to determine treatment efficacy and survivor rates, to assist in locating regional cancer clusters, or to identify patients eligible for enrollment in new drug trials. It is up to the medical record worker to ensure the accuracy and quality of the information.

The American Medical Association’s Code of Ethics has always been firm on the topic of patient privacy. They unequivocally state that all information disclosed to a physician during the course of medical care is confidential to the utmost degree. All medical practices must strictly adhere to this rule. For the medical records worker, it means that tremendous care must be taken to ensure all patient information is handled within proper privacy guidelines. Files must not be left out in areas accessed by non-staff members. Notes and garbage must be disposed of in a way that makes it impossible for it to be read or deciphered (i.e., it must be shredded or incinerated). Additionally, workers must take care not to discuss patient information where non-staff might overhear. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 turned the guideline into law, stating that people have the legal right to have all health information kept private. Information can only be shared with the express written consent of the patient. With this new law, the security precautions taken by medical records workers became imperative. Breaches in confidentiality are punishable by law and can devastate a medical practice.

Until recently, all medical records consisted of information on paper. Emerging technology is starting a move toward electronic files. The use of electronic files will standardize medical record keeping, potentially making filing claims and the transfer of patient information much easier. Additionally, it can help medical caregivers in identifying patterns of disease and determining the best treatment outcomes. However, it does raise new concerns about maintaining compliance with HIPAA, as computers can be hacked.

Clearly the role of medical records management is an integral part of any practice management. It is a constantly evolving field, as new technologies and policies alter the job and its responsibilities.

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