Patient Records Program Requirements for a Hospital

Whether electronic or paper, medical records are any information collected and documented that concern a patient's health care. This includes information on point of care, diagnoses and actions. Certain standards govern the maintenance and management of patient medical records. Based upon federal and individual state laws, health care records must meet certain guidelines of maintenance, confidentiality and content.

Maintenance

• Records must be maintained for all individuals who are treated or seen on an emergency, outpatient or inpatient basis. The contents of the records should include any necessary imaging with the patient's information clearly designated as well as summaries and evaluations of the information. Records should go in a "designated medical records department or area" reports the University of California Office of the President. When removing records from this department, employees of the health care facility should log out or make note of the records' destination. Original reports should be available, along with copies, when feasible.

Confidentiality

• Of chief importance in any medical records program is the confidentiality of the patient. All records must be kept confidential except when authorized by the patient or as outlined in privacy practices of the participating medical facility. Additionally, workers must give special consideration to records concerning mental health, alcohol or drug abuse, adult or child abuse reports, as well as HIV and AIDS related information.

Content

• Depending upon the state, a medical facility must follow specific regulations to ensure that they meet all legal and patient obligations. For instance, in California, inpatient medical records must be fully complete no later than two weeks after the patient's discharge date. In addition, when the patient is covered under Medicare or other government funded insurances, the content must include the participatory conditions. The patient's information, including full name and any record numbers, must be clearly noted on all documents contained within the records. This is important because photocopies, faxes, and other digital images may become separated from the overall records. Other information such as age, gender, legal and marital status, address, allergies and medical history should all be noted within the records. Workers should make entries in the records as close to the time of care or diagnoses as possible and date them accurately.